Advanced Cancer In Palliative Care Research Articles

Barriers to palliative care research for emergency department patients with advanced cancer.

Patients with advanced cancer often visit the emergency department (ED). Little is known about their willingness or ability to engage in palliative care research, although enrollment in clinical trials of other seriously ill ED patients—those with stroke, for example—has been shown to be feasible. To identify barriers to the enrollment of ED patients with advanced cancer in palliative care research. We prospectively tracked factors that affected patient accrual into a trial of palliative care for adults with metastatic solid tumors at an urban, academic ED. Research staff screened the electronic medical records for patients admitted to the hospital with metastatic solid tumors 8-12 hours a day, Monday through Friday. The ED attending of record and the patient's medical oncologist had to agree before research staff invited the patient to participate. Informed consent was obtained at the bedside in the ED, and patients were offered a $20 incentive to participate. Attempts were made to enroll 150 eligible patients in the study, and 73 were enrolled (49% enrollment rate). Barriers to enrollment for the 77 patients who did not participate were deduced from the field notes and placed into the following categories: patient refusal (n = 38, 49%), diagnostic uncertainty regarding cancer stage (n = 11, 14%), symptom burden (n = 9, 12%), family refusal (n = 7, 9%), physician refusal (n = 7, 9%), and/or patient unaware of illness or stage (n = 5, 7%). The findings are descriptive and do not test predetermined hypotheses. Patient refusal, symptom burden, and diagnostic disparities are common barriers encountered when recruiting ED patients with advanced cancer. Despite the barriers, recruitment was feasible for such ED patients. This study was funded by a Mentored Research Scholar Grant from the American Cancer Society (Dr Grudzen), a Medical Student Training in Aging Research Grant from the American Federation on Aging (Mr Kandarian), and by a Mid- Career Investigator Award in Patient Oriented Research (K24 AG022345) from the National Institute on Aging (Dr Morrison).

Predictors of Suffering in Advanced Cancer

Suffering is a complex experience. Identifying its predictors is useful to signal at-risk patients. To identify suffering predictors in patients with advanced cancer in palliative care. A total of 98 patients participated in the study. A semistructured interview examining suffering levels and physical, psychological, social, and spiritual aspects was used. Instruments included Pictorial Representation of Illness and Self Measure (PRISM), Edmonton Symptom Assessment System (ESAS), Detection of emotional distress (DED), and Structured Interview of Symptoms and Concern (SISC). Variance-based structural equation model was used for the data analysis. All measures were valid and reliable. The structural model explained 64% of the variance. Suffering levels were directly determined by psychological and adjustment problems and indirectly determined by physical, psychological, and spiritual aspects and coping strategies. Our study supports the proposed theoretical model and signals the important mediating effect of psychological and spiritual variables between physical symptoms and suffering.

Involvement, attitudes and training needs in palliative care of doctors in Camau, Vietnam

BackgroundThe Camau Province of Vietnam has a population of over 1.2 million and the number of cancer patients needing palliative care is estimated approximately 1500. In 2010, an educational project...

Older Survivors and Cancer Care

The current sizeable population of cancer survivors has brought to the forefront key issues related to treatment decisions, management of adverse consequences of cancer and its treatment, and complex health needs related to cancer and other chronic comorbid conditions ( 1 ). Although improvements in cancer diagnosis, early detection, and treatment have led to dramatically increasing numbers of cancer survivors, cancer continues to be the second most common cause of death in the United States, and an estimated 1 444 920 new patients are expected to be diagnosed with cancer during this year alone ( 2 ). Cancer survivorship research focuses on the health and life of individuals living with the late or long-term effects of can cer or its treatment(s). By defi nition, patients living with advanced disease are cancer survivors. Individuals older than age 65 account for 60% of the estimated 10.8 million cancer survivors in the United States today ( 1 ). With the aging of the population, a rising trend in numbers of older cancer survivors is expected. Given the median age at diagnosis (67 years; all sites combined) and increasing survival estimates, comorbid conditions, especially among older survivors, are and will be an important factor in treatment decisions, posttreatment follow-up care, and palliative care ( 3 , 4 ). Studies have demonstrated that the presence of comorbid health conditions and perceived health vulnerability of the elderly by physicians can lead to under- or less aggressive treatment of the elderly, with resulting poor prognoses. Comorbidity in older patients may limit the ability to obtain (or for patients to undergo procedures that furnish) prognostic information (eg, axillary lymph node dissection), minimize treatment options (eg, breast-conserving therapy), and increase the risk of death from causes other than cancer ( 5 ). We propose that “cancer-related care” can be envisioned at four levels: 1) acute treatment of the cancer; 2) surveillance and follow-up care for disease recurrence, management of adverse treatment – related consequences and noncancer comorbidities; 3) palliative care for advanced cancer; and 4) end-of-life care. Supportive and palliative care have been recognized as important components of quality care for all cancer patients, particularly for those with advanced or incurable disease ( 6 , 7 ). Although it is increasingly accepted that quality palliative care should be provided through an interdisciplinary team approach with a focus on comfort and quality of life ( 8 ), the lack of a strong evidence-based foundation for this important area of research may result in missed treatment opportunities, the provision of nonbenefi cial and burdensome interventions, and over