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We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com. Back to Healio Key takeaways: Patients with serious hematologic cancers can oscillate between being ready for prognostic conversations and not wanting them. Uncertainty can open the door to talks. Patients with serious illness may gradually develop a form of \u201cdouble awareness\u201d \u2014 the ability to hold hope for continued living while also preparing for the possibility of dying. Optimistic prognostic discussions could result in hopeful perspectives, but they may lead to disappointment or depression if treatment does not work. Conversely, clinicians may not provide enough assurance, which may threaten hope and meaningful engagement with life.
An analysis of discussions between clinicians and patients with hematologic malignancies and their caregivers revealed readiness for prognostic dialogue can shift multiple times within a single conversation, and educational training could allow physicians and nurses to provide both hope and realism concurrently. \u201cSerious illness conversations should not be understood as a single disclosure of prognostic information. They are relational and evolving processes that unfold over time,\u201d C\u00e6cilie Borregaard Myrh\u00f8j, RN, MScN, PhD, clinical nurse specialist in the department of hematology at Copenhagen University Hospital \u2013 Rigshospitalet, told Healio. \u201cClinicians do not need to eliminate uncertainty before engaging in these conversations. In fact, acknowledging uncertainty honestly and compassionately may help create space for discussions about both hope and preparation. Our findings suggest that patients can simultaneously hold hope for more time or treatment while also reflecting on future concerns and priorities.\u201d Optimism vs. taking away hope Clinicians who treat people with serious illnesses such as hematologic cancers have the difficult task of discussing the potential for improvement or cure with the reality that not all patients will benefit. \u201cBefore this study, some of our patients told us that conversations sometimes focused mainly on optimistic possibilities and hope for further treatment, while more difficult or realistic scenarios were postponed,\u201d Borregaard Myrh\u00f8j said. \u201cPatients described that when optimistic expectations later no longer held true, it could create feelings of disappointment and sometimes challenge their trust in the clinicians caring for them. \u201cAt the same time, many clinicians were afraid of taking away hope too early, which is also a well-described barrier in the literature. As a result, they often delayed conversations about uncertainty or more serious scenarios until they felt more certain about the prognosis. But in hematology, certainty may come very late, and by then the patient may be critically ill and opportunities for reflection and preparation may already have been lost.\u201d Healio previously reported on a survey about prognostic communication in pediatric oncology, which showed direct and individualized communication could substantially improve these conversations. Borregaard Myrh\u00f8j and colleagues investigated how prognostic dialogue \u201cunfolds\u201d and the impact training could have. They analyzed audio-recorded transcripts of conversations from a randomized clinical trial in Denmark evaluating the Serious Illness Care Program. Clinicians and nurses in the intervention arm received training on subjects such as flexible conversation, communication, trust building and exploration of goals, illness understanding, worries and values. The analysis involved conversations between 25 patient-caregiver dyads (median patient age, 73 years; interquartile range [IQR], 67-79; 56% men; median caregiver age, 66 years; IQR, 52-72; 80% women) and 16 physician-nurse teams (median physician age, 46 years; IQR, 41-48; 69% women; median nurse age, 38 years; IQR, 32-46; 100% women). Patients had multiple myeloma (32%), lymphoma (32%), myelodysplastic syndrome (24%) and acute leukemia (12%). Communication dynamics served as the primary endpoint. \u2018Back and forth\u2019 Prior to conversations with physician-nurse teams, the most common patient- and caretaker-identified treatment goals were life prolongation (patients = 48%; caretakers = 44%), cure (patients = 24%; caretakers = 28%) and symptom relief (both = 24%). Researchers observed two themes from dialogue between clinicians trained in the program and patients and caregivers: Clinicians adapt to the readiness of prognostic discussions, and all parties use prognostic uncertainty to try to balance both hope and reality. Patients and caregivers frequently expressed discordant cues on readiness, shifting between hesitation, openness and withdrawal. Borregaard Myrh\u00f8j described that as \u201cone of the most surprising findings.\u201d \u201cPatients did not simply either \u2018want to know\u2019 or \u2018not want to know,\u2019\u201d she said. \u201cInstead, they often moved back and forth between engaging with difficult realities and stepping away from them. This was a real eye-opener because it highlighted how important it is for clinicians to listen carefully for small emotional or verbal cues and continuously adapt the conversation accordingly \u2014 what we describe as clinical attunement.\u201d Clinicians demonstrated responsiveness to patient and caregiver changes and showed they could adjust within a single conversation. In one example, a 76-year-old patient with multiple myeloma said he did not want any information because, \u201cI don\u2019t think I could handle knowing about it.\u201d During the same conversation, a caregiver expressed the importance of knowing if something changed. The patient then asked, \u201cCan the illness suddenly change and progress?\u201d The clinician responded, \u201cIt is rare for myeloma to change quickly … Usually you first see small changes in the blood samples, and then a month or two later a bit more. At that point, we might adjust treatment, but we usually have time to talk before making changes.\u201d Clinicians frequently had to deal with different levels of readiness between caregivers and patients, necessitating both caution and openness in prognostic information. Patients and caregivers expressed both hope and fear when facing prognostic uncertainty. Clinicians used prognostic uncertainty to set realistic expectations and open the door to possibilities. A physician told one dyad, \u201cWhen we talk about the future, there\u2019s always the possibility that treatment may not work. That uncertainty gives us a chance to discuss plan B. I don\u2019t think we are there<\/p>\n","protected":false},"author":1,"featured_media":2922,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-2921","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/2921","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2921"}],"version-history":[{"count":0,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/2921\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/media\/2922"}],"wp:attachment":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2921"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2921"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2921"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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