**Intervention of Coordination by Liaison Nurse Where Ward Staff Struggled to Establish a Therapeutic Relationship with a Patient Because of Failure to Recognize Delirium: A Case Study**

**Yuri Nakai <sup>1</sup> , Yusuke Nitta 2,\* and Reiko Hashimoto <sup>2</sup>**


**Abstract:** In this case study, ward staff found it difficult to establish a therapeutic relationship with a patient with advanced gastric cancer because they misdiagnosed delirium as a psychogenic reaction to the cancer diagnosis. This article reports on the process and effects of intervention by a liaison nurse. The liaison nurse recognized the misdiagnosis and approached the ward staff via a psychiatristled team. This enabled rapid revision of the treatment policy. The liaison nurse contributed to the continuation of treatment by enabling the ward staff and patient to understand each other better and to collaborate to build a relationship and control the patient's mental health symptoms, including attention disorder and excessive demands. The patient and family had different views on discharge because of the patient's mental health issues. The liaison nurse encouraged the ward staff to inform the family caregiver about the patient's medical condition, the expected future course of the disease, and likely symptoms, and provide appropriate professional services. This enabled the patient to be discharged in line with their wishes. This case highlights the role of the liaison nurse in coordinating care and helping ward staff to recognize symptoms and provide appropriate care and support for patients and their families.

**Keywords:** delirium; liaison nurse; misrecognition of delirium; coordination

#### **1. Introduction**

Delirium is caused by a range of factors such as the presence of predisposing conditions, including cognitive impairment, severe illness, visual impairment, drug therapy, and hospitalization [1]. When delirium develops during treatment, it interrupts the treatment and increases the risk of complications and further functional deterioration. It is associated with adverse events such as confusion and falls in hospitalized patients [2], and self-extraction of the infusion line [3]. This may mean that the length of hospital stay is extended, and labor costs and material costs for the stay are both increased [4]. This can also increase mortality [5]. The etiology of delirium is unknown, but prophylactic nursing interventions may be an efficient and cost-effective solution [6]. Careful observation and intervention by nurses are important to avoid the adverse consequences of delirium, allow patients to receive the desired treatment, and return to their daily lives.

The prevalence of delirium in cancer patients increases toward the end of life [7]. Delirium is a common psychiatric complication in cancer patients, but it is often not accurately recognized. In one study of psychiatric examinations of cancer patients, doctors were distracted by symptoms such as pain and missed the diagnosis of delirium in 46% of patients [8]. Overall, 61% of patients referred to palliative care had delirium overlooked by the primary referral team [9]. Approximately 50% of the primary teams of patients referred to liaison services for reasons other than delirium were unaware of the delirium [10]. In particular, delirium is prone to be unrecognized in younger cancer patients [11]. The

**Citation:** Nakai, Y.; Nitta, Y.; Hashimoto, R. Intervention of Coordination by Liaison Nurse Where Ward Staff Struggled to Establish a Therapeutic Relationship with a Patient Because of Failure to Recognize Delirium: A Case Study. *Healthcare* **2022**, *10*, 1335. https:// doi.org/10.3390/healthcare10071335

Academic Editor: Margaret Fitch

Received: 17 June 2022 Accepted: 16 July 2022 Published: 18 July 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

symptoms of delirium are diverse and appear irregularly. Patients with delirium may also try to address or hide agitation, apathy, emotional instability, and disorientation [12]. If treatment continues without the presence of delirium being recognized, it will have less or no therapeutic effect. Misdiagnosis can also lengthen the period in which nurses have difficulty responding to the patient, which can have effects on the whole ward. The nurses and medical staff who directly respond to patients' abuse and excessive demands are especially likely to experience serious psychological distress and stress. Nurses have the most frequent and closest contact with patients and play an important role in caring for and comforting delirium patients. It is therefore very important to be aware of and minimize their needs and stress [13]. Nurses and medical staff may also develop negative feelings toward patients with unrecognized delirium, which hinders the proper treatment and care for these patients. Early recognition of delirium, identification of possible causes, and provision of knowledgeable care will improve the quality and outcome of patient care [1,14]. If a nurse or other member of staff may have failed to recognize delirium, rapid intervention is needed to address the situation and reorient both patient and staff to appropriate treatment and care. Certified nurse specialists (CNS) in Japan are nurses who participate in clinical practice, consultation, coordination of activities, ethical management, education, and research [15]. These nurses are responsible for guiding staff in difficult situations, identifying learning needs, and highlighting the right approach [16]. They can therefore improve outcomes for patients.

In the case reported here, nurses and medical staff failed to recognize a variety of psychological symptoms caused by delirium in a gastric cancer patient. Instead, they believed that these were psychogenic reactions associated with the patient's recent diagnosis of advanced gastric cancer. It was therefore difficult for the nurses to establish a therapeutic relationship with the patient. The purpose of this study is to report on the process and effects of coordination and intervention by the CNS who was part of the liaison team. This may help to improve best practice for delirium cases in younger cancer patients.

