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Background: Children and young people with life-limiting conditions and their families need physical and emotional support to manage the challenges of their lives. There is a lack of synthesised qualitative research about how music therapy is experienced by children, young people and their families supported by paediatric palliative care services. Aim: To systematically identify and synthesise qualitative research on experiences of music therapy in paediatric palliative care from stakeholder perspectives. Design: A Qualitative Evidence Synthesis was conducted using Thematic Synthesis. The review protocol was registered in PROSPERO (registration number: CRD42021251025). Data sources: Searches were conducted with no dates imposed via the electronic databases PsycINFO, MEDLINE, EMBASE, AMED and CINAHL in April 2021 and updated in April 2022. Studies were appraised for quality using the Critical Appraisal Skills Programme tool (CASP). Results: A total of 148 studies were found, 5 studies met the eligibility criteria reporting the experiences of 14 mothers, 24 family members and 4 staff members in paediatric palliative care. There were five overarching themes: emotional and physical reprieve, opportunity for normalised experiences, thriving despite life limited condition, enhance family wellbeing and therapeutic relationship central to outcomes. Conclusion: Music therapy provides unique benefits for this paediatric population particularly in supporting child and family wellbeing. The therapeutic relationship, interpersonal skills of the therapist and experience in paediatric palliative care are perceived as central to these positive outcomes. [ABSTRACT FROM AUTHOR]

Background: Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes. Aim: To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes. Design: A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes. Data sources: Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023. Results: The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined. Conclusion: This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed. [ABSTRACT FROM AUTHOR]

The article focuses on introducing the concept of "interpersonal energy" as a metaphor to enhance human connection in end-of-life care, suggesting its potential to support the spiritual needs of patients and families. Topics include the definition and exploration of interpersonal energy, its application in palliative care health professions education, and its implications for fostering compassionate patient care and understanding of the subjective experiences in end-of-life interactions.

Background: The impact of assisted hydration on symptoms and survival at the end of life is unclear. Little is known about optimal strategies for communicating and decision-making about this ethically complex topic. Hydration near end of life is known to be an important topic for family members, but conversations about assisted hydration occur infrequently despite guidance suggesting these should occur with all dying people. Aim: To explore the views and experiences of doctors experienced in end-of-life care regarding communicating with patients and families and making decisions about assisted hydration at the end of life. Design: Qualitative study involving framework analysis of data from semi-structured interviews. Setting/participants: Sixteen UK-based Geriatrics and Palliative Medicine doctors were recruited from hospitals, hospices and community services from October 2019 to October 2020. Results: Participants reported clinical, practical and ethical challenges associated with this topic. The hospital setting provides barriers to high-quality communication with dying patients and their families about assisted hydration, which may contribute to the low incidence of documented assisted hydration-related conversations. Workplace culture in some hospices may make truly individualised decision-making about this topic more difficult. Lack of inclusion of patients in decision-making about assisted hydration appears to be common practice. Conclusions: Proactive, routine discussion with dying people about hydration-related issues is indicated in all cases. There is room for debate regarding the limits of shared decision-making and the benefits of routine discussion of assisted hydration with all dying people. Clinicians have to navigate multiple barriers as they strive to provide individualised care. [ABSTRACT FROM AUTHOR]

Background: Palliative care professionals have had to adapt to rapidly changing COVID-19 restrictions with personal protective equipment and physical distancing measures impacting face-to-face communication with patients and relatives. Aim: To explore the narratives of palliative care doctors working during the pandemic to understand their experiences at a personal and professional level. Design: In-depth narrative interviews were carried out via video call. Interviews were transcribed verbatim and analysed using a joint paradigmatic and narrative approach to elucidate common themes and closely explore individual narratives. Setting/participants: Eight palliative care doctors who had worked on a hospice inpatient unit in the UK before and during the pandemic were recruited from two hospices in Scotland. Results: Three intersecting themes are described, the most significant being moral distress. Participants articulated a struggle to reconcile their moral convictions with the restrictions enforced, for example, wanting to provide support to patients through physical proximity but being unable to. To differing degrees, this resulted in internal conflict and emotional distress. Two further themes arose: the first concerned a loss of humanity in interaction and a striving to re-humanise communication through alternative means; the second being a change in staff morale as the pandemic progressed. Conclusions: Restrictions had a considerable impact on palliative care doctors' ability to communicate with and comfort patients which led to moral distress and contributed to decreasing morale. Future research could explore moral distress in palliative care settings internationally during the pandemic with a view to compare the factors affecting how moral distress was experienced. [ABSTRACT FROM AUTHOR]

Background: Lesbian, gay, and bisexual (LGB) older women have unmet communication needs around palliative and end-of-life care. Past research has found communication differences for LGB women patients. Consequently, older LGB women may experience healthcare communication barriers around advance care planning. Aim: To explore experiences of bereaved LGB older women to understand perspectives regarding advance care planning communication between clinicians, patients, and dyads. Design: Guided by queer gerontology as a theoretical framework, this qualitative descriptive study employed individual interviews with purposively recruited participants. Interviews were conducted in person using a semi structured protocol and analyzed using inductive thematic analysis. Setting/participants: Sixteen LGB women, age 60 years or older from across the United States who had lost a spouse/partner within the past 5 years. Results: Four main themes emerged from the transcripts, LGB older women: (1) experience unclear advance care planning communication and end-of-life care support from clinicians, (2) often avoid advance care planning discussions with spouse or partners, (3) lack of knowledge about palliative or end-of-life care, and (4) have more positive experiences when there is consistent communication with spouse or partner and clinicians during a spouse/partner's illness and end-of-life. Discussion: While certain experiences and opinions may reflect those of non-LGB older adults, novel advance care planning barriers exist for LGB older women. Greater understanding among clinicians is needed regarding advance care planning conversations with LGB dyads. We recommend four improvements in training, recognition, acceptance, and dyad-based communication interventions. [ABSTRACT FROM AUTHOR]

