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Context: Prolonged management of critical illnesses in long-term acute care hospitals (LTACH) makes serious illness communication (SIC), a clinical imperative. SIC in LTACH is challenging as clinicians often lack training and patients are typically unable to participate—making caregivers central. Objectives: This qualitative descriptive study characterized caregiver engagement in SIC encounters, while considering influencing factors, following the implementation of Ariadne Labs' SIC training at a LTACH in the Northeastern United States. Methods: Clinicians' documented SIC notes (2019-2020) were analyzed using directed content analysis. Codes were grouped into four categories generated from two factors that influence SIC—evidence of prognostic understanding (yes/no) and documented preferences (yes/no)—and caregiver engagement themes identified within each category. Results: Across 125 patient cases, 251 SIC notes were analyzed. In the presence of prognostic understanding and documented preferences, caregivers acted as upholders of patients' wishes (29%). With prognostic understanding but undocumented preferences, caregivers were postponers of healthcare decision-making (34%). When lacking prognostic understanding but having documented preferences, caregivers tended to be searchers, intent on identifying continued treatment options (13%). With poor prognostic understanding and undocumented preferences, caregivers were strugglers, having difficulty with the clinicians or family unit over healthcare decision-making (21%). Conclusion: The findings suggest that two factors—prognostic understanding and documented preferences—are critical factors clinicians can leverage in tailoring SIC to meet caregivers' SIC needs in the LTACH setting. Such strategies shift attention away from SIC content alone toward factors that influence caregivers' ability to meaningfully engage in SIC to advance healthcare decision-making. [ABSTRACT FROM AUTHOR]

The Revised Illness Perception Questionnaire (IPQ-R) assesses patients' perspectives of their illnesses. Original psychometric testing occurred in limited populations. The purpose of this reliability generalization meta-analysis was to: (1) estimate internal consistency reliability of each IPQ-R subscale, and (2) test moderators of these estimates. Web of Science was searched in July 2022 for articles citing the original IPQ-R paper that reported IPQ-R reliability data. Cronbach's alphas (⍺) were pooled for each IPQ-R subscale using inverse variance weighting and DerSimonian and Laird estimation. Sixty-six studies met criteria. Overall pooled ⍺ estimates were acceptable: 0.71–0.87. Treatment control reliability was reduced among cardiac (⍺ = 0.68), diabetes/kidney disease (⍺ = 0.63), and mixed/other (⍺ = 0.66) samples; cyclical reliability was reduced in cancer (⍺ = 0.65) samples. Age, gender, and race were also significant moderators. Subscale reliability varied based on sample characteristics. Adapting IPQ-R subscales to account for sample variation could improve measurement of illness perception constructs. [ABSTRACT FROM AUTHOR]

There is widespread agreement that clinicians should talk to seriously ill patients and their families about their illnesses. However, advance directives as a quality metric have been called into question because of the lack of data that these conversations lead to goal-concordant care. The controversy has led many to reexamine the purpose of conversations with seriously ill patients and what should be discussed in ambulatory visits. In this Controversies in Palliative care, experts in palliative care review the literature and suggest both how it influences their clinical practice and what research needs to be done to clarify the controversy. While there is not a single outcome that the experts agree on, they posit a variety of different ways to assess these conversations. [ABSTRACT FROM AUTHOR]

There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer. To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer. Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990–2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting. Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes—cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use—were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use. This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field. [ABSTRACT FROM AUTHOR]

PURPOSE Research eliciting patients' illness concerns has typically focused later in the cancer continuum, rather than during cancer treatments. Family caregiver concerns are overlooked during this time. Less is known about how patients and caregivers prioritize concerns during cancer treatments, which holds potential for improving supportive oncology care (ie, primary palliative care). The purpose of this study was to elicit and compare which domains of supportive oncology are of highest importance to patients and caregivers during cancer treatments. METHODS Freelisting, a cognitive anthropology method, was used to elicit concerns in order of importance. Freelist data were analyzed using Smith's salience index. Qualitative interviews were conducted with a caregiver subsample to add explanatory insights. RESULTS In descending order, pain, death, fear, family, and awful were salient Freelist items for patients (n 5 65), whereas sadness, time-consuming, support, anger, tired, death, and frustration were salient for caregivers (n 5 24). When integrated with supportive oncology domains, patients' concerns reflected a prioritization of the physical (pain) and emotional (death, fear, and awful) domains, with less emphasis on social (family) aspects. Caregivers' prioritized the emotional (sadness, anger, death, and frustration) and social (timeconsuming and support) domains, with less emphasis on the physical (tired) aspects. CONCLUSION Our findings suggest that enhancing primary palliative care delivery by oncology teams requires systems thinking to support both the patient and caregiver as the primary unit of care. Primary palliative care may be improved by prioritizing interventions that address physical concerns among patients as well as key social concerns among caregivers to support the complex caregiving role while patients undergo cancer treatments. [ABSTRACT FROM AUTHOR]