#### **2. Case Presentation**

*2.1. Terminology*

#### 2.1.1. Liaison Team

The liaison team in Japan is a team of three or more people, including a psychiatrist, a nurse with more than 3 years of experience in psychiatry, and a medical professional with more than 3 years of experience in psychiatry. Medical professionals include pharmacists, occupational therapists, mental health social workers, and certified psychologists. The liaison team treats and cares for mental health symptoms and psychological problems of hospitalized patients and their families, using specialized skills from a physical, mental, and social perspective. The team aims to improve the mental health of patients and their families. It also supports the physical and mental health of staff involved in treatment, improves their motivation to work, and prevents them from burning out [17,18].

#### 2.1.2. Certified Nurse Specialist (CNS)

A certified nurse specialist is a nurse who has completed the certified nurse specialist education course at a Japanese graduate school and has passed the certified nurse specialist certification examination. As of February 2022, there are 14 specialist fields, including cancer nursing, psychiatric mental health nursing, and community health nursing. CNSs have six key roles: practice, consultation, coordination, ethical coordination, education, and research [19].

#### *2.2. Case Information*

This case report describes a woman in her 40s. She works as a salesperson, has never been married, and lives alone. Her parents are dead. Her family caregiver is her younger brother. Her only medical history is an oral treatment for bronchial asthma. She has no history of psychiatric treatment.

#### *2.3. Clinical Findings*

In June 20XX, the patient complained of an enlarged feeling in her abdomen and was diagnosed with advanced gastric cancer (stage IV). She was admitted to medical oncology on July 18. After admission, she was informed that her prognosis was 1 year. She chose to receive chemotherapy and started anticancer drugs (TS1 + cisplatin) (SP therapy) on July 20th. The second cycle was carried out on 10 August. From 15 August, she started frequent refusal of treatment and examinations and behaved aggressively toward the ward staff. On the night of 30 August, the patient's words and actions became uncoordinated and communication became difficult. Her dissatisfaction, anger, and shouting worsened. The patient's symptoms and ward staff behavior by stage of medical treatment are shown below.

#### 1. 30 August–14 September

After August 10th, the patient was reported as developing an intimidating attitude and emotional instability, making excessive demands on the nurses, having a silly smile, and being silent and immobile. The ward staff decided that these symptoms were a psychogenic reaction to the news that the cancer was advanced. They, therefore, responded without complaint to the patient's demands and requests.

#### 2. 15 September–10 October

The patient was prescribed an antipsychotic drug, and her anger disappeared, but the irritability remained. The psychological burden on the ward staff was heavy, and they continued to struggle to deal with the patient. The patient started to show overactivity, attention dysfunction, excessive demands, and frequent family phone calls. These seem to have been triggered by spending nights away from the ward, and the resumption of the therapy. The psychological burden on the ward staff, therefore, became even higher, and they began to complain to the head nurse that it was difficult to deal with this patient on a general ward.

#### 3. 11 October–1 November

After three cycles of SP therapy, the patient showed attention dysfunction and garrulity, but wanted to be discharged to the community and live alone. The ward staff decided that she would be able to do this by using social resources such as home-visit nursing. However, her family caregiver thought it would be difficult for her to live alone because of her symptoms. He was also worried that if the patient's condition worsened or suddenly changed, treatment would be delayed. There was therefore a conflict of opinion about discharge between the patient and her family caregiver. The ward staff respected the views of the family caregiver rather than those of the patient and suggested that the patient should give up the idea of living alone.

#### *2.4. Timeline*

The phase-by-phase medical conditions and the liaison nurse's interventions are shown below.

The need for the liaison nurse to intervene, and the nurse's actions, were classified into Phases 1, 2, and 3 by treatment and date. Figure 1 shows the patient's physical and psychotic symptoms, blood test values, and treatments by phase.

on the nurses.


**Figure 1.** Physical and psychotic symptoms by phase, blood test values, and treatment. **Figure 1.** Physical and psychotic symptoms by phase, blood test values, and treatment.