Background: Intensive care doctors have to find the right balance between sharing crucial decisions with families of patients on the one hand and not overburdening them on the other hand. This requires a tailored approach instead of a model based approach. Aim: To explore how doctors involve families in the decision-making process regarding life-sustaining treatment on the neonatal, pediatric, and adult intensive care. Design: Exploratory inductive thematic analysis of 101 audio-recorded conversations. Setting/participants: One hundred four family members (61% female, 39% male) and 71 doctors (60% female, 40% male) of 36 patients (53% female, 47% male) from the neonatal, pediatric, and adult intensive care of a large university medical center participated. Results: We identified eight relevant and distinct communicative behaviors. Doctors' sequential communicative behaviors either reflected consistent approaches—a shared approach or a physician-driven approach—or reflected vacillating between both approaches. Doctors more often displayed a physician-driven or a vacillating approach than a shared approach, especially in the adult intensive care. Doctors did not verify whether their chosen approach matched the families' decision-making preferences. Conclusions: Even though tailoring doctors' communication to families' preferences is advocated, it does not seem to be integrated into actual practice. To allow for true tailoring, doctors' awareness regarding the impact of their communicative behaviors is key. Educational initiatives should focus especially on improving doctors' skills in tactfully exploring families' decision-making preferences and in mutually sharing knowledge, values, and treatment preferences. [ABSTRACT FROM AUTHOR]

Background: In 2020, the COVID-19 pandemic caused an acute risk of deterioration and dying for many, and an urgent need to start advance care planning. Aim: To explore how general practitioners (GPs) experienced discussing values, goals and preferences with patients during COVID-19. Design and setting: Qualitative research in general practice. Methods: Semi-structured interviews for which Dutch GPs were recruited via purposive sampling. Content analysis was used. Results: Fifteen GPs were interviewed. Six themes were identified: (i) urge of advance care planning, (ii) the GP's perceived role in it, (iii) preparations for it, (iv) (proactively) discussing it, (v) essentials for good communication and (vi) advance care planning in the (near) future. Calls for proactively discussing advance care planning in the media and in COVID-guidelines caused awareness of it's importance. GPs envisaged an important role for themselves in initiating it, especially with patients at risk to deteriorate or die from COVID-19. Timing advance care planning appeared difficult but crucial. The recommended digital way of communication was considered problematic due to missing nonverbal communication and difficulties in involving relatives. It was noted that admission to the ICU, which was hardly discussed before the COVID-19 pandemic, should remain a topic during advance care planning. Conclusion: The COVID-19 pandemic brought advance care planning into a new light, GPs were more experienced with discussing it and patients were more aware of their frailty. Because of the nearing 'grey wave', advance care planning should remain top priority. Therefore, it should be central in GP and post-academic training. [ABSTRACT FROM AUTHOR]

Background: One of the main obstacles of providing home-based palliative care to transfusion-dependent hematology patients is the lack of home transfusions services. While healthcare professionals are concerned with safety and cost of home transfusions, the attitude of the patients toward home transfusions are mostly unknown. Aim: To obtain quantitative data regarding the willingness and concerns of transfusion-dependent patients with hematological diseases toward the option of home transfusions. Design: A cross sectional survey including a self-administered questionnaire in one of the three main spoken languages in Israel was administered to patients in 17 hospital hematology outpatient clinics between May 2019 and March 2020. Results: About 52% of 385 patients that participated in the survey preferred home transfusions to hospital transfusions. Gender, age, education, or type of disease were not associated with preference for home transfusions, nor were hospital location or its size. The likelihood to prefer home transfusions was significantly higher among the Hebrew-speakers and those who had not experienced adverse effects previously. The most significant factor associated with preference of home transfusions was a perceived negative effect of hospital-based transfusion on quality of life. The main reason to reject home transfusions was fear of possible adverse effects and concerns over losing contact with the medical staff at the treating hospital. Conclusion: These data suggest that a significant portion of transfusion-dependent patients in Israel view home transfusions as a preferred treatment option and that its successful implementation requires maintaining ongoing contact with the treating hospital. [ABSTRACT FROM AUTHOR]

Background: Chronic obstructive pulmonary disease is associated with an uncertain trajectory, which challenges prognostication and means that most patients are not involved in advance care planning and do not receive palliative and end-of-life care. Aim: To understand the preferences of patients with chronic obstructive pulmonary disease for discussions about palliative and advance care planning with clinicians. Design: Semi-structured interviews were conducted with patients with chronic obstructive pulmonary disease. Data analysis was guided by principles of interpretative phenomenological analysis, of which symbolic interactionism and interpretation principles were employed throughout. Setting/Participants: A total of 33 British patients with chronic obstructive pulmonary disease at different stages of their disease trajectory were recruited. Results: Patients preferred to discuss palliative care with clinicians they perceived had greater levels of competency and authority in care and with whom they had an established relationship, usually a specialist. Patients favoured large amounts of information about treatments and care, but reported a lack of illness-related information and problems accessing appointments with clinicians. Consequently, patients deferred discussions to the future, usually once their condition had deteriorated significantly or planned to wait for clinicians to initiate conversations. This was not rooted in patient preferences, but related to clinicians' lack of time, absence of an established relationship and belief that appointments were for managing current symptoms, exacerbations and disease factors rather than future care and preferences. Conclusion: Different perceptions, competing priorities and service rationing inhibit patients from initiating early discussions with clinicians, so palliative care conversations should be initiated by respiratory-expert clinicians who know the patient well. After a sudden deterioration in the patient's condition may be a suitable time. [ABSTRACT FROM AUTHOR]

Background: Factors facilitating/hindering concordance between preferred and received life-sustaining treatments may be distorted if preferences and predictors are measured long before death. Aim: To examine factors facilitating/hindering concordance between cancer patients' preferred and received life-sustaining-treatment states in their last 6 months. Design: Longitudinal, observational design. Setting/participants: States of preferred and received life-sustaining treatments (cardio-pulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, and nasogastric tube feeding) were examined in 218 Taiwanese cancer patients by a latent transition model with hidden Markov modeling. Multivariate logistic regression modeling was used to examine factors facilitating/hindering concordance between preferred and received life-sustaining-treatment states. Results: Concordance between preferred and received life-sustaining-treatment states was poor (40.8%, kappa value (95% confidence interval): 0.05 [–0.03, 0.14]). Patients who accurately understood their prognosis and preferred comfort care were significantly more likely to receive preferred life-sustaining treatments before death than those who did not know their prognosis but wanted to know, those who were uniformly uncertain about what life-sustaining treatments they preferred to receive, and those who preferred nutritional support but declined other life-sustaining treatments. Patient age, physician–patient end-of-life-care discussions, symptom distress, and functional dependence were not associated with concordance between preferred and received life-sustaining-treatment states. Conclusion: Prognostic awareness and preferred states of life-sustaining treatments were significantly associated with concordance between preferred and received life-sustaining-treatment states. Personalized interventions should be developed to cultivate terminally ill cancer patients' accurate prognostic awareness, allowing them to formulate realistic life-sustaining-treatment preferences and facilitating their receiving value-concordant end-of-life care. [ABSTRACT FROM AUTHOR]

