Measuring therapeutic alliance between oncologists and patients with advanced cancer

The Human Connection Scale

Authors

  • Jennifer W. Mack MD, MPH,

    Corresponding author
    1. Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
    2. Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    3. Department of Medicine, Children's Hospital, Boston, Massachusetts
    • Department of Pediatric Oncology, Harvard Medical School, 44 Binney Street, Boston, MA 02115===

    Search for more papers by this author
    • Fax: (617) 632-2270

  • Susan D. Block MD,

    1. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    Search for more papers by this author
  • Matthew Nilsson BS,

    1. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    Search for more papers by this author
  • Alexi Wright MD,

    1. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    2. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
    Search for more papers by this author
  • Elizabeth Trice MD, PhD,

    1. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    2. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
    Search for more papers by this author
  • Robert Friedlander MD,

    1. New Hampshire Oncology-Hematology PA, Hooksett, New Hampshire
    Search for more papers by this author
  • Elizabeth Paulk MD,

    1. Palliative Care Service, University of Texas, Southwestern Medical Center, Dallas, Texas
    Search for more papers by this author
  • Holly G. Prigerson PhD

    1. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    Search for more papers by this author

Abstract

BACKGROUND:

Patients consider their human connection with a physician an important aspect of end-of-life (EOL) care. In this study, the authors sought to develop and validate a measure of therapeutic alliance between patients with advanced cancer and their physicians and to evaluate the effects of therapeutic alliance on EOL experiences and care.

METHODS:

The Human Connection (THC) scale was developed to measure the extent to which patients felt a sense of mutual understanding, caring, and trust with their physicians. The scale was administered to 217 patients with advanced cancer along with measures of attributes that have been related hypothetically to therapeutic alliance, including emotional acceptance of terminal illness. EOL outcomes in 90 patients who died during the study also were examined.

RESULTS:

The 16-item THC questionnaire was consistent internally (Cronbach α = .90) and valid based on its expected positive association with emotional acceptance of terminal illness (r = .31; P < .0001). THC scores were related inversely to symptom burden (r = −.19; P = .006), functional status (Karnofsky performance status; r = .22; P = .001), and mental illness (THC score: 50.69 for patients with any Diagnostic and Statistical Manual [DSM] diagnosis vs 55.22 for patients with no DSM diagnosis; P = .03). THC scores were not associated significantly with EOL discussions (P = .68). Among the patients who died, EOL intensive care unit (ICU) care was associated inversely with therapeutic alliance (THC score: 46.5 for patients who received ICU care vs 55.5 for patients without ICU care; P = .002), so that patients with higher THC scores were less likely to spend time in the ICU during the last week of life.

CONCLUSIONS:

The THC scale is a valid and reliable measure of therapeutic alliance between patients with advanced cancer and their physicians. In addition, there was no evidence to suggest that EOL discussions harm patients' therapeutic alliance. A strong therapeutic alliance was associated with emotional acceptance of a terminal illness and with decreased ICU care at the EOL among patients with advanced cancer. Cancer 2009. © 2009 American Cancer Society.

Ancillary