#### *2.5. Therapeutic Interventions*

*2.5. Therapeutic Interventions*  2.5.1. Interventions of the Liaison Nurse with Ward Staff: Phase 1

2.5.1. Interventions of the Liaison Nurse with Ward Staff: Phase 1 Coordination by Liaison Nurse in Phase 1

Coordination by Liaison Nurse in Phase 1 The liaison nurse held a conference with the liaison team and ward staff to correct the failure to recognize delirium. At the conference, the liaison nurse explained that the patient's psychological symptoms may be caused by delirium related to the chemotherapy, rather than a psychogenic reaction to her diagnosis. The team then clarified the role of each group of staff in supporting patients with delirium, to help to rebuild the support relationship between the patient and ward staff. Physical management of the patient was the responsibility of the doctor in charge of cancer treatment, nurses and physiotherapists should provide a non-pharmaceutical response to paralysis, and the liaison team would manage the mental health of the patient and support the mental health of ward staff (Table The liaison nurse held a conference with the liaison team and ward staff to correct the failure to recognize delirium. At the conference, the liaison nurse explained that the patient's psychological symptoms may be caused by delirium related to the chemotherapy, rather than a psychogenic reaction to her diagnosis. The team then clarified the role of each group of staff in supporting patients with delirium, to help to rebuild the support relationship between the patient and ward staff. Physical management of the patient was the responsibility of the doctor in charge of cancer treatment, nurses and physiotherapists should provide a non-pharmaceutical response to paralysis, and the liaison team would manage the mental health of the patient and support the mental health of ward staff (Table 1).

1). **Table 1.** Patient's delirium symptoms in Phase 1, state of ward staff, and liaison nurse intervention **Table 1.** Patient's delirium symptoms in Phase 1, state of ward staff, and liaison nurse intervention needs.


logically burdened, and more negative

about the patient.

2.5.2. Education on How to Deal with Attention Disorders, Rebuilding the Therapeutic Relationship between Patients and Ward Staff: Phase 2 Coordination by Liaison Nurse in Phase 2

The liaison nurse suggested how to respond to the concern from the ward staff that resuming SP therapy would worsen the patient's psychological symptoms. The team worked with the patient and nurses to enable certified psychologists to conduct an evaluation of the patient's condition using the Japanese version of the Young Mania Rating Scale (YMRS-J) and to consider countermeasures. The liaison nurse assisted in communication about countermeasures to make it easier for the patient and nurses to talk about their concerns. The agreed measures were as follows: (1) the patient should self-check her mental condition; (2) the patient should inform nurses if she becomes aware of any changes in her mental state; (3) nurses should carefully observe any changes in the patient's mental state; (4) if either the patient or nurses noticed changes in the patient's mental state, they should discuss this together and consider how to deal with it, and (5) the nurse in charge should inform all ward staff about the coping method jointly decided by the patient and the nurse in charge to provide a unified response (Table 2).

**Table 2.** Patient's delirium symptoms in Phase 2, state of ward staff, and liaison nurse intervention needs.


After this discussion, the nurse in charge commented:

"I didn't point out her psychological symptoms to the patient because I was afraid that doing so would worsen her intimidating attitude, emotional instability, and excessive demands." She added,

"I learned that the practice of sharing psychological symptoms with patients and considering countermeasures can be an option as an intervention method."

2.5.3. Managing a Conflict of Views about the Patient's Discharge from the Hospital: Phase 3

Coordination by Liaison Nurse in Phase 3

The liaison nurse suggested that the ward staff should find out more about the background behind the family caregiver's opposition to the patient's discharge to the community. She suggested the following three actions: (1) ward staff should try to understand the family caregiver's concerns; (2) ward staff should identify the reason for concerns and intervene to reduce the family caregiver's anxiety, and (3) ward staff should guarantee to the family caregiver that the hospital would continue to provide treatment support, psychiatric support, and living support to help the patient use social resources even after she was discharged to the community (Table 3).


**Table 3.** Patient's delirium symptoms in Phase 3, state of ward staff, and liaison nurse intervention needs.

#### **3. Discussion**

In cases where the liaison nurse finds an unrecognized patient with dementia in the ward, a patient has a mental health problem, (e.g., attention disorder or excessive demands) due to dementia caused by chemotherapy and has an issue with the discharge destination, or there is a conflict of intention between the patient and family caregiver regarding the discharge destination, the liaison nurse will coordinate interventions as described below.

Delirium is the most common complication in patients with advanced cancer. However, it is often difficult to identify, which leads to improper management [20]. Delirium in younger patients in particular may be missed because of the lack of disorientation [21]. The patient in this case study showed emotional instability and an intimidating attitude toward the nurses. The patient was in her 40s and the ward staff may have failed to recognize her delirium because she had no symptoms of disorientation. If someone identifies a patient with delirium-induced psychological symptoms that have not previously been recognized, it is important to provide a correct diagnosis as soon as possible, so that appropriate treatment or care can be provided. In this case, the correction using a team approach centered on the liaison psychiatrist helped the ward staff to quickly correct the misrecognition. It seems likely that ward staff will find it easier to accept a correction from the liaison team as a whole, rather than the liaison nurse alone. We suggest that this approach enabled the misrecognition to be corrected promptly. The ward staff and liaison team then correctly diagnosed the situation and worked together to solve the problem.