Background: Patients with advanced chronic obstructive pulmonary disease have difficulty reporting their holistic support needs to health care professionals, undermining delivery of person-centred care. We lack tools that directly support patients with this. Aim: To develop an evidence-based, designed-for-purpose, tool to enable patients to directly identify and express support needs to health care professionals. Design: Two-stage qualitative study. Stage 1: domains of support need were identified through a systematic review, analysis of an established qualitative dataset and patient/carer focus groups. Stage 2: draft tool developed using the identified domains of need and then refined through feedback from patients, carers and health care professionals, ensuring acceptability and suitability. Setting/participants: Stage 1 patients/carers recruited via four primary care practices and two patient support groups (East of England). Stage 2 health care professionals recruited via the Clinical Research Network and local community trust and patients/carers through two further practices and two additional support groups (East of England). In total, 57 patients, carers and health care professionals participated. Results: A comprehensive set of evidence-based support domains (for example: overcoming boredom or loneliness, knowing what to expect in the future) was identified and formulated into questions. The resulting tool asks patients to consider whether they need more support in 15 broad areas. Patients, carers and clinical stakeholders broadly endorsed the tool's content and wording. Conclusion: The Support Needs Approach for Patients (SNAP) tool is a concise evidence-based tool designed to help patients with advanced chronic obstructive pulmonary disease identify and express their support needs to enable delivery of person-centred care. [ABSTRACT FROM AUTHOR]

Background: As modern medicine extends the life expectancy of patients with life-limiting illnesses and health system resource pressures intensify, palliative care physicians increasingly need to transfer stable patients from specialist palliative care units to nursing homes. The experience of palliative care physicians in decision-making and communicating with patients and families about the need for this transition is underexplored in the literature. Aim: This study aimed to explore the experiences of and communication techniques used by palliative care physicians as they consider and discuss nursing home placements for their patients. Design: A qualitative approach using semi-structured interviews was used. Interviews were transcribed verbatim and analysed using thematic analysis. Setting/participants: Purposive sampling was used to recruit 18 Australian palliative care physicians known for their interest or strength in communication skills across a range of palliative care settings. Results: Themes emerged from domains of physician experience (abandonment, systemic pressures, prognostic uncertainty, exacerbation of loss, and restoring resilience) and communication strategies (forecasting, checking in, provide context, and acknowledging grief). Conclusion: This study highlights the tension Australian palliative care physicians experience when transferring palliative care patients to nursing home and the complexity involved in decision-making. Physicians identified several communication strategies to engage patients and families to ease the transition. [ABSTRACT FROM AUTHOR]

Background: Discharge from inpatient palliative care units to long-term care can be challenging. In the United Kingdom, hospice inpatients move to a care home if they no longer require specialist palliative care and cannot be discharged home. There is evidence to suggest that patients and families find the prospect of such a move distressing. Aim: To investigate the issues that arise when patients are transferred from hospice to care home at the end of life, from the perspective of the hospice multidisciplinary team. Design: A qualitative study, using thematic analysis to formulate themes from focus group discussions with hospice staff. Setting/participants: Five focus groups were conducted with staff at five UK hospices. Participants included multidisciplinary team members involved in discharge decisions. All groups had representation from a senior nurse and doctor at the hospice, with group size between three and eight participants. All but one group included physiotherapists, occupational therapists and family support workers. Results: A major focus of group discussions concerned dilemmas around discharge. These included (1) ethical concerns (dilemmas around the decision, lack of patient autonomy and allocation of resources); (2) communication challenges; and (3) discrepancies between the ideals and realities of hospice palliative care. Conclusion: Hospice palliative care unit staff find discharging patients to care homes necessary, but often unsatisfactory for themselves and distressing for patients and relatives. Further research is needed to understand patients' experiences concerning moving to care homes for end of life care, in order that interventions can be implemented to mitigate this distress. [ABSTRACT FROM AUTHOR]

Background: An increasing number of young people are living with life-limiting conditions. Current research about advance care planning for young people indicates differing experiences for those involved. Understanding how far young people are engaged in their own advance care plan is important to shape future practice and facilitate young people's wishes. Aim: To identify and assess the current evidence to determine the barriers and facilitators to the engagement of young people in their own advance care planning process. Design: A systematic narrative synthesis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using a quality assessment framework previously used in similar research. Data sources: CINAHL Complete, MEDLINE, PubMed and PsycINFO were searched for articles published between 1 January 1990 and 31 October 2017. Grey literature was searched using Google Scholar and Open Grey. Results: Most studies related to the engagement of young people were conducted in hospitals or other institutions. Research reported not only the aim to include young people in their own advance care planning but also potential barriers to engagement. Barriers include poor communication, conflict within relationships of those in the planning process and patchy education and training for healthcare professionals. Some existing studies are characterised by a lack of rigorous, high-quality research, limiting their impact. Conclusion: Irrespective of setting, engagement of young people would benefit their advance care planning. More detailed, highquality research is needed to understand the extent of the barriers to young people's engagement in their own advance care plan and how to facilitate their involvement. [ABSTRACT FROM AUTHOR]

