Journal Article Annotations
2024, 2nd Quarter

Palliative Care

Annotations by Barbara Lubrano, MD and R Garrett Key , MD
July, 2024

Shared decision-making in palliative cancer care: A systematic review and metasynthesis.
Patient, Caregiver, and Clinician Perceptions of Palliative Care that Influence Access and Use: A Qualitative Meta-Synthesis.
Palliative care patients’ attitudes and openness towards psilocybin-assisted psychotherapy for existential distress.

PUBLICATION #1 — Palliative Care

Shared decision-making in palliative cancer care: A systematic review and metasynthesis.

Jannicke Rabben, Bella Vivat, Mariann Fossum, Gudrun Elin Rohde.

Abstract: Review Palliat Med. 2024 Apr;38(4):406-422. doi: 10.1177/02692163241238384. Epub 2024 Mar 13.

Background:
Shared decision-making is a key element of person-centred care and promoted as the favoured model in preference-sensitive decision-making. Limitations to implementation have been observed, and barriers and limitations, both generally and in the palliative setting, have been highlighted. More knowledge about the process of shared decision-making in palliative cancer care would assist in addressing these limitations.

Aim:
To identify and synthesise qualitative data on how people with cancer, informal carers and healthcare professionals experience and perceive shared decision-making in palliative cancer care.

Design:
A systematic review and metasynthesis of qualitative studies. We analysed data using inductive thematic analysis.

Data sources:
We searched five electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL and Scopus) from inception until June 2023, supplemented by backward searches.

Results:
We identified and included 23 studies, reported in 26 papers. Our analysis produced four analytical themes; (1) Overwhelming situation of ‘no choice’, (2) Processes vary depending on the timings and nature of the decisions involved, (3) Patient-physician dyad is central to decision-making, with surrounding support and (4) Level of involvement depends on interactions between individuals and systems.

Conclusion:
Shared decision-making in palliative cancer care is a complex process of many decisions in a challenging, multifaceted and evolving situation where equipoise and choice are limited. Implications for practice: Implementing shared decision-making in clinical practice requires (1) clarifying conceptual confusion, (2) including members of the interprofessional team in the shared decision-making process and (3) adapting the approach to the ambiguous, existential situations which arise in palliative cancer care.

Annotation

The finding:
Shared decision-making in palliative cancer care is a complex process of many decisions, in a challenging, multifaceted and evolving situation with limited equipoise and choice. Involvement in shared decision-making in this context depends on both individual and system level factors, including the ability and opportunity to build trusting relationships between health care providers, people with cancer and informal carers.

Strength and weaknesses:
A strength of this review and metasynthesis is its integration of the perspectives of all potential participants in shared decision-making, not only people with palliative cancer, but also interprofessional healthcare teams and informal carers. The qualitative metasynthesis design, focussing specifically on palliative cancer care, enables this integration of qualitative findings and so the creation of new, deeper knowledge. Limitations to this study resulted from the variety of papers included. All included studies were conducted in Western/Northern cultural contexts, and so this review presents a particular perspective on shared decision-making, with a particular cultural bias.

Relevance:
CL Psychiatrists are often times called to evaluate and assist cancer patients with regards to their decision-making process involving end-of-life care. The complexities of caring for these patients necessitate that the interprofessional team effectively complement each other to fully engage individuals with palliative cancer and their informal caregivers to the extent they desire.

PUBLICATION #2 — Palliative Care

Patient, Caregiver, and Clinician Perceptions of Palliative Care that Influence Access and Use: A Qualitative Meta-Synthesis.

Kim Slusser, Roque Anthony F Velasco, Heather Coats.

Abstract: Am J Hosp Palliat Care. 2024 Apr;41(4):452-464. doi: 10.1177/10499091231185344. Epub 2023 Jun 22.

Objective:
Benefits of integration of palliative care early in the trajectory of a patient’s serious illness are well established in the literature. Yet, barriers to palliative care access in the US continue to exist. The purpose of this study is to synthesize existing qualitative data of patient, caregiver, and clinician perceptions of palliative care (PC) that influence PC access and use in the US.

Methods:
A formal qualitative meta-synthesis was completed. The meta-synthesis included 1) a systematic literature search of qualitative studies conducted from 2016 to 2021, 2) a critical appraisal of the included studies, and 3) a reciprocal translation of the study’s findings through an interpretive thematic analysis.

Results:
Seven articles met inclusion criteria resulting in a sample size of patients (n=18), caregivers (n=15), and clinicians (n=118). Three themes emerged with associated subthemes: knowledge and opinions of PC (subthemes of patient and caregiver knowledge and awareness and clinician knowledge and beliefs); care coordination and collaboration (subthemes of communication and trust); and social and structural drivers (subthemes of socioeconomic demographics and time and resources).

Conclusions:
This qualitative meta-synthesis identifies barriers and facilitators to palliative care access and use. The study findings illuminate the commonalities and differences of the perceptions of the three key stakeholder groups. In addition, this qualitative meta-synthesis reveals the complexities within the US healthcare system, and the challenges patients and their caregivers face accessing PC.

