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The authors argue on the need to replace advance directive (AD) with a patient activation approach to serious illness communication, including engaging a surrogate decision-maker. Topics covered include complexity that challenges the practicality and utility of AD, how AD and patient activation are distinct in may ways, and the three steps that will improve serious illness communication and the patient, family, and care partner experience in the end-of-life care.

PURPOSE: This study (1) assesses the level of clinical work intensity medical oncologists and oncologic nurse practitioners experience providing care and (2) identifies patient, provider, and practice factors mediating intensity. PATIENTS AND METHODS: Seventeen medical oncologists (12 physicians and five nurse practitioners) from five national sites national reported on the level of work intensity associated with 339 patient visits. Data collection at each site occurred over a 2- to 6 week period; for each provider, five visits were randomly selected from each of 4 randomly selected clinic days, yielding 20 visits per provider. Intensity was measured by the NASA–Task Load Index. Patient and visit characteristics were abstracted from the medical record; provider characteristics were self-reported by questionnaire. RESULTS: Clinical work intensity increased monotonically with level of service and was greatest when the visit involved discussion of either chemotherapy or terminal prognosis. Provider characteristics (including age, sex, and years of experience) were unrelated to intensity. Dimensions of work intensity that correlated directly with level of service included mental, physical, and temporal demand; effort; frustration; and stress. Perceptions of performance and of satisfaction with the visit were unrelated to level of service. Visits related to chemotherapy had greater mental, physical, and temporal demand, and effort, but worse perception of performance. When the visit involved a discussion of a terminal prognosis, greater intensity was reflected in all dimensions; stress was also greater, whereas visit satisfaction was significantly lower. CONCLUSION: Clinical work intensity increases with level of service provided and is greater for visits involving discussion of either terminal prognosis or chemotherapy. [ABSTRACT FROM AUTHOR]

Although lay beliefs about hope have been studied extensively in college student populations, little is known about how working professionals understand hope. Accordingly, the present study examined lay beliefs about hope among healthcare workers through the prism of two prominent models of hope. A directed content analysis of healthcare professionals' qualitative responses indicated that the top seven most prevalent lay beliefs about hope were: cognition, implicit goal, agency thoughts, future orientation, likely, affect, and pathway thoughts. Consistent with the dominant perspective in the hope literature, Snyder's Hope Theory, the three key ingredients of hope—agency thoughts, pathway thoughts, and goals—were all present, albeit to varying degrees. Aspects of Herth's hope model, another prominent conceptualization, were less supported by our findings. When examining whether agency thoughts or pathway thoughts were more prevalent, there were no significant differences. When examining whether cognition or affect were more prevalent, there was a significant difference such that lay theories of hope typically reflected cognitive rather than affective processes. We discuss implications for existing hope models, implications for healthcare professionals, and future research avenues. [ABSTRACT FROM AUTHOR]

The solutions, however, lie in changing the system to better equip the clinician to deal with system dysfunction and moral injury, rather than blaming the clinician for lack of "tolerance of uncertainty." The study reporting an association of physician low "tolerance of uncertainty" with physician burnout[1] errs by framing physician burnout as a physician "coping problem" rather than a healthcare system problem. Like patient safety, burnout is better understood as a failure of "the system" rather than individual providers.[4] Clinician burnout is indeed associated with low-quality care[5]. [Extracted from the article]

Background: Survivors of rectal cancer experience persistent bowel dysfunction after treatments. Dietary interventions may be an effective approach for symptom management and posttreatment diet quality. SWOG S1820 was a pilot randomized trial of the Altering Intake, Managing Symptoms in Rectal Cancer (AIMS‐RC) intervention for bowel dysfunction in survivors of rectal cancer. Methods: Ninety‐three posttreatment survivors were randomized to the AIMS‐RC group (N = 47) or the Healthy Living Education attention control group (N = 46) after informed consent and completion of a prerandomization run‐in. Outcome measures were completed at baseline and at 18 and 26 weeks postrandomization. The primary end point was total bowel function score, and exploratory end points included low anterior resection syndrome (LARS) score, quality of life, dietary quality, motivation, self‐efficacy, and positive/negative affect. Results: Most participants were White and college educated, with a mean age of 55.2 years and median time since surgery of 13.1 months. There were no statistically significant differences in total bowel function score by group, with the AIMS‐RC group demonstrating statistically significant improvements in the exploratory end points of LARS (p =.01) and the frequency subscale of the bowel function index (p =.03). The AIMS‐RC group reported significantly higher acceptability of the study. Conclusions: SWOG S1820 did not provide evidence of benefit from the AIMS‐RC intervention relative to the attention control. Select secondary end points did demonstrate improvements. The study was highly feasible and acceptable for participants in the National Cancer Institute Community Oncology Research Program. Findings provide strong support for further refinement and effectiveness testing of the AIMS‐RC intervention. In this feasibility and preliminary efficacy randomized trial, the Altering Intake, Managing Symptoms in Rectal Cancer (AIMS‐RC) diet modification intervention did not significantly improve total bowel function among survivors of rectal cancer but demonstrated improvements in the frequency of bowel movements and low anterior resection syndrome. SWOG S1820 and the AIMS‐RC intervention were highly feasible and acceptable for participants enrolled via the National Cancer Institute Community Oncology Research Program. [ABSTRACT FROM AUTHOR]