Background: Integrated palliative care is correlated with earlier end-of-life discussion and improved quality of life. Patients with haematological malignancies are far less likely to receive care from specialist palliative or hospice services compared to other cancers. Aim: The main goal of this study was to determine hematologists' barriers to end-of-life discussions when potentially fatal hematological malignancies recur. Design: Qualitative grounded theory study using individual interviews. Setting/participants: Hematologists (n = 10) from four hematology units were asked about their relationships with their patients and their attitudes toward prognosis and end-of-life discussions at the time of recurrence. Results: As long as there are potential treatments, hematologists fear that end-of-life discussions may undermine their relationship and the patient's trust. Because of their own representations, hematologists have great difficulty opening up to their patients' end-oflife wishes. When prognosis is uncertain, negative outcome, that is, death, is not fully anticipated. Persistent hope silences the threat of death. Conclusion: This study reveals some of the barriers clinicians face in initiating early discussion about palliative care or patients' endof- life care plan. These difficulties may explain why early palliative care is little integrated into the hematology care model. [ABSTRACT FROM AUTHOR]

Background: General practitioners have overall responsibility for community care, including towards end of life. Current policy places generalists at the centre of palliative care provision. However, little is known about how patients and carers understand the general practitioner's role. Aims: To explore patient and carer perspectives of (1) the role of the general practitioner in providing palliative care to adult patients and (2) the facilitators and barriers to the general practitioner's capacity to fulfil this perceived role. Design: Systematic literature review and narrative synthesis. Data sources: Seven electronic databases (MEDLINE, Embase, PsycINFO, BNI, CINAHL, Cochrane and HMIC) were searched from inception to May 2017. Two reviewers independently screened papers at title, abstract and full-text stages. Grey literature, guideline, hand searches of five journals and reference list/citation searches of included papers were undertaken. Data were extracted, tabulated and synthesised using narrative, thematic analysis. Results: A total of 25 studies were included: 14 employed qualitative methods, 8 quantitative survey methods and 3 mixed-methods. Five key themes were identified: continuity of care, communication between primary and secondary care, contact and accessibility, communication between general practitioner and patient, and knowledge and competence. Conclusion: Although the terminology and context of general practice vary internationally, themes relating to the perceived role of general practitioners were consistent. General practitioners are considered well placed to provide palliative care due to their breadth of clinical responsibility, ongoing relationships with patients and families, and duty to visit patients at home and coordinate healthcare resources. These factors, valued by service users, should influence future practice and policy development. [ABSTRACT FROM AUTHOR]

Background: In many countries, achieving a home death represents a successful outcome from both a patient welfare and commissioning viewpoint. Significant variation exists in the proportion of home deaths achieved internationally, with many countries unable to meet the wishes of a large number of patients. This review builds on previous literature investigating factors influencing home death, synthesising qualitative research to supplement evidence that quantitative research in this field may have been unable to reach. Aim: To identify and understand the barriers and facilitators influencing death at home. Design: Meta-ethnography. Data sources: The review adhered to the PRISMA guidelines. A systematic literature search was conducted using five databases: PubMed, EMBASE, Ovid, CINAHL and PsycINFO. Databases were searched from 2006 to 2016. Empirical, UK-based qualitative studies were included for analysis. Results: A total of 38 articles were included for analysis. Seven overarching barriers were identified: lack of knowledge, skills and support among informal carers and healthcare professionals; informal carer and family burden; recognising death; inadequacy of processes such as advance care planning and discharge; as well as inherent patient difficulties, either due to the condition or social circumstances. Four overarching facilitators were observed: support for patients and healthcare professionals, skilled staff, coordination and effective communication. Conclusion: Future policies and clinical practice should develop measures to empower informal carers as well as emphasise earlier commencement of advance care planning. Best practice discharge should be recommended in addition to addressing remaining inequity to enable non-cancer patients greater access to palliative care services. [ABSTRACT FROM AUTHOR]

Background: Particularly at the end of life, treatment decisions should be shared and incorporate patients’ preferences. This study examines elaboration and preference construction. Aim: To examine the values, appraisals and preferences that patients express, as well as the oncologists’ communicative behaviour that facilitates these expressions in consultations on palliative chemotherapy. Design: Verbatim transcripts of audio-recorded consultations (n = 60) were analysed in MAXqda10 software. Two independent coders identified and categorised patients’ preference-related utterances and oncologists’ utterances, preceding and following such expressions. Setting/participants: Cancer patients (n = 41) with a median life expectancy <1 year and oncologists (n = 13) meeting with them in either initial or evaluative follow-up consultations. Results: Most frequent were patients’ expressions of treatment preferences (65% of consultations), often the simple wish to have treatment. Expressions of underlying values (48%) and appraisals of treatment aspects (50%) were less common. Most preference-related utterances concerned single statements (59%); in 51% of the consultations, true dialogue was observed. Preference-related utterances were least common in follow-up consultations concerning stable disease or response. Preference-related fragments were patient-initiated (42%), oncologist-facilitated (28%) or oncologist-invited (30%). Oncologist responses likely to trigger more preference-related talk were showing empathy, checking and probe questioning. Likely to reduce space were providing information, personally agreeing and neutral responses. Conclusion: Elaboration and joint preference construction is not standard practice in consultations on palliative chemotherapy. Oncologists may benefit from realising this and training skills that support this key step of shared decision making. Also, repeated shared decision making throughout the course of palliative chemotherapy should be stimulated. [ABSTRACT FROM AUTHOR]

Background: No systematic meta-analysis is available on the prevalence of cancer patients' accurate prognostic awareness and differences in accurate prognostic awareness by publication year, region, assessment method, and service received. Aim: To examine the prevalence of advanced/terminal cancer patients' accurate prognostic awareness and differences in accurate prognostic awareness by publication year, region, assessment method, and service received. Design: Systematic review and meta-analysis. Methods: MEDLINE, Embase, The Cochrane Library, CINAHL, and PsycINFO were systematically searched on accurate prognostic awareness in adult patients with advanced/terminal cancer (1990-2014). Pooled prevalences were calculated for accurate prognostic awareness by a random-effects model. Differences in weighted estimates of accurate prognostic awareness were compared by meta-regression. Results: In total, 34 articles were retrieved for systematic review and meta-analysis. At best, only about half of advanced/terminal cancer patients accurately understood their prognosis (49.1%; 95% confidence interval: 42.7%-55.5%; range: 5.4%-85.7%). Accurate prognostic awareness was independent of service received and publication year, but highest in Australia, followed by East Asia, North America, and southern Europe and the United Kingdom (67.7%, 60.7%, 52.8%, and 36.0%, respectively; p = 0.019). Accurate prognostic awareness was higher by clinician assessment than by patient report (63.2% vs 44.5%, p < 0.001). Conclusion: Less than half of advanced/terminal cancer patients accurately understood their prognosis, with significant variations by region and assessment method. Healthcare professionals should thoroughly assess advanced/terminal cancer patients preferences for prognostic information and engage them in prognostic discussion early in the cancer trajectory, thus facilitating their accurate prognostic awareness and the quality of end-of-life care decision-making. [ABSTRACT FROM AUTHOR]