It is probable that the ward staff had high levels of negative feelings toward the patient because of the stress placed on them by the patient's intimidating attitude and excessive demands. Nurses should not rush to diagnose a patient with delirium, but should be aware that patients may have this condition [22]. Cases of hypomanic symptoms have been reported during S1 and cisplatin therapy for patients with gastric cancer [23], but it is not common. It is, therefore, possible that the staff on this ward were unfamiliar with psychological symptoms and did not appreciate the possibility of delirium. However, they did recognize the association with the SP therapy and suggested that, if the symptoms recurred on further treatment, it would be difficult for them to manage. The liaison nurse found that the ward staff felt responsible for managing all the patient's psychological symptoms when they occurred on the ward. The liaison nurse, therefore, contributed to the continuation of treatment by observing the mental health symptoms of the ward staff and working with the patient to enable her to self-check her own symptoms.

In Phase 3, the patient and family caregiver disagreed about discharge. The patient wanted to be discharged to the community, but the family caregiver thought this would be difficult because of the patient's complex psychological symptoms. Ward staff supported the family caregiver's view. This is considered inappropriate in this case because they had initially supported discharge and because of the patient's short life expectancy. It is important to provide information and involve family caregivers when older people are discharged from the hospital [24]. Family caregivers involved in discharge planning are more likely to accept the role of providing post-discharge care [25]. In this case, the

family caregiver's view suggests that they were given little information and not involved in the discharge planning. A previous study found that failure to discharge a COPD patient because of a bureaucratic organizational workflow may not be in the patient's best interests [26]. In this case, it is possible that ward staff felt that the family caregiver's opposition to the patient's discharge to the community would make the process harder. This suggests that the organization as a whole may not be focused on the best interests of the patient. Other studies have noted that the actions of liaison nurses in the discharge process, and especially coordinating with a specialist on behalf of the patient, help to continue care after discharge [27]. In this case, the liaison nurse's intervention to prompt the ward staff to provide more information to the family caregiver may have contributed to discharge, in line with the patient's wishes. The liaison nurse asked the ward staff to explain to the family caregiver about the changes in the patient's personality, and provide more information about the attention disorder, and how it affected behavior. The liaison team also asked the ward staff to arrange for treatment and home-based services for the patient after she was discharged. This support included home-visit nursing services, confirmed contact information in an emergency, a continuous support system by the hospital, and access to a consultation desk for family caregivers. In this case, the liaison nurse helped the ward staff to understand the challenges, and also evaluated their direct care and support to the patient and family.

This case report has some limitations. First, it is a report of a single case and cannot be generalized. Second, the classification of Phases 1–3 is based on our assessment of the patient's treatment stage, and not on existing theories or protocols. Third, this paper focused on the intervention of the liaison nurse and its effects; however, the intervention of the liaison team as a whole may also have influenced the effects. Despite these limitations, this case report provides useful information for the practice of liaison nurses working with staff who have difficulty responding to changes in personality and diverse psychological symptoms in patients with advanced cancer.

#### **4. Conclusions**

If a liaison nurse discovers a patient with delirium that has not been recognized on the ward, we recommend that the mistake is pointed out by the whole liaison team, led by liaison psychiatrists. This is because ward staff may be offended by having their mistake highlighted by another nurse, and may not be prepared to consider the possibility of delirium. For mental health problems such as attention disorder and excessive demands caused by delirium arising from chemotherapy, the liaison nurse should support the ward staff and patient to observe each other's psychological symptoms and work together to build a relationship that can control the symptoms. To enable patients with advanced cancer to make their own decisions about their lives, the liaison nurse needs to help the ward staff to provide family caregivers with information about the medical condition, its expected future course and symptoms, and professional services that are available to help.

**Author Contributions:** Y.N. (Yuri Nakai) and Y.N. (Yusuke Nitta); methodology, Y.N. (Yuri Nakai) and Y.N. (Yusuke Nitta); formal analysis, Y.N. (Yuri Nakai), Y.N. (Yusuke Nitta) and R.H.; investigation, Y.N. (Yuri Nakai), Y.N. (Yusuke Nitta) and R.H.; resources, Y.N. (Yuri Nakai), Y.N. (Yusuke Nitta) and R.H.; data curation, Y.N. (Yuri Nakai); writing—original draft preparation, Y.N. (Yuri Nakai), Y.N. (Yusuke Nitta) and R.H.; writing—review and editing, Y.N. (Yuri Nakai) and Y.N. (Yusuke Nitta); visualization, Y.N. (Yusuke Nitta); supervision. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** This research was conducted in accordance with the Declaration of Helsinki, 1995 (as revised in Seoul, 2008) and carried out with the consent of the medical research ethics review committees at the Kanazawa Medical University Hospitals (No. H266).