Annotation

The finding:
Despite a wealth of evidence supporting the benefits of early involvement of palliative care (PC), specifically increase quality of life and increased caregiver burden. (For patients with serious illnesses, barriers persist in hindering early referral and integration of palliative care due to misconceptions, misunderstandings, and stigma surrounding the nature of palliative care and its associated benefits. Over 70% of people in the US have no knowledge of PC, with more prevalence in minority populations. Misconceptions include associating PC with death, equating PC with hospice, and belief that PC requires stopping all other treatment. The data was evaluated with relevance to three key stakeholder groups: clinicians, patients, and caregivers and found similarities in barrier identification across the groups.

Strength and weaknesses:
The review was conducted according to PRISMA standards and included studies were evaluated systematically for quality. There was a greater amount of data included from the physician perspective, which is a limitation, with only one from the patient stakeholder group which introduces some bias risk. The study intentionally included only US based studies and there were limits on details around the influence of socioeconomic factors on PC engagement.

Relevance:
CL psychiatrists practice in areas of medicine that often overlap with the scope of practice for Palliative Medicine. Our two disciplines share a common enemy in underutilization as a consequence of bias and misunderstanding of our potential roles and detailed awareness of this problem can help us to advocate more effectively for integration into care pathways to improve patient care and the effectiveness of our healthcare system overall in alleviating suffering.

PUBLICATION #3 — Palliative Care

Palliative care patients’ attitudes and openness towards psilocybin-assisted psychotherapy for existential distress.

Julia Ruixi Wang, Samuel J Mendez Araque, Gina Micciche, Andrew McMillan, Emily Coughlin, Rosalie Mattiola Diana English , Kristopher Kaliebe.

Abstract: Front Psychiatry. 2024 Apr 18:15:1301960. doi: 10.3389/fpsyt.2024.1301960. eCollection 2024.

Introduction:
Patients with incurable illnesses often experience existential distress, profoundly impacting their well-being. Current medical approaches have limitations in addressing these burdens. Psilocybin, a promising psychedelic compound, may offer therapeutic benefits. This pilot survey study aimed to investigate the attitudes and openness toward psilocybin-assisted psychotherapy (PAT) among patients with incurable illnesses. The objective is to assess patients’ attitudes toward PAT and identify potential barriers and concerns, including exploring the association between beliefs in psilocybin’s therapeutic benefits and interest in receiving this treatment.

Methods:
The survey study was conducted at the Tampa General Hospital Palliative Care Outpatient office in the United States. Participants were 32 English-fluent patients, aged 18 or older, with incurable illnesses. The survey included demographic questions, a validated tool to measure existential distress, and questions about knowledge and concerns regarding psilocybin. Attitudes toward PAT and interest in its future use were assessed using Likert scale responses.

Results:
Among the 31 analyzed participants, 51.6% expressed interest in future psilocybin treatment, while 32.3% did not indicate interest. Belief in the psilocybin’s therapeutic benefits for stress and anxiety significantly correlated with interest in use. Concerns included risk of psychosis, lack of trained providers, and potential for exploitation. No demographic factors were associated with interest or levels of distress.

Conclusions:
This pilot study provides insights into the attitudes and concerns toward PAT among patients with incurable illnesses. Over half of participants expressed interest. However, concerns regarding its use were identified, with patients’ concern for the risk of exploitation associated with PAT as an especially novel concern documented in this patient population. This highlighted the need for further education of risks and benefits or PAT by trained clinicians and rigorous training of clinicians with the establishment of safeguards against exploitation. Further research is necessary to explore the potential benefits of PAT and related non-psilocybin psychedelic compounds in addressing existential distress among patients with incurable illnesses.

Annotation

The finding:
Interest in psilocybin exhibited statistically significant associations with individual convictions about psilocybin’s therapeutic potential, concerns regarding safety risks, and its availability for medical, recreational, and spiritual purposes and not directly related to participants’ overall level of existential distress. Furthermore, patients’ interest correlated with the belief in psilocybin’s ability to address spiritual or emotional distress but not with a history of using medication for depression, anxiety, or other psychological disorder. Thus, personal experience or exposure to psilocybin, psychological medication, or recreational cannabis does not have to be a consideration for future implementation of psilocybin psychotherapy.

Strength and weaknesses:
A limitation found of this study was the need to use shorter surveys that capture essential data, maintain participant engagement and minimize the chances of participant disinterest or agitation toward the end of the survey. The survey also asked primarily about diagnoses without prognosis, and future studies can look at the correlation between prognosis of disease to level of Existential distress (EXD) experienced by the patient. This survey was also limited by small sample size, convenience sample, and non-experimental design. Strengths included that the integration of psilocybin offers a unique and rapid approach to symptom reduction, with lower risks and a potential for sustained therapeutic benefits, with social acceptability within groups of providers and the general population shifting towards support of such therapies.

Relevance:
CL psychiatrists are often times consulted for treatment alternative for depression, anxiety and existential distress in patients with life limiting illnesses. Recent interest in the use of psilocybin, among patients as well as other specialties involved in the care of these patients, has increased. Better understanding of the attitudes towards psilocybin-assisted psychotherapy (PAT) in a population of patients with incurable illnesses can guide CL psychiatrists into more informed treatment recommendations.