Epidemiology of Fear, Sadness, and Anger Expression in Palliative Care Conversations

Abstract

Context: Advancing the science of serious illness communication requires methods for measuring characteristics of conversations in large studies. Understanding which characteristics predict clinically important outcomes can help prioritize attention to scalable measure development.

Objectives: To understand whether audibly recognizable expressions of distressing emotion during palliative care serious illness conversations are associated with ratings of patient experience or six-month enrollment in hospice.

Methods: We audiorecorded initial palliative care consultations involving 231 hospitalized people with advanced cancer at two large academic medical centers. We coded conversations for expressions of fear, anger, and sadness. We examined the distribution of these expressions and their association with pre/post ratings of feeling heard and understood and six-month hospice enrollment after the consultation.

Results: Nearly six in 10 conversations included at least one audible expression of distressing emotion (59%; 137 of 231). Among conversations with such an expression, fear was the most prevalent (72%; 98 of 137) followed by sadness (50%; 69 of 137) and anger (45%; 62 of 137). Anger expression was associated with more disease-focused end-of-life treatment preferences, pre/post consultation improvement in feeling heard and understood and lower six-month hospice enrollment. Fear was strongly associated with preconsultation patient ratings of shorter survival expectations. Sadness did not exhibit strong association with patient descriptors or outcomes.

Conclusion: Fear, anger, and sadness are commonly expressed in hospital-based palliative care consultations with people who have advanced cancer. Anger is an epidemiologically useful predictor of important clinical outcomes.

Keywords: Anger; decision making; emotion; fear; palliative care; sadness; serious illness conversations.