1. Recognize five distinct trajectories of serious illness communication among patients admitted to a long-term acute care hospital. 2. Discuss the qualitative differences that help to distinguish these serious illness communication trajectories. Through novel qualitative longitudinal analysis of SIC notes, this study identified five SIC trajectories that culminated along a continuum from reluctance to acceptance. Incorporating intentional starting points, purposeful inclusion of conversation participants, modifying expectations, and addressing discord offer ways to enhance communication across SIC encounters to facilitate informed healthcare decision-making. Little is known about how serious illness communication (SIC) evolves over time to influence healthcare decision-making among chronic critically ill patients in the long-term acute care hospital (LTACH) setting.1,2,3 To characterize trajectories of SIC among patients admitted to an LTACH. A qualitative methodology for understanding longitudinal care processes—trajectory analysis—was conducted for a subset of patient cases where three or more SIC notes were documented between 2019 to 2020.4 This involved a time-ordered matrix to organize and code SIC notes by patient case according to time. Within each patient case, themes were identified with respect to the evolution of the patient's (and caregiver's) orientation toward decision-making across SIC encounters. Patterns among themes defined the trajectories. Across 125 patient cases, 28 patients had three or more SIC notes. Mean age was 70 years. Patients were predominantly White (71%), female sex (68%), admitted with respiratory failure for an average of 38 days. Five SIC trajectories were identified: (1) maintain clinical course (n=3); (2) in-limbo: focus on all possible treatments (n=10); (3) de-escalation of treatment: reactive (n=3); (4) in-limbo: contemplating comfort (n=7); (5) de-escalation of treatment: proactive (n=5). Overall, trajectories began from a place of stagnation and culminated along a continuum from reluctance to acceptance. Several features distinguished trajectories (e.g., role of the patient's voice, code status preferences, and presence of discord), which may have served as key drivers of the conversation evolution. These findings underscore the importance of the collective impact of SIC over time and the need for clinicians to leverage factors during conversations that will help build on prior interactions to engage in informed healthcare decision-making. This study adds insight into the features of SIC that may help conversations evolve over time and avoid conversations that solely recapitulate prior interactions and stagnate decision-making. [ABSTRACT FROM AUTHOR]

1. Utilizing a case-based approach, participants will articulate the process of implementing an evidence-based advance care planning educational intervention in the faith-based community in the underserved rural population. 2. Utilizing a case-based approach, participants will describe the impact of a culturally sensitive faith-based community educational intervention on advance care planning knowledge and engagement in the underserved rural population. There is a need to increase Advance Care Planning (ACP) knowledge and engagement, making ACP culturally sensitive and accessible to underserved rural populations. This presentation describes implementing and evaluating an evidence-based ACP educational workshop in a rural faith-based community to address the gap in limited public awareness and participation. Advance Care Planning (ACP) facilitates high-quality, person-centered end-of-life care. Yet only 30% of Americans have engaged in ACP. The problem of limited public awareness and participation in ACP can lead to unnecessary healthcare interventions that are not preference-matched—poorly impacting patients' quality of life and patients' and caregivers' experiences of distress at the end of life. This project is a response to the growing demand to bring ACP outside the walls of healthcare facilities. Opportunity exists for hospice and palliative care professionals to partner with faith-based communities to provide culturally sensitive community-based education to enhance ACP knowledge and engagement in underserved rural populations. The purpose of this project is to 1) implement an evidence-based ACP educational workshop hosted in a rural faith-based community, and 2) evaluate its impacts on ACP knowledge and engagement. This project utilizes a pre- and post-test design to examine the impact of the workshop on ACP knowledge and engagement. Three self-contained workshops will utilize the ACP educational materials developed by PREPARE (prepareforyourcare.org) and be offered in a faith-based community in rural northwest Ohio. The workshops will be open to adults aged 18 and older in the surrounding communities. ACP knowledge and engagement will be measured using a validated ACP Knowledge Questionnaire and ACP Engagement Survey before and after the education. In-progress results will be presented, based on data from the planned delivery of the ACP educational workshop in September, October, and November 2023. Anticipated outcomes include increased ACP knowledge and engagement among an underserved rural faith-based community, representing steps toward improved high-quality, person-centered end-of-life care for all. If the results show promise, this approach to ACP education offers an exemplar for continued work in promoting access to and awareness of ACP in this largely untapped setting for facilitating community-based ACP. Shared Decision Making / Advance Care PlanningCommunication [ABSTRACT FROM AUTHOR]

