Talking about dying and death: Essentials of communicating about approaching death from the perspective of major stakeholders.

OBJECTIVES Although caring for dying patients and their family caregivers (FC) is integral to patient care, training in communication about approaching death is almost inexistent in medical and nursing curricula. Consequently, many health professionals have insufficient knowledge about conducting these conversations. In order to gain a broader insight into essential aspects of this communication from different perspectives, we conducted focus groups with key stakeholders. METHODS Medical specialists, nurses, medical students, bereaved FC and patient representatives participated in five focus groups (n = 30). Following a focus group schedule, we elicited relevant aspects of communication about approaching death, associated emotions, and appropriate communication frameworks. We analyzed data thematically. RESULTS Four main themes were central to conversations about approaching death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others. SIGNIFICANCE OF RESULTS Communicating about approaching death with dying patients and their FC can be complex and challenging at a professional and personal level. With the recognition of the dying phase, a process is initiated for which health professionals need solid clinical knowledge about but also effective communication skills, constant self-reflection and self-care strategies. Comprehensive training and supervision while dealing with the challenges of communicating approaching death to dying patients and their FC are key, particularly for trainees, less experienced physicians and nurses. The essential components identified in this study can help health professionals to master these conversations

Über’s Sterben sprechen: Das Wesentliche der Kommunikation über den nahenden Tod aus unterschiedlichen Perspektiven

Fragestellung: Obwohl die Betreuung von sterbenden Patientinnen und Patienten und ihren Angehörigen zum Alltag von Gesundheitsfachpersonen gehört, ist entsprechendes Training in Bezug auf die Kommunikation über den bevorstehenden Tod in der Ausbildung von medizinischen Fachkräften nahezu inexistent. Viele Fachpersonen fühlen sich in Folge unbehaglich und nicht kompetent genug, um solche Gespräche zu führen. In dieser Studie wurden Schlüsselelemente der Kommunikation über den bevorstehenden Tod aus Sicht der Hauptbeteiligten identifiziert, welche erfahrungsgemäß für solche Gespräche relevant sind. Methoden: Insgesamt wurden 5 Fokusgruppen mit Fachärztinnen und –ärzten, Pflegefachkräften, Medizinstudierenden, Mitglieder eines Spital-Patientenrates und trauernden Angehörigen durchgeführt (n=32). Basierend auf einem semistrukturierten Leitfaden wurden relevante verbale und nonverbale Aspekte eines Gesprächs über das Sterben, damit verbundene Emotionen und geeignete Rahmenbedingungen der Kommunikation eruiert. Alle Gespräche wurden aufgezeichnet und gemäß der thematischen Analyse1 ausgewertet. Ergebnisse: Basierend auf den Erfahrungen der Teilnehmenden, konnten sechs Hauptthemen bezüglich der Kommunikation über den bevorstehenden Tod identifiziert werden: 1. Professionelle und private Einstellung gegenüber Sterben und Tod sowie der familienzentrierten Betreuung, 2. Fachkompetenzen bezüglich dem Erkennen der Sterbephase, Wissen über den Sterbeprozess und die Notwendigkeit der Selbstreflexion, 3. Anerkennen der Einzigartigkeit jeder Situation inkl. Fokus auf individuelle Bedürfnisse und Ressourcen der Betroffenen, 4. Rahmenbedingungen und Inhalte des Gesprächs, 5. Aspekte der therapeutischen Beziehung wie Vertrauen und Authentizität, 6. Lernstrategien für diese Gespräche wie Training on the job, Rollenmodelle, Feedback. Diskussion: Die Ergebnisse zeigen die Vielschichtigkeit der Kommunikation über den bevorstehenden Tod mit sterbenden Patientinnen und Patienten und deren Angehörigen. Die Herausforderungen bei solchen Gesprächen sind fachlicher als auch persönlicher Natur. Mit dem Erkennen der Sterbephase wird ein Prozess eingeleitet, dem eine positive Grundhaltung gegenüber der familienzentrierten Betreuung und der Endlichkeit des Lebens förderlich ist. Dabei benötigen Fachpersonen solides Fachwissen aber auch mitmenschliche Fähigkeiten und nicht zuletzt stetige Selbstreflexion und wirksame Strategien der Selbstfürsorge, welche nur in der aktiven Auseinandersetzung mit solchen Gesprächen geübt und vertieft werden können. Take Home Messages: Dass Menschen sterben, gehört zum Leben. Darüber zu sprechen, ist jedoch (noch) nicht integraler Bestandteil der medizinischen Ausbildung. Eine frühzeitige, begleitete Auseinandersetzung mit den einzigartigen Herausforderungen in der Kommunikation mit sterbenden Patientinnen und Patienten und ihren Angehörigen ist ebenso erwünscht wie notwendig, um Menschen auch am Lebensende adäquat begleiten und betreuen zu können

Identifying the essentials of communicating about imminent death from key stakeholders' perspectives