**Informed Consent Statement:** Informed consent was obtained from the patient involved in the case study.

**Data Availability Statement:** Not applicable.

**Acknowledgments:** We thank Melissa Leffler for editing a draft of this manuscript.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


## *Article* **Psychosocial Intervention Cultural Adaptation for Latinx Patients and Caregivers Coping with Advanced Cancer**

**Normarie Torres-Blasco 1,\* , Rosario Costas-Muñiz <sup>2</sup> , Lianel Rosario <sup>1</sup> , Laura Porter <sup>3</sup> , Keishliany Suárez <sup>1</sup> , Cristina Peña-Vargas <sup>1</sup> , Yoamy Toro-Morales <sup>1</sup> , Megan Shen <sup>4</sup> , William Breitbart <sup>2</sup> and Eida M. Castro-Figueroa <sup>1</sup>**


**Abstract:** Latinx advanced cancer patients and caregivers are less likely to have adequate access to culturally congruent psychosocial interventions. Culturally relevant and adapted interventions are more effective within minority groups. We obtained patients' and caregivers' initial evaluations of the Caregivers–Patients Support to Latinx coping with advanced-cancer (CASA) protocol. A qualitative study was conducted, and an acceptance questionnaire and semi-structured interviews were conducted to culturally adapt the psychosocial intervention for Latinx coping with cancer. The semi-structured interview described and demonstrated intervention components and elicited feedback about each one. Latinx advanced cancer patients (Stage III and IV) and caregivers (n = 14 each) completed the acceptance survey, and N = 7 each completed semi-structured interviews. A total of 12 of the 14 patients and caregivers (85.7%) reported high acceptance of the goals and purposes of the intervention protocol. They also reported willingness to daily use of the content of the intervention components: Communication Skills, the Willingness of Meaning, Life has Meaning, Freedom of Will, Identity, Creative Sources of Meaning, and Homework. Most of the participants reported high acceptance (n = 9) of integrating family caregivers into therapy and the high acceptance (n = 10) of the length of the 4-session intervention.

**Keywords:** Latinx; family; meaning; communication; coping with advanced cancer

#### **1. Introduction**

Adapting and developing culturally sensitive interventions is needed for Latinx families coping with advanced cancer (stage III or IV) [1–3]. Latinx patients coping with cancer have reported the need to include cultural values such as family and spirituality [4,5]. Family is a core value in the Latinx community and may facilitate the caring process for this group's advanced cancer patients [6–8]. The inclusion of Latinx values is especially essential when evidence suggests that working with spirituality and family needs (e.g., communication) could improve psychological symptoms [6–8].

Including cultural values is critical to developing a culturally sensitive intervention. The adaptation of culturally sensitive interventions is more effective towards the specific culture, rather than non-adapted interventions [9]. The cultural adaptation of evidencebased interventions (e.g., meaning-centered psychotherapy and couple communication training skills) is feasible and acceptable for ethnic minority groups [9–12]. Meta-analytic evidence suggests that culturally adapted interventions targeting a specific cultural group

**Citation:** Torres-Blasco, N.; Costas-Muñiz, R.; Rosario, L.; Porter, L.; Suárez, K.; Peña-Vargas, C.; Toro-Morales, Y.; Shen, M.; Breitbart, W.; Castro-Figueroa, E.M. Psychosocial Intervention Cultural Adaptation for Latinx Patients and Caregivers Coping with Advanced Cancer. *Healthcare* **2022**, *10*, 1243. https://doi.org/10.3390/ healthcare10071243

Academic Editor: Margaret Fitch

Received: 18 April 2022 Accepted: 29 June 2022 Published: 4 July 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

(e.g., Puerto Ricans as part of the Latinx community) are four times more effective than those provided to groups containing various cultural backgrounds [12].

Most literature among advanced cancer patients has been developed for white patients and not adapted for Latinx patients and caregivers. Cultural adaptation of interventions designed to support advanced cancer patients and their families is a novel approach that may benefit both patients and caregivers [9–12] coping with advanced cancer. An intervention for advanced Latinx cancer patients and caregivers should consider cultural values that may affect the end-of-life process [13]. This study aimed to obtain advanced cancer patients' and caregivers' initial evaluations of a protocol titled: Caregivers–Patients Support to Latinx coping advanced-cancer (CASA). In this brief report, the study team included results from interviews conducted with patients and caregivers to help adjust and refine the protocol.

