Cancer advance care planning: development of a screening tool.

OBJECTIVES: Advance care discussions are a useful communication tools for medical preferences and beneficial for shared decision-making processes in hospital settings. The present study developed the first screening tool for need for advance care planning (ACP). METHODS: In phase 1 (n=92), items were evaluated using feasibility analysis and item reduction. In phase 2 (n=201), reduced screening items were analysed for predictive value of need for ACP. Statistical analysis included receiver-operating characteristics analysis (area under the curve>0.80), optimal cut-off based on sensitivity and specificity, interpretation of OR and construct validity using correlation with death anxiety, communication avoidance within families and trust based on the relationship with the treating physician. RESULTS: Participants in both phases were approximately 60 years old with non-curative prognosis. After item reduction, predictive values of four possible items with good item difficulty and discrimination were compared for mild, moderate and great levels of death anxiety. A two-item combination of I am burdened by thoughts of an unfavourable course of the disease and I am burdened by the feeling of being ill-prepared for the end of life showed best prediction of death anxiety and communication avoidance. Clinical cut-off at sum-score ≥6 was of high sensitivity (95%) and specificity (81%). Previous use of social support and readiness for ACP was related to higher chance of interest in ACP. CONCLUSION: Screening for need of ACP is possible with two objective items and one subjective item. Positive screening therefore indicates when to offer ACP discussions and provides routine estimation of ACP need in clinical practice.

Developing a care pathway for hospital-based advance care planning for cancer patients: A modified Delphi study.

OBJECTIVES: The objective of this study is to develop a care pathway for a hospital-based advance care planning service for cancer patients. METHODS: A web-based modified Delphi study consulted an expert panel consisting of a convenience sample of stakeholders including professionals with a special interest in advance care planning as well as a 'public and patient involvement group'. After generating ideas for core elements of a care pathway in the first round, numerical ratings and rankings informed the multi-professional research steering group's decision process eventually resulting in a final pathway. RESULTS: The 41 participants in the Delphi study identified 177 potential core elements of the pathway in the first round. In two further rounds, consensus was reached on a final version of the pathway with 148 elements covering the 10 domains: prerequisites, organisation and coordination, identification and referral, provision of information, information sources, family involvement, advance care planning discussion, documentation, update and quality assurance. CONCLUSION: We propose a care pathway for advance care planning for hospital patients with cancer based on the results of a Delphi study that reached consensus on an implementation strategy. Our study pioneers the standardisation of the process and provides input for further policy and research with the aim of aligning cancer patients' care with their preferences and values.

Death anxiety as general factor to fear of cancer recurrence.

OBJECTIVE: Fear of cancer recurrence or progress is strongly related to death anxiety (DA) in cancer patients, but due to lack of conceptualization and measurement methods, the relationship was not analyzed quantitatively before. The aim of the present study was to investigate the conceptual relationship of both constructs, with DA expected to be the general construct. METHODS: Cancer patients (N = 121) participated in an online study. They provided information on socio-demographical, medical and psychological measures including DA and fear of cancer recurrence or progression (FoP-Q-SF). Relation of constructs was assessed using a two-step process: Confirming individual construct structure with confirmatory factor analysis, including correlation of constructs and modification of measurement model, followed by structural equation modeling and comparison of structure models for best model fit. RESULTS: The measurement model was modified to include three residual correlations within and between constructs. Comparison of structure models supported a bifactor structure with DA as general factor and fear of recurrence or progression as group factor: SBχ2 (173) = 207.74 (p < 0.05), SB = 1.538, relative χ2  = 1.2, rRMSEA = 0.05 [0.01, 0.07] (p > 0.05), SRMR = 0.07, CFI = 0.94, AIC = 7543.60. CONCLUSIONS: DA can be interpreted as general factor to fear of cancer recurrence or progression. Psychological interventions to reduce emotional burden of cancer patients need to focus additionally on existential threat and individual fears regarding DA.

Validation of the Readiness for End-of-Life Conversations (REOLC) scale in a German hospital setting.

Objective: For every health behavior, readiness to engage is a necessary and crucial foundation for following conversations, interventions or behavior changes. The present study aims to support a one-factor structure for the Readiness for End-of-Life Conversations (REOLC) scale (Berlin et al., 2021) in a population of cancer patients (N = 295). Methods: For validation purposes, data of patients participating in a screening development study at a university clinic was used. Model adequacy was analyzed with structural equation modelling and controlled for with goodness of fit indices: χ2-test, SRMR, rRMSEA. Discriminant and convergent validity were assessed with correlations of REOLC and psychological or health behavior measures. Results: Factor structure was supported with good fit indices, discriminant validity and convergent validity. Readiness correlated significantly with age and reported death anxiety. Conclusion: The REOLC scale is a reliable instrument to assess cancer patients' readiness for end-of-life conversations. Future studies may further address moderating and mediating effects of socio-demographic, medical and psychological factors. Innovation: The assessment of readiness may further indicate anxiety levels of cancer patients and enables practitioners to provide interventions accordingly. However, in a clinical setting and especially for patients with a palliative prognosis, end-of-life care conversations may need to be introduced early.

Development and Validation of the Readiness for End-of-Life Conversations (REOLC) Scale.

Background: Engaging in end-of-life care considerations is beneficial when the time is right. The purpose of this study is to provide a valid instrument to assess peoples readiness for end-of-life conversations before they are initiated. Materials and Methods: A community sample was recruited in study one for exploratory factor analysis of a 13-item questionnaire. In study two, psychometric properties were analyzed with structural equation modeling in a population affected by cancer. Convergent and discriminant validity were assessed with questionnaires measuring distress, depression, anxiety, fear of progression, and distress of death and dying. Results: In study one (N = 349) exploratory factor analysis resulted in three subscales readiness (α = 0.84), communication (α = 0.76), and values (α = 0.56) with a possible common factor (α = 0.84) for a community sample. In study two (N = 84) the three-factor solution with 13 items was not supported for cancer patients. Factor structure was adapted to 12 items with one common factor readiness (α = 0.87). Model fit was good: χ2(50) = 59.18, p>0.05 (Satorra-Bentler-correction = 1.27), with χ2/df = 1.184, rRMSEA = 0.053 (90%-CI[0.000;0.100]), and rSRMR = 0.072. Convergent validity was supported by moderate correlations to trait gratitude, ratings of readiness to provide a living will or talk with family about the end of life. Divergent validity was supported by no or small correlation with distress, depression, general and death anxiety and fear of progression, respectively. Conclusions: Results support usage of the REOLC Scale in different settings with adapted factor structure. The questionnaire is interpreted as valid and reliable instrument to assess objective readiness for end-of-life conversations.