Discusses several issues on internal medicine. Computer searching of medical literature; Nursing home placement of a demented patient; Immune thrombocytopenia in homosexual men.

Background: Financial toxicity is a growing problem in oncology, but no prior studies have prospectively measured the financial impact of cancer treatment in a diverse national cohort of newly diagnosed cancer patients. S1417CD was the first cooperative group-led multicenter prospective cohort study to evaluate financial hardship in metastatic colorectal cancer (mCRC) patients.Methods: Patients aged 18 years or older within 120 days of mCRC diagnosis completed quarterly questionnaires for 12 months. We estimated the cumulative incidence of major financial hardship (MFH), defined as 1 or more of increased debt, new loans from family and/or friends, selling or refinancing home, or 20% or more income decline. We evaluated the association between patient characteristics and MFH using multivariate cox regression and the association between MFH and quality of life using linear regression.Results: A total of 380 patients (median age = 59.9 years) were enrolled; 77.7% were White, 98.0% insured, and 56.5% had annual income of $50 000 or less. Cumulative incidence of MFH at 12 months was 71.3% (95% confidence interval = 65.7% to 76.1%). Age, race, marital status, and income (split at $50 000 per year) were not statistically significantly associated with MFH. However, income less than $100 000 and total assets less than $100 000 were both associated with greater MFH. MFH at 3 months was associated with decreased social functioning and quality of life at 6 months.Conclusions: Nearly 3 out of 4 mCRC patients experienced MFH despite access to health insurance. These findings underscore the need for clinic and policy solutions that protect cancer patients from financial harm. [ABSTRACT FROM AUTHOR]

Background: Hopefulness, whether inherently present (dispositional hope) or augmented (by enhancement techniques), may affect outcomes. This study was performed to determine the association of dispositional hope with survival among patients diagnosed with advanced cancer.Methods: Data from ENABLE (Educate, Nurture, Advise, Before Life Ends), a palliative care intervention, were reanalyzed to determine the association of higher dispositional hope and patient survival. This was a secondary analysis of data combined from the ENABLE II and ENABLE III randomized controlled trials (RCTs) with respect to dispositional hope and survival. A dispositional hope index was created from 3 hope items from 2 validated baseline questionnaires. Dispositional hope and survival data were collected during the 2 RCTs. In ENABLE II, participants were randomly assigned to the ENABLE intervention or to usual care. In ENABLE III, participants were randomly assigned to receive the intervention immediately or 12 weeks after enrollment.Results: In all, 529 persons were included in Cox proportional hazards regression analyses to model the effects of dispositional hope on survival. An initial analysis without covariates yielded a significant effect of hope (Wald statistic, 8.649; hazard ratio, 0.941; confidence interval, 0.904-0.980; P = .003), such that higher dispositional hope was associated with longer survival. In a subsequent analysis that included all covariates, the effect of dispositional hope approached statistical significance (Wald statistic, 2.96; hazard ratio, 0.933; confidence interval, 0.863-1.010; P = .085).Conclusions: Higher levels of dispositional hope were associated with longer survival in patients with advanced cancer. Prospective trials are needed to determine the effects of dispositional and augmented hope on the outcomes of patients with advanced cancer. [ABSTRACT FROM AUTHOR]

Optimal treatment for cancer of unknown primary (CUP) can challenge clinicians. This study sought to determine the efficacy and toxicity of weekly paclitaxel and carboplatin in CUP. Forty-two subjects enrolled. Treatment was intravenous paclitaxel (80 mg/m2) plus carboplatin (AUC = 2) on Days 1, 8, and 15 every 28 days. Seven (18 percent) responded (complete = 2, partial = 5); median survival was 8.5 months; estimated survival (12 and 24-month) was 33 and 17 percent, respectively. Median time to progression was 3.7 months, and estimated progression-free survival (12 and 24 months) was 14 and 7 percent, respectively. Median duration of response was 17.3 months. This combination produced modest antitumor activity in advanced CUP. [ABSTRACT FROM AUTHOR]