Background: Despite the importance of accurate prognostic understanding in patients with advanced cancer, there is little consensus around how to conceptualize and measure the multidimensional construct. Most studies focus on single aspects of prognostic understanding (e.g., curability) that clinicians have identified as important; no previous research has asked patients how they define "prognosis.", Aim: The present study examined how patients with advanced cancer conceptualize their "prognosis." It also explored how patients assigned value to prognostic information and the impact of prognosis on life perspectives., Design: A phenomenological approach was used to analyze semi-structured interviews with individuals with advanced cancer to examine how patients define prognosis., Setting/participants: English and Spanish-speaking patients with advanced cancer ( N  = 29) were recruited from ambulatory clinics at a comprehensive cancer center in New York City., Results: To conceptualize prognosis, patients focused on concrete medical data, anticipated survival and quality of life, impact on meaningful life events, uncertainty, and physician affect. They discussed the importance of maintaining normalcy despite prognosis, knowledge as a form of coping, information reframing, and altered decision-making as means of coping with prognostic information., Conclusions: Given the range of ways patients define prognosis and assign value to prognostic information, clinicians should incorporate a thorough assessment of patient information preferences, values, and coping styles when engaging in end-of-life discussions. Trainings should emphasize the importance of nonverbal cues (i.e., affect management, body language) in prognostic disclosure.

The author discusses the relationship between palliative care physicians and assisted dying, or euthanasia, legislation, including the implications surrounding the legalisation of assisted dying within the palliative care patient-physician relationship. It comments on the Italian politics surrounding the possible legalisation of assisted dying.

Background: Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient’s wishes or delayed physician–family communications on preference. Aim: To determine whether advance care documentation encourages healthcare professional’s timely engagement in end-of-life discussions. Design: Systematic review of the English language articles published from January 2000 to April 2015. Data sources: EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists. Results: A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available. Conclusion: Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians’ confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review. [ABSTRACT FROM AUTHOR]

Background: Dying physicians may present unique challenges to palliative care teams. Studies of dying physicians are scarce, but those that exist suggest a potential absence of a coordinating clinician, prolongation of curative treatments, resistance to palliative care input and barriers to discussing psychosocial needs. Aim: The aim was to describe and examine the care provided to physician-patients referred to an Australian palliative care service, and to identify issues faced by the physician-patient and by the treating team. Design and participants: A retrospective case-note audit of the case notes of medical practitioners referred for palliative care and dying between January 2007 and April 2013 was conducted. Results: There was evidence of medically qualified friends or family members initiating referrals and directing treatment decisions. There was some evidence of increased consultant-led decision-making and bypassing of usual referral pathways and systems for providing after-hours advice and calling consultants directly. There also appeared to be some reluctance by junior doctors to make decisions, because of the patient’s desire for consultant-level advice only. Conclusion: This study adds to the growing body of literature that identifies the potential difficulties associated with caring for medical practitioners. By understanding some of the complexity of this particular doctor–patient relationship, clinicians can approach the management of physician-patients facing the end of their lives with a more sound understanding of their particular care needs. [ABSTRACT FROM AUTHOR]

Background: Discussion of religion and/or spirituality in the medical consultation is desired by patients and known to be beneficial. However, it is infrequent. We aimed to identify why this is so. Aim: We set out to answer the following research questions: Do doctors report that they ask their patients about religion and/or spirituality and how do they do it? According to doctors, how often do patients raise the issue of religion and/or spirituality in consultation and how do doctors respond when they do? What are the known facilitators and barriers to doctors asking their patients about religion and/or spirituality? Design: A mixed qualitative/quantitative review was conducted to identify studies exploring the physician’s perspective on discussion of religion and/or spirituality in the medical consultation. Data sources: We searched nine databases from inception to January 2015 for original research papers reporting doctors’ views on discussion of religion and/or spirituality in medical consultations. Papers were assessed for quality using QualSyst and results were reported using a measurement tool to assess systematic review guidelines. Results: Overall, 61 eligible papers were identified, comprising over 20,044 physician reports. Religion and spirituality are discussed infrequently by physicians although frequency increases with terminal illness. Many physicians prefer chaplain referral to discussing religion and/or spirituality with patients themselves. Such discussions are facilitated by prior training and increased physician religiosity and spirituality. Insufficient time and training were the most frequently reported barriers. Conclusion: This review found that physician enquiry into the religion and/or spirituality of patients is inconsistent in frequency and nature and that in order to meet patient needs, barriers to discussion need to be overcome. [ABSTRACT FROM AUTHOR]

The article analyzes experiences of pediatric clinicians regarding existing practices of pediatric advance care planning prior to implementation of Medical Orders for Life-Sustaining Treatment (MOLST) in Maryland and impact of MOLST on communication, documentation and workflow across health-care settings. It is noted that communication training has been perceived necessary for successful implementation of MOLST

The article presents a cross-sectional survey study that examined the correlates of physician-patient end-of-life-care discussions and their associations with patient end-of-life-care preferences. The study found that physician-patient end-of-life-care discussions are negatively associated with the aggressive end-of-life care preferences of terminally ill cancer patients. It also indicated that 7.8% of the respondents discussed end-of-life-care preferences with their physicians.

The article presents information on a study on the role of doctors in helping dying cancer patients to achieve peace. The study aimed at understanding the features of a peaceful patient and preferences of patients about the role of the doctor in facilitating peace. The study was conducted on 15 dying cancer patients. It is concluded that communication from doctors on prognosis can promote spiritual well-being in cancer patients.