#### **2. Method**

The present study consisted of qualitative analyses for the semi-structured interview, alongside descriptive statistics for the demographic and acceptance questionnaire. The Ponce Research Institute Institutional Review Board (IRB), with the permission of the oncology clinic, approved all study procedures. Participants were recruited from an oncology clinic in southern Puerto Rico referred by the nurse or oncologist. Potential participants were introduced to the study by an IRB-approved introductory letter. This was followed by an in-person research staff meeting with participants to provide information, answer questions, and administer the Distress Thermometer to determine eligibility. The inclusion criteria for both patients and caregivers was a score > 3 on the Distress Thermometer. Those eligible and interested completed an informed consent form. A call was scheduled for those who consented to complete the questionnaire and interview. Patients and caregivers each received USD 30 for completing the interview and volunteering their time and effort. An a priori sample size of 14 participants was selected based on recommendations for qualitative studies of this nature [14,15].

The team collected demographic information and acceptance questionnaire responses from patients and caregivers separately (14 patients and 14 caregivers) and then conducted a one-time 45 min semi-structured interview (NTB) that introduced information about the intervention to participants and elicited their feedback using a standardized interview guide. Patients and caregivers were interviewed separately so their responses would not be affected. The interviewer described and provided examples of intervention components (see Table 1) and elicited feedback about each intervention component and format in the semi-structured interview. Participants were also asked about their preferred mode of intervention delivery. Interviews were audio-recorded and then transcribed. The study team reviewed the recordings and transcriptions and analyzed them using thematic content coding [14,15].

The measures used in this project are a demographic questionnaire, an acceptance questionnaire, and a semi-structured interview. The demographic questionnaire includes questions regarding biological sex, age, employment, years of school completed, marital status, insurance, annual income, type of cancer, and caregiver relationship with the patient. The acceptance questionnaire comprised 34 questions assessing the acceptance of the goals and concepts of meaning-centered psychotherapy (MCP, 16 items), couples communication skills training (CCST, 8 items), and the feasibility of the goals and therapeutic methods (10 items) of MCP and CCST. The acceptance questions assess the importance of the concepts and goals. The feasibility questions assess the likelihood of participating in a psychotherapy intervention. The semi-structured interview describes the CASA intervention content (Table 1) and includes five sections: (1) purpose and goals; (2) intervention content—MCP and CCST; (3) homework; (4) other possible topics for discussion; and (5) intervention format.


**Table 1.** Caregivers–Patients Support to Latinx coping advanced-cancer" (CASA) content presented in the interview. The X indicate the inclusion of intervention related content.

#### **3. Analysis**

Descriptive statistics were conducted using IBM SPSS Statistics 21 to examine the demographic and acceptance questionnaires. The semi-structured interview analyses, integration, and interpretation were completed in Spanish. A coding dictionary was developed and defined a priori, following standard deductive analysis procedures [5,6,16,17], which included developing a structured coding matrix with categories, codes, and definitions [5,6,16,17]. The qualitative codes used for the interviews included high, moderate, low, and neutral acceptance. Acceptance was noted as high when the patient or caregiver clearly stated that he or she liked the definition/question/exercise; as moderate when the patient or caregiver reported that he or she moderately liked the content or they liked it but felt that other patients or caregivers might not; and low when the patient or caregiver reported not liking the content. When the level of acceptance could not be established, it was coded as neutral.

Using the report and query functions of ATLAS.ti, the qualitative analysts (CP, LR, and KS) independently coded the transcripts and discussed divergence and convergence points [5,6,16,17]. The qualitative coders then coded the remaining transcriptions using the coding dictionary, and meetings were held to reach a consensus about the applied codes. Through consensus meetings, divergence, and convergence, points were discussed in the group until consensus was met. There were no significant differences between the coders, and if there was a difference (two to one), a consensus was reached after discussion. Reliability was conducted through team-based consensus building. The team's previous publications include more details about the methodology [15–18]. All investigators had expertise in qualitative analysis, and the last author moderated these discussions [15–18].

#### **4. Results**

Demographic survey. Fourteen patient–caregiver dyads completed the demographic and acceptance questionnaire. The patients' mean age was 59 years (SD = 11, range = 40–76), 57% were female, and 100% were Latinx. Patients' diagnoses included stage III cancer (n = 3) and stage IV cancer (n = 10). The caregivers' mean age was 52 years (SD = 13, range = 25–79), 57% were female, and 100% were Latinx. Among the caregivers, 9 were spouses or husbands (64.2%), 2 sisters (14.2%), 1 daughter (7.2%), 1 grandson (7.2%), and 1 friend (7.2%).

Acceptance questionnaires. Twelve patients (85.7%) and eleven caregivers (78.6%) reported high acceptance of the treatment goal. The acceptance data are summarized, and the separate voices of patients and caregivers are included in Table 2.


**Table 2.** Descriptive statistics for the acceptance questionnaire.

#### *4.1. Treatment Goal*

The goal of the intervention consists of exploring the meaning of life after a cancer diagnosis by sharing thoughts and feelings between cancer patients and their caregivers, facilitating a greater understanding of possible sources of meaning before and after the diagnosis, and making decisions or solving problems. On the acceptance questionnaire, patients (n = 12) and caregivers (n = 11) reported high acceptance of the intervention (see Table 2). In the qualitative interview, thirteen participants' responses were categorized with high acceptance of the treatment goal (see Table 3). See also the illustrative quotations in Table 4.