Aims: We evaluated the potential effect of sonidegib at an oral dose of 800 mg once daily (QD) on the pharmacokinetics (PK) of the probe drugs warfarin (CYP2C9) and bupropion (CYP2B6). Methods: This was a multicentre, open‐label study to evaluate the effect of sonidegib on the PK of the probe drugs warfarin and bupropion in patients with advanced solid tumours. Cohort 1 patients received a single warfarin 15‐mg dose on Day 1 of the run‐in period and on Cycle 2 Day 22 (C2D22) of sonidegib administration. Cohort 2 patients received a single bupropion 75‐mg dose on Day 1 of run‐in period and on C2D22 of sonidegib administration. Sonidegib 800 mg QD oral dosing began on Cycle 1 Day 1 of a 28‐day cycle after the run‐in period in both cohorts. Results: The geometric means ratios [90% confidence interval] for (S)‐warfarin with and without sonidegib were: area under the concentration–time curve from time 0 to infinity (AUCinf) 1.15 [1.07, 1.24] and maximum plasma concentration (Cmax) 0.88 [0.81, 0.97]; and for (R)‐warfarin were: AUCinf 1.10 [0.98, 1.24] and Cmax 0.93 [0.87, 1.0]. The geometric means ratios [90% confidence interval] of bupropion with and without sonidegib were: AUCinf 1.10 [0.99, 1.23] and Cmax 1.16 [0.95, 1.42]. Sonidegib 800 mg had a safety profile that was similar to that of lower dose sonidegib 200 mg and was unaffected by single doses of the probe drugs. Conclusions: Sonidegib dosed orally at 800 mg QD (higher than the Food and Drug Administration‐approved dose) did not impact the PK or pharmacodynamics of warfarin (CYP2C9 probe substrate) or the PK of bupropion (CYP2B6 probe substrate). [ABSTRACT FROM AUTHOR]

Chronic cancer-related symptoms (stress, fatigue, pain, depression, insomnia) may be linked with sympathetic nervous system over-activation and autonomic imbalance. Decreased heart rate variability (HRV) is an indicator of autonomic dysregulation that is commonly observed among cancer survivors. HRV biofeedback (HRVB) training induces HRV coherence, which maximizes HRV and facilitates autonomic and cardiorespiratory homeostasis. This randomized, wait-list-controlled, pilot intervention trial tested the hypothesis that HRVB can improve HRV coherence and alleviate cancer-related symptoms. The intervention group (n = 17) received 4–6 weekly HRVB training sessions until participants demonstrated skill acquisition. Controls (n = 17) received usual care. Outcomes assessed at baseline and follow-up included 15-min HRV recordings (HRV Coherence Ratio), and symptoms of: stress, distress, post-traumatic stress disorder (PTSD), pain, depression, fatigue, and sleep disturbance. Linear mixed models for repeated measures were used to assess Group-by-Time interactions, pre- versus post-treatment differences in mean symptom scores, and group differences at follow-up. Mean HRV Coherence Ratios (± standard error) improved in the HRVB group at follow-up (baseline: 0.37 ± 0.05, post-intervention: 0.84 ± 0.18, p = 0.01), indicating intervention validity. Statistically significant Group-by-Time interactions indicated treatment-related improvements in HRV Coherence Ratios (p = 0.03, Pre-vs. post-treatment effect size [Cohen's d]: 0.98), sleep symptoms (p = 0.001, d = 1.19), and sleep-related daytime impairment (p = 0.005, d = 0.86). Relative to controls, the intervention group experienced trends toward improvements in stress, distress, fatigue, PTSD, and depression, although no other statistically significant Group-by-Time interactions were observed. This pilot intervention found that HRVB training reduced symptoms of sleep disturbance among cancer survivors. Larger-scale interventions are warranted to further evaluate the role of HRVB for managing symptoms in this population. Registration: NCT 03692624 www.clinicaltrials.gov [ABSTRACT FROM AUTHOR]

Purpose: This randomized controlled trial (RCT: NCT02633748) examined effectiveness of an abbreviated mindfulness program on psychosocial symptoms, behaviors, and inflammation. Methods: Cancer survivors (n = 36) underwent a 4-week mindfulness intervention compared to a breathing control. Data included psychosocial questionnaires, anthropometrics, actigraphy, and blood draws. Clinic visits occurred at baseline, post-intervention, and a 3-month post-follow-up. Results: Compared to baseline, the intervention arm displayed reductions in sedentary time and perceived stress and improvements in subjective sleep quality, and daily steps at post-follow-up. Conclusions: An abbreviated mindfulness intervention in feasible in cancer survivors and signs of efficacy warrant further mindfulness studies among this population. [ABSTRACT FROM AUTHOR]