The article discusses a study which aims to examine how to avoid hospitalizations in the last three months of life based on the insights of general practitioners in the Netherlands. The study conducted in-depth interviews among general practitioners after conducting a cross-sectional nationwide questionnaire study. Results show that 46% of the avoidable hospitalizations can be prevented by proactive patient communication while 28% by additional care at home.

The article presents a study which explores the barriers and facilitators of family physicians' early identification of palliative care needs. The researchers conducted interviews with patients with diseases including heart failure, dementia and cancer, and used thematic analysis to derive themes covering barriers and facilitators. Results found barriers and facilitators relate to perceived role of family physician, communication styles and continuity of care.

The article discusses research which examined healthcare professionals' stand on palliative care patients' hope described in literature. It cites the association of palliative care patients' hope with their psycho-spiritual well-being. Findings revealed that 31 literary articles were of sufficient quality and described perspectives of nurses or physicians. The types of perspectives on hope of palliative care patients include realistic, functional and narrative perspective.

The article reports a study which discusses the effects of an individualized training program regarding end-of-life communication on the doctor's acceptability, confidence and communication skills in hospital settings. The results revealed that the training was useful for the doctors. It was also observed that significant improvements were found in doctor's communication skills and sense of personal accomplishment after the program.

The article discusses development of a model for breaking bad news to people with intellectual disabilities(IDs). The findings based on survey feedback for preliminary model was collected from 60 out of 109 participants including people with IDs, family carers, ID professionals, general health professionals and other stakeholders recommends to consider aspects of capacity, people and support to derive robust outcome measures for developing new model for breaking bad news to people with ID.

While effective general practitioner (GP)–patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP–patient communication in palliative care. In a systematic review seven computerized databases were searched to find empirical studies on GP–patient communication in palliative care. Fifteen qualitative studies and seven quantitative questionnaire studies were included. The main perceived barriers were GPs’ lack of availability, and patients’ and GPs’ ambivalence to discuss ‘bad prognosis’. Main perceived facilitators were GPs being available, initiating discussion about several end-of-life issues and anticipating various scenarios. Lack of availability and failure to discuss former mistakes appear to be blind spots of GPs. GPs should be more forthcoming to initiate discussions with palliative care patients about prognosis and end-of-life issues. Empirical studies are needed to investigate the effectiveness of the perceived barriers and facilitators. [ABSTRACT FROM PUBLISHER]

Palliative care exists in a variety of settings and palliative care teams form many guises within this. A Palliative Medicine Outpatient Clinic (PMOC) exists to meet the flexible provision of the needs and preferences of individuals within whatever care setting they reside. This explorative study used a qualitative methodology, capturing patients’ actual experience of care in preference to their satisfaction, as this is a more accurate measure of how and what patients judge as important in their healthcare. The overall themes in this paper point to the ‘value’ that patients perceived from attending the PMOC and how important the clinics were to clinicians that provided the care. The clinic facilitates much more than symptom control and here lies the challenge in how we convert the very positive experience of individuals into a language of outcome measures that captures the ‘essence’ of our work in this fiscally driven health economy. [ABSTRACT FROM AUTHOR]

Little has been reported regarding the nature of home visits by palliative care specialist physicians to assist in the management of complex cases. We determined the characteristics, actionable clinical findings and recommendations made during consecutive home visits conducted by a specialist physician for patients registered with a community palliative care service. Patient demographic information and clinical records were reviewed. Ninety-one patients received a total of 104 home and residential facility visits. Median patient age was 59 (Q1-Q3, 43-72). Ten children (under the age of 14) received a total of 15 visits. Seventy-three patients (80%) had a cancer diagnosis. Median visit duration was 60 min (Q1-Q3, 45-60). The major actionable clinical findings were pain (120), gastrointestinal (115), neuropsychiatric (58), mouth and skin (33) and respiratory (29). One-third of recommendations involved changes in analgesia regimen (opioids 67, adjuvants 44). The specialist physician home visit resulted in multiple patient care recommendations. This information may help palliative care programmes improve their care for patients and families in the community. [ABSTRACT FROM AUTHOR]

Many of the drugs prescribed commonly to palliative care patients have potentially significant side-effects and are of unproven benefit. The acquisition of evidence to support the prescribing of these drugs has been very slow. Single patient trials (SPTs) (also known as n-of-1 trials) offer a potential means of obtaining the evidence necessary to support or refute the use of several of the drugs and interventions whose use is currently based on physician experience or anecdote alone. A list of SPTs considered "most urgent", for commonly employed treatments and for the most common and most troublesome symptoms in palliative care is presented. These are drugs for which the gap between evidence and practice is greatest, where the evidence of efficacy is most lacking, where significant side effects potentially lead to the greatest morbidity, or where cost is a major patient burden. Although not all the drugs used in palliative care are suitable, SPTs provide a potential alternative method of gathering evidence in palliative care. [ABSTRACT FROM AUTHOR]

Outpatient palliative care can provide significant benefits to seriously ill patients, but several barriers to appropriate referrals remain. No study has examined the physician factors associated with referral to outpatient palliative care. To determine physician factors, with a focus on physician beliefs, associated with referral to palliative care. Cross-sectional study of 170 primary care physicians at Kaiser Permanente (KP), a large non-profit Health Maintenance Organisation (HMO), using a self-administered questionnaire. Of the 145 respondents, 100 (70%) reported referring any patients to the palliative care program in the prior year, with a median of 3 referrals (interquartile range 2, 6). Factors associated with referral included working at KP between 10 and 20 years as compared to <10 years [Odds ratio [OR] 6.29 (95% confidence interval [CI] 1.38, 28.6)] and having personal experience with palliative care [OR 2.13 (95% CI 0.95, 4.976)]. None of the beliefs scales was associated with referral. Physician characteristics other than their beliefs about palliative care played a significant role in determining referral. Palliative care programs should aim to increase their visibility in the outpatient setting to increase referrals by primary care physicians. Tools that help physicians identify seriously ill patients who could benefit from palliative care may also serve to increase appropriate referrals. [ABSTRACT FROM AUTHOR]