Introduction: Based on many published reports, African American patients with cancer experience higher pain severity scores and lower pain relief than White patients. This disparity results from undertreatment of pain and is compounded by low adherence to prescribed non-opioid and opioid analgesics among African American patients with cancer. While nearly one in four patients use cannabis to manage cancer-related symptoms, less is known about how cannabis use influences pain relief in this patient population. Methods: This study is based on preliminary data from an ongoing study of longitudinal outcomes of opioid therapy among African American and White patients with cancer. Linear mixed-effects models were utilized to assess the interaction of race and cannabis use on pain relief using "least pain" item scores from the Brief Pain Inventory (BPI) averaged across three time points. Models were adjusted for sociodemographic and clinical variables. Results: This analysis included 136 patients (49 African American, 87 White). Overall, 30.1% of the sample reported cannabis use for cancer pain. The mean "least pain" score on BPI was 3.3 (SD=2.42) on a scale of 0– 10. African American patients had a mean "least pain" score 1.32± 0.48 units higher (indicating lower pain relief) than White patients (p=0.006). Cannabis use did not have a significant main effect (p=0.28). However, cannabis use was a significant moderator of the relationship between race and "least pain" (p=0.03). In the absence of cannabis use, African Americans reported higher "least pain" scores compared to Whites (mean difference=1.631± 0.5, p=0.001). However, this disparity was no longer observed in African American patients reporting cannabis use (mean "least pain" difference=0.587± 0.59, p=0.32). Conclusion: These findings point to the possible role of cannabis in cancer pain management and its potential to reduce racial disparities. These findings are preliminary and further research into the role of cannabis in cancer pain outcomes is needed. [ABSTRACT FROM AUTHOR]

Background: National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory. Objective: To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites. Methods: A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis. Results: Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity). Conclusions: The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience. [ABSTRACT FROM AUTHOR]

Parenting stress is common and may lead to worsening health, particularly in the context of other risk factors such as mental disorders or a history of abuse. This study investigated how parenting-related stress impacts the effect of abuse experiences on health among mothers with mental health disorders. Survey data was analyzed from 172 predominantly Hispanic mothers receiving outpatient behavioral health services. Most (80.2%) mothers had experienced abuse. Those reporting childhood abuse had 3.82 greater odds of experiencing abuse in adulthood. Findings demonstrated worse health outcomes among those experiencing abuse in both childhood and adulthood and those with a greater number of abuse experiences. Caregiving load intensified the relationship between abuse and anxiety and sleep disturbance. Parenting self-agency intensified the relationship between abuse and cigarette use. These findings have important implications for mental health nursing practice by identifying parenting-stress as an important target for interventions to improve health among women with histories of abuse and mental health disorders. [ABSTRACT FROM AUTHOR]