**Table 3.** High, moderate, low, and neutral acceptance of the intervention.

**Table 4.** Caregivers–Patients Support to Latinx coping advanced-cancer (CASA) illustrative quotations for the high acceptance themes.



**Table 4.** *Cont*.


**Table 4.** *Cont*.

#### *4.2. Communication Skills Training*

The communication skills training includes components to assist couples in communicating effectively (e.g., how to speak and listen), decreasing the avoidance of critical cancer-related issues, and supporting each other. On the acceptance questionnaire, patients (n = 13) and caregivers (n = 14) reported high acceptance of the communication skills training speaker technique (see Table 2). Moreover, patients (n = 12) and caregivers (n = 12) reported high acceptance of the listening technique in the communication skills training (see Table 2). Thirteen participants' responses were categorized as high acceptance regarding how to listen to instructions. In the qualitative interview, all 14 participants' responses were categorized as high acceptance of the how-to-speak instructions (Table 3).

#### *4.3. Meaning Content*

On the acceptance questionnaire (see Table 2), patients (n = 14) and caregivers (n = 11) reported high acceptance of the will to meaning content. The meaning content is based on the principles of Viktor Frankl's work and his concepts of logotherapy by enhancing a sense of meaning, peace, and purpose as they approach the end of life. Patients (n = 12) and caregivers (n = 13) reported high acceptance of the identity content and experiential sources of meaning content. Patients (n = 12) and caregivers (n = 14) also reported high acceptance of the Homework: Share Your Legacy task, and patients (n = 14) and caregivers (n = 13) also reported high acceptance of the Homework: Connecting with Life task (see Table 2).

In the semi-structured interviews (see Table 3), the content identity and experiential sources of meaning were categorized as high acceptance, with 12 participants responding (see Table 3). The sources' meaning content was categorized as high acceptance for 13 participants. The content related to freedom of will was categorized as high acceptance, with 11 responses. The content related to will meaning and life has meaning was categorized as high acceptance, with 10 responses. Regarding the meaning content of homework, connecting with life, the response of 13 participants was categorized as high acceptance. Ten responses were categorized as high acceptance regarding the Encountering Life's Limitations and Legacy Project homework. When asked about the will to include the Legacy Project homework, 12 participants' responses were categorized as high acceptance. Regarding the Connecting with Life homework, 11 participants' responses were categorized as high acceptance.

#### *4.4. Intervention Format*

On the acceptance questionnaire, patients (n = 12) and caregivers (n = 12) reported high acceptance when asked about family integration into the therapy sessions (see Table 2). When asked about session intervention length, in the semi-structured interviews, 10 participants' responses were categorized as high acceptance, two as low acceptance, and two as neutral (Table 3).

#### *4.5. Integration of the Findings to Protocol*

The text was independently reviewed, followed by consensus meetings to discuss every intervention session, provide feedback, and discuss further modifications until a consensus was reached. The most accepted content of Caregivers-Patients Support to Latinx coping advanced-cancer (CASA) was included [17]. The cultural expert (NTB) and collaborators (CP, LR, and KS) conducted the integration of the qualitative findings to develop the CASA fixed in Table 5. The most commonly endorsed content of the CASA intervention was Communication Skills: Speaker, followed by Communication Skill: Listen, Creative Sources of Meaning, and Homework: Connecting with Life. The treatment goal, the content related to identity, and the experiential sources of meaning were also accepted, as were freedom of will, the will to meaning, life has meaning, Encountering Life's Limitations, and the Legacy project.

**Table 5.** CASA components that were culturally and linguistically adapted and integrated after the interviews and feedback. The X indicate the inclusion of intervention related content and the cultural adaptation.


Dr. Rosario Costas Muñiz, the treatment and cultural expert, reviewed the text to ensure the adaptation considers the dimensions of the ecological validity model, a framework used to create culturally sensitive interventions for Hispanics [18]. Fidelity to CASA's concepts, goals, and a theoretical model was preserved during the adaptation process to ensure language, metaphor, strategy, cultural context, and value acceptance. See Table 5 to see the intervention protocol's content and adaptation.

#### **5. Discussion**

This study aimed to obtain patient-caregiver dyads' initial evaluation of the Caregivers-Patients Support to Latinx coping advanced-cancer (CASA) protocol, specifically tailored to address spirituality and communication among Latinx patients. Included in this brief report were results from the interviews conducted with patients and caregivers to help adjust and refine the protocol. Based on the findings of the acceptance questionnaire and the semi-structured interviews, the study team refined the intervention content and format.