This study estimates the frequency of different medical end-of-life decisions (ELDs) made in the United Kingdom (UK) in 2007-2008, comparing these with 2004. Postal survey was carried out with 8857 medical practitioners, of whom 3733 (42%) practitioners replied, with 2869 having attended a person who died in the previous year. The proportion of UK deaths involving (1) voluntary euthanasia (0.21%; CI: 0-0.52), (2) physician-assisted suicide (0.00%) and (3) ending of life without an explicit request from the patient (0.30%; CI: 0-0.60) is low. Better questions about ELDs showed both non-treatment decisions (21.8%; CI: 19.0-24.5) and double effect measures (17.1%; CI: 14.6-19.6) to be much less common than suggested in earlier estimates, rarely involving intent to end life or being judged to have shortened life by more than a day. Continuous deep sedation (16.5%; CI: 14.3-18.7) is relatively common in UKmedical practice, particularly in hospitals, home care settings and with younger patients. Further findings about the distribution of ELDs across subgroups are also reported. Survey research in this area requires careful control over question wording if valid estimates and comparisons of the prevalence of ELDs are to be made. The high rate of sedation compared with other countries may be a cause for concern. [ABSTRACT FROM AUTHOR]

Background: It is possible that patients with advanced cancer, who are from the medical profession, have different or additional care needs than other patients. Previous training, professional experiences and access to information and services may influence their needs and subsequent illness behaviour. Caring for 'one of our own' may also evoke particular feelings and emotions from health professionals involved in their care and pose unique challenges in the delivery of equitable patient-centred care. Aim: To explore the experiences of palliative care physicians when caring for members of the medical profession with advanced incurable cancer. Participants and methods: Semi-structured interviews exploring the experiences of senior palliative care physicians were recorded and transcribed verbatim. Transcripts were analysed using interpretative phenomenological analysis (IPA) for emergent themes. Data were collected from ten senior palliative care physicians with a combined total of 107 years of palliative care career experience, caring for a reported combined estimate of 120 doctor-patients. Results: On the basis of their reflections, palliative care physicians reported that doctor-patients appear to find it difficult to assume a patient role, especially at a time they are likely to be truly vulnerable. This patient group will routinely attempt to maintain control of their care and environment using various strategies. These include self-referrals, accessing their own tests, directing the consultation and putting barriers up to psychosocial aspects of palliative care. Doctor-patients' general practitioners are at risk of exclusion from the management of care, and referral to palliative care services appears to occur later in the illness journey of doctor-patients compared to lay patients. Participants recalled how caring for colleagues evokes powerful emotional responses, such as a strong desire to provide the best care possible as well as feelings of anxiety. They frequently find themselves under pressure to disclose confidential information from medical colleagues not involved in the doctor-patients' care. Doctor-patients frequently receive what other healthcare professionals perceive as preferential treatment, which may unintentionally result in suboptimal care. Conclusion: The core needs of doctors with advanced cancer could be assumed to be the same as other patients. However, the juxtaposition of role from professional to patient appears to evoke unique care needs from the patient, and behaviour responses from the professional. Forewarning and awareness of these issues may help prevent potential problems in this patient group's cancer journey as well as the experience of the professionals involved in their management. [ABSTRACT FROM AUTHOR]

Most people with an incurable disease prefer to stay and die at home, cared for by their general practitioner (GP). This paper aims at describing the prevalence of symptoms in patients receiving palliative care at home. Within the framework of a nation wide survey of general practice in the Netherlands, GPs received a questionnaire for all patients who died within the 1-year survey period to determine whether patients received palliative care (n=2194). The response rate was 73% (n=1608), and 38% of these patients received palliative care until death. Information regarding encounters during the last 3 months of life was derived from the records kept by the GPs. Digestive symptoms (59%) and pain (56%) were the most prevalent. The total number of symptoms per patient was higher in cancer patients (11.99) than in non-cancer patients (7.62). Not reported in previous studies were musculoskeletal symptoms (20%) and chronic ulcer (18%). Concluding, this showed that Dutch GPs encounter a diversity and wide range of symptoms in palliative care. To face these complex challenges in patients receiving palliative care at home, GPs have to be trained as well as supported by specialized palliative care consultants. [ABSTRACT FROM AUTHOR]

Objective: Using physician assessments of patients' health related quality of life may improve the feasibility of studies in palliative care. However, poor agreement between patients and physicians has been found. We investigated whether subgroups of patients with good agreement existed. Study design and setting: Patient and physician assessments of twelve European Organisation for Research and Treatment of Cancer Quality of Life Care Questionnaire 30 domains were obtained once a week for up to 13 weeks. The association between agreement and patient characteristics at the first assessment (n = 115) was investigated using multivariate logistic regression. Significant associations were verified using the follow-up time-points combined (total n = 263). Results: Significant associations between patient characteristics and agreement were found for most domains. However, few subgroups had good agreement. The evaluations on follow-up data did not confirm the findings of subgroups with good agreement. Conclusion: Based on our findings physician assessments cannot be recommended as a substitute for patient self-assessment for any subgroups of palliative care patients. [ABSTRACT FROM AUTHOR]

A major issue in the care of terminally ill patients is communication and information provision. This paper reports the extent to which physicians in Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland discuss topics relevant to end of life care with terminally ill patients and their relatives (without first informing the patient), and possible associations between physician-specific characteristics and such discussions. Response rates to the postal survey ranged from 39% to 68% ( n = 10139). Physicians in most of the countries except Italy ‘in principle, always’ discuss issues related to terminal illness with their patients but not with patients' relatives without first informing the patient, unless the relatives ask. Cross-national differences remained strong after controlling for physician characteristics. The majority of physicians appeared to support the principle of patient-centred care to terminally ill patients, consistent with palliative care philosophy and with the law and/or professional guidelines in most of the countries studied. [ABSTRACT FROM AUTHOR]