Context: Advance care planning (ACP) is used to prepare patients and caregivers for future "in the moment" decisions at the end-of-life. Patients with cancer generally do not engage in all 3 components of ACP (documented living will, health-care surrogate, end-of-life discussions); however, little is known about the impact of these varying levels of ACP engagement on caregivers postdeath. Objective: To examine the relationship between varying levels of ACP engagement and caregivers' perceptions of cancer decedents' end-of-life experiences. Methods: A secondary analysis of the 2002 to 2014 waves of the Health and Retirement Study data using structural equation modeling was conducted. Five levels of ACP engagement were defined: full (discussions/documents), augmented discussions, documents only, discussions only, and no engagement. Results: Among the 2172 cancer death cases, the analyzed sample included 983 cases where end-of-life decisions occurred. Compared to no ACP, all levels of ACP were significantly associated with caregivers' positive perceptions of cancer decedents' end-of-life experiences (P ≤.001), controlling for sex, race, and Hispanic ethnicity (R 2 =.21). However, the relative impact of each level of ACP engagement was not equal; full engagement (β =.61) was associated with a greater impact compared to each of the partial levels of engagement (augmented discussions [β =.33], documents only [β =.17], discussions only [β =.17]). Conclusion: Partial ACP engagement, not just nonengagement, serves as an important clinically modifiable target to improve the end-of-life care experience among patients with cancer and the perceptions of those experiences among bereaved caregivers. [ABSTRACT FROM AUTHOR]

• End-of-life decision making is a process , not a discrete event, spanning the chronic illness. • It involves three phases: preparation, decisions, outcomes; caregivers are vital throughout. • Preparation occurs in the chronic illness, and decisions (which are many) in the terminal illness. • Preparation includes clinically modifiable factors for improving end-of-life decision making. • Measurement of the process is needed; including the dose, content , and quality of all factors. Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research. To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model. Walker and Avant's approach to concept analysis. End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences). Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes. [ABSTRACT FROM AUTHOR]

Nurses are confronting a number of negative mental health consequences owing to high burdens of grief during COVID-19. Despite increased vaccination efforts and lower hospitalization and mortality rates, the long-term effects of mass bereavement are certain to impact nurses for years to come. The nurse coaching process is an evidence-based strategy that nurse leaders can use to assist staff in mitigating negative mental health outcomes associated with bereavement. The End-of-Life Nursing Education Consortium brought together a team of palliative nursing experts early in the pandemic to create resources to support nurses across settings and promote nurse well-being. This article shares a timely resource for health systems and nursing administration that leverages the nurse coaching process to support bereaved staff in a safe and therapeutic environment. [ABSTRACT FROM AUTHOR]

1. By the end of this session, learners will be able to identify at least one strategy for improving serious illness conversation encounters with family caregivers in the long-term acute care setting 2. By the end of this session, learners will be able to describe qualitative strategies for studying serious illness communication notes documented in the electronic health record of a long-term acute care setting The prolonged management of critical illnesses in long-term acute care hospitals (LTACHs) makes palliative care interventions, such as serious illness communication (SIC), an imperative. SIC in the LTACH is onerous because healthcare providers often lack training and patients are typically unable participate, making caregivers the center of these interactions. This study characterized caregiver engagement in SIC encounters in the year following a SIC healthcare provider training in an LTACH. SIC notes documented in the electronic health record were qualitatively analyzed using an a priori coding framework and open coding in NVivo. Before thematic analysis, the codes were grouped according to an SIC quality context, which considered two underlying features of the encounter: evidence of prognostic understanding and documented treatment preferences. This resulted in four contexts, SIC with prognostic understanding and documented preferences, prognostic understanding but undocumented preferences, a lack of prognostic understanding but documented preferences, or a lack of prognostic understanding and undocumented preferences. Across 125 patient cases, 251 SIC notes were analyzed. Most patients were admitted for respiratory failure (79%), and caregivers were typically spouses or adult children (69%). Four manifestations of caregiver engagement emerged. In the highest-quality context (prognostic understanding and documented preferences) caregivers were engaged in SIC as upholders of patients' wishes. With prognostic understanding but undocumented preferences, caregivers tended to be deferrers of healthcare decision making. In the opposing context (lack of prognostic understanding, documented preferences), caregivers were searchers, intent on treatment options. Under poor circumstances (lack of prognostic understanding and undocumented preferences), conflict emerged, where caregivers were instigators of disagreements with the healthcare team or family. These findings underscore the important influence of the SIC quality context on caregiver engagement in SIC. These findings should be considered in priming SIC interactions in a way that meets the caregivers' needs and facilitates healthcare decision making. [ABSTRACT FROM AUTHOR]