Latinx patients and caregivers described the communication skills content as highly acceptable and relevant to coping with patient and caregiver needs. The most endorsed content of the CASA intervention was Communication Skills: Speaker, followed by Communication Skill: Listen. These findings are consistent with the literature [6,7] suggesting the acceptance of incorporating communication skills training in patients-caregivers coping with cancer. The team only includes the most acceptable content for the adaptation of CASA. These include incorporating the content endorsed by the caregivers and patients through the semi-structured interview related to Creative Sources of Meaning, identity, and experiential Sources of Meaning. Participants also reported high acceptance of freedom of will, followed by the Will to Meaning, Life has a Meaning and Homework Encountering life limitations and Legacy project. This acceptable content was similar to the team's previous research in adapting individual meaning-centered psychotherapy (IMCP) for Latinxs [6]. We also integrate the adapted protocol's most accepted intervention homework by patients and caregivers: the Legacy project and Connecting with Life.

Concerning the format of CASA, many participants preferred sessions accompanied by caregivers; however, some patient–caregiver pairs reported the barrier of attending simultaneously. Thus, the intervention length was refined based on the findings of the semi-structured interview and recommendations of the cultural expert. As suggested in the findings from the acceptance survey, the format of the CASA intervention will need to match the needs and resources of patients and caregivers (e.g., videoconferences, telephone intervention, or home visits). As evidenced by the present study, most participants reported high acceptance of incorporating caregivers into the intervention and high acceptance of the intervention length.

#### **6. Conclusions**

In conclusion, patient–caregiver dyads found CASA's communication and meaning content acceptable, as evidenced in the acceptance survey and semi-structured interviews. Additionally, caregivers and patients expressed the acceptance of participating in this intervention together. The results make the CASA adaptation an essential step towards refinement and piloting with Latinx families coping with advanced cancer. Furthermore, including communication skills and meaning-centered content will assist Latinx patients and caregivers with their palliative and end-of-life decision-making.

Implementing CASA in different communities is feasible because of this study's variety of patients and types of cancers. However, cultural differences should be considered. This study may contribute to the development of cultural adaptations by proving sensitive ways to conduct interventions. Given the heterogeneity of Latinx culture, it will provide a practical way to facilitate the way interventions are conducted with Latinx patients. This line of research's future direction should include the adapted intervention's pilot test.

#### **7. Limitation**

Consenting with patients and caregivers and collecting data remotely were challenging and time-consuming. An additional limitation was that the team did not include a pilot test of the intervention. We also did not have sexual orientation and sexual identity in the demographic data. By not collecting this critical information, we could not divide the responses by gender or sexual identity or consider the gender of the interviewer for the results of this study. For future studies, we should consider the participants' sexual orientation and sexual identity to report findings. Nonetheless, these preliminary

findings suggest that a patient–caregiver intervention is acceptable and may be a promising approach to managing spirituality and communication in patients and caregivers coping with advanced cancer.

**Author Contributions:** Conceptualization, N.T.-B., L.P., E.M.C.-F., M.S., W.B. and R.C.-M.; methodology, N.T.-B. and R.C.-M.; software, L.R., C.P.-V., K.S. and N.T; validation, N.T.-B., R.C.-M. and E.M.C.-F.; formal analysis, L.R., C.P.-V., Y.T.-M. and K.S.; investigation, N.T.-B.; resources, N.T.-B. and E.M.C.-F.; data curation, L.R., C.P.-V., K.S. and N.T.-B.; writing—original draft preparation; writing N.T.-B.—review and editing, N.T.-B. and R.C.-M.; visualization, N.T.-B.; supervision, L.P., E.M.C.-F., M.S., W.B. and R.C.-M.; project administration, N.T.-B.; funding acquisition, N.T.-B. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the National Institute of Minority Health and Health Disparities (5G12MD007579, 5R25MD007607, R21MD013674, and 5U54MS007579-35); National Cancer Institute National Cancer Institute (2U54CA163071 and 2U54CA163068), R21CA180831-02 (Cultural Adaptation of Meaning-Centered Psychotherapy for Latinos), 1R25CA190169-01A1 (Meaning-Centered Psychotherapy Training for Cancer Care Providers), 5K08CA234397 (Adaptation and Pilot Feasibility of a Psychotherapy Intervention for Latino with Advanced Cancer) and the Memorial Sloan Kettering Cancer Center grant (P30CA008748). Supported in part by 133798-PF-19-120-01-CPPB from the American Cancer Society.

**Institutional Review Board Statement:** This project was revised and approved by the Ponce Health Sciences University–Ponce Research Institute Review Board (IRB). It complies with the United States 45 Code of Federal Regulations part 46 (45 CFR 46) related to the Common Rule and human subject regulation.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


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