Study objective: Most oncologists have not received adequate training in physician–patient communication, and existing effective courses tend to be time and resource intensive. We are developing and testing a tailored CD-ROM educational intervention that includes feedback on oncologists' own audio-recorded conversations with their advanced cancer patients. In this report, we describe the study methods and identify challenges to implementation and how these were overcome. Study design: A three-phase, randomized, controlled trial. In Phase 1, we audio-recorded oncologist–patient clinic encounters. In Phase 2, oncologists were randomly assigned to a communication CD-ROM intervention or control. Phase 3 consisted of audio-recording all participating oncologists conversing with a new sample of patients, two to 12 months after the intervention, to assess its effectiveness. Setting: Oncology clinics at Duke University Medical Center (DUMC) and the Durham Veterans Affairs Medical Center (DVAMC) in Durham, NC, and the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, PA. Participants: Medical, radiation and gynecological oncologists and their patients with advanced cancer. Intervention: A tailored CD-ROM that contains an interactive educational interface with reference materials and video-clips of model conversations, along with the oncologists' own Phase 1 audio-recorded conversations. Conclusion: We present challenges and solutions to oncologist recruitment, identifying appropriate patients with advanced cancer, adapting to clinic flow, and developing a self-administered communications intervention. [ABSTRACT FROM AUTHOR]

The literature on breaking bad news (BBN) tends to focus on professional consensus rather than empirical patient evidence – the 'giver' rather than the 'receiver'. Using semi-structured interviews, this study explores the experiences of patients with haematological cancer as they reflect on the process and content of receiving bad news. Fifteen patients with a diagnosis of leukaemia or lymphoma were recruited through a haematology service during a routine clinical visit, with the decision to participate being made later. Interviews were audiotaped, transcribed and analysed using thematic content analysis. Patients place importance on not being rushed during the bad news consultation and the doctor's manner. Receiving bad news was the first step on a journey, not an isolated incident. Doctors were regarded as the best judge of their information needs, with leaflets and written summaries as supplements. Patients had strong preferences about continuity and language use. Displays of empathy were important, but must be genuine. Patients wanted to know about likely emotional reactions and future support. Where patients brought a companion, they found this valuable. Patients concur with much of the content of the guidelines, but place more emphasis on their illness journey, the doctor's ability to adapt to their emotional needs, language used, information leaflets, having a companion and genuinely personalizing the approach. Reflection on these patient-derived factors may help health professionals better serve patients with serious illness. [ABSTRACT FROM AUTHOR]

The progression of advanced disease often brings enormous adaptational challenges related to a loss of the capacity to be self-sufficient and to a heightened need for support from others. The increasing need to rely on others at the end of life may reactivate relational problems and may trigger threatening feelings of vulnerability and dependency. Clinicians may find it difficult to identify and respond appropriately to the specific relational needs of individuals receiving end-of-life care. Attachment theory is a developmentally-based approach to understanding the formation and maintenance of relationships relevant to felt security. Although attachment theory has been widely applied to parent–child relationships and to relationships of individuals with chronic medical conditions to their medical caregivers, it has not previously been applied to the understanding of clinician–patient relationships in the palliative care setting. This paper provides an overview of this theory and demonstrates its application and relevance to palliative care. [ABSTRACT FROM AUTHOR]

The purpose of this study was to identify demographic, disease, health care, and psychosocial-spiritual factors associated with death distress (death-related depression and anxiety). Cross-sectional baseline data from a randomized controlled trial were used. Outpatients (n=70) were recruited from an urban academic medical centre and proprietary hospital. All patients had life-threatening medical conditions, including cancer; pulmonary, cardiac, liver, or kidney disease; HIV/AIDS; or geriatric frailty. Measures of death distress, physical symptom severity, depression and anxiety symptoms, spiritual well-being, social support, patient-perceived physician communication, and patient-perceived quality of health care experiences were administered. In a hierarchical multiple regression model, higher death distress was significantly associated with living alone, greater physical symptom severity, more severe depression symptoms, lower spiritual well-being, and less physician communication as perceived by the patient. Death distress as a unique experiential construct was discriminable among younger patients with specific, diagnosable life-threatening conditions, but less so among geriatric frailty patients. The findings suggest that the experience of death distress among patients with life-threatening medical conditions is associated with the psychosocial-spiritual dimensions of the patient's life. Attention to these dimensions may buffer the negative affects of death distress. [ABSTRACT FROM AUTHOR]

Investigates the process of communication between cancer patients and oncologists during consultations in outpatient clinics. Definition and identification of pain as a substantial topic; Importance of exploring patient's pain; Predominance of doctor-initiated questions; Emphasis on holistic care.

The subject of communication between palliative care physicians and their patients regarding their diagnosis and prognosis has not been extensively researched. The purpose of this survey was to compare the attitudes and beliefs of palliative care specialists regarding communication with the terminally ill in Europe, South America, and Canada. A sample of palliative care physicians from South America (Argentina and Brazil), French-speaking Europe, and Canada were identified, and posted a questionnaire. Physicians who stated that they practised palliative care at least 30% of their time were considered evaluable as palliative care specialists. Of a total of 272 questionnaires, 228 were returned (84%); and 182/228 (81%) respondents were considered to be palliative care specialists. Palliative care physicians in all three regions believed that cancer patients should be informed of their diagnosis and the terminal nature of their illness. Physicians reported that at least 60% of their patients knew their diagnosis and the terminal stage of their illness in 52% and 24% of cases in South America, and 69% and 38% of cases in Europe, respectively. All physicians agreed that 'do not resuscitate' orders should be present, and should be discussed with the patient in all cases. While 93% of Canadian physicians stated that at least 60% of their patients wanted to know about the terminal stage of their illness, only 18% of South American, and 26% of European physicians said this (P < 0.001). Similar results were found when the physicians were asked the percentage of families who want patients to know the terminal stage of their illness. However, almost all of the physicians agreed that if they had terminal cancer they would like to know. There was a significant association between patient based decision-making and female sex (P = 0.007), older age (P = 0.04), and physicians from Canada and South America (P < 0.001). Finally, in their daily decision making, South American physicians were significantly more likely to support beneficence and justice as compared with autonomy. Canadian physicians were more likely to support autonomy as compared with beneficence. In summary, our findings suggest that there are major regional differences in the attitudes and beliefs of physicians regarding communication at the end of life. More research is badly needed on the attitudes and beliefs of patients, families, and health care professionals in different regions of the world. [ABSTRACT FROM AUTHOR]