Background Caring for dying patients is an integral aspect of care, however medical and nursing students lack training and exposure to conversations with dying patients and their families. Thus, many health professionals lack the skills to communicate about imminent death causing a long-lasting impact to all involved. As a basis to develop an educational module, this study aimed at identifying aspects that are essential to conversations about imminent death from the perspective of key stakeholders. Methods Five focus groups were conducted with medical specialists, nurses, medical students, patient representatives, and bereaved relatives (n=30). Based on a semi-structured guide, relevant verbal and nonverbal aspects of conversations about imminent death, associated emotions, and appropriate frameworks for communication were elicited. All conversations were recorded and thematically analyzed. Findings Based on participants’ experiences four main themes were identified as essential to conversations about imminent death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others. Discussion The Findings: indicate that communicating about imminent death with dying patients and their family members is a complex and challenging task for health professionals at a professional as well as personal level. Hence, comprehensive training is needed in order to impart clinical and interpersonal skills that support health professionals to recognize when and how to engage in these conversations. Furthermore, self-reflection processes and self-care practices are to be taught and encouraged to promote positive coping strategies in the long term. Guidance and supervision are also essential to support debriefing practices in order to revisit confronting experiences, as well as to consolidate and optimize what has been learned

Concurrent chemo-radiotherapy in elderly patients: tolerance and compliance in a series of 137 patients

INTRODUCTION: Aggressive cancer treatment is a challenge in elderly patients. The present study aims to assess tolerance in terms of acute toxicity and compliance of concurrent chemo-radiotherapy (cCRT) in a series of patients aged 6570 years. MATERIALS AND METHODS: Clinical records of patients aged 6570 years who underwent cCRT between January 2005 and December 2013 were reviewed. Concurrent CRT had curative intent in 134 patients (97.8 %) and palliative intent in 3 patients (2.2 %). Chemotherapy (CT) drugs and schedule were selected according to tumor histology. Radiotherapy median dose was 45.0 Gy (range 11-70 Gy) for curative purposes and 54 Gy (range 40-56 Gy) for palliative purposes. Incidence of acute toxicity and compliance to cCRT were analyzed and correlated with age, Karnofsky Performance Status (KPS), and Charlson Comorbidity Index (CCI). RESULTS: Overall, 137 patients, 82 males (60 %) and 55 females (40 %), median age 74 years (range 70-90 years) were analyzed. Concurrent CRT schedule was completed by 132 patients (96.4 %). Thirty-one of these patients (23.5 %) temporarily interrupted treatment. Hematological toxicity with grade 651 was observed in 25 patients (18.2 %), gastrointestinal toxicity in 55 (40.1 %), and genitourinary in 13 (9.5 %). Mucositis with grade 651 was recorded in 19 patients (13.9 %). No statistical significant correlation between KPS, CCI, and toxicity was found. A correlation trend between mucositis and patient age (p = 0.05) was observed. CONCLUSION: Concurrent CRT for elderly was feasible and quite well tolerated. Great attention in prescribing CT dose should be paid to limit acute toxicity

A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee

Many clinical trials have evaluated the benefit of long-term use of antiplatelet drugs in reducing the risk of clinical thrombotic events. Aspirin and ticlopidine have been shown to be effective, but both have potentially serious adverse effects. Clopidogrel, a new thienopyridine derivative similar to ticlopidine, is an inhibitor of platelet aggregation induced by adenosine diphosphate. METHODS: CAPRIE was a randomised, blinded, international trial designed to assess the relative efficacy of clopidogrel (75 mg once daily) and aspirin (325 mg once daily) in reducing the risk of a composite outcome cluster of ischaemic stroke, myocardial infarction, or vascular death; their relative safety was also assessed. The population studied comprised subgroups of patients with atherosclerotic vascular disease manifested as either recent ischaemic stroke, recent myocardial infarction, or symptomatic peripheral arterial disease. Patients were followed for 1 to 3 years. FINDINGS: 19,185 patients, with more than 6300 in each of the clinical subgroups, were recruited over 3 years, with a mean follow-up of 1.91 years. There were 1960 first events included in the outcome cluster on which an intention-to-treat analysis showed that patients treated with clopidogrel had an annual 5.32% risk of ischaemic stroke, myocardial infarction, or vascular death compared with 5.83% with aspirin. These rates reflect a statistically significant (p = 0.043) relative-risk reduction of 8.7% in favour of clopidogrel (95% Cl 0.3-16.5). Corresponding on-treatment analysis yielded a relative-risk reduction of 9.4%. There were no major differences in terms of safety. Reported adverse experiences in the clopidogrel and aspirin groups judged to be severe included rash (0.26% vs 0.10%), diarrhoea (0.23% vs 0.11%), upper gastrointestinal discomfort (0.97% vs 1.22%), intracranial haemorrhage (0.33% vs 0.47%), and gastrointestinal haemorrhage (0.52% vs 0.72%), respectively. There were ten (0.10%) patients in the clopidogrel group with significant reductions in neutrophils (< 1.2 x 10(9)/L) and 16 (0.17%) in the aspirin group. INTERPRETATION: Long-term administration of clopidogrel to patients with atherosclerotic vascular disease is more effective than aspirin in reducing the combined risk of ischaemic stroke, myocardial infarction, or vascular death. The overall safety profile of clopidogrel is at least as good as that of medium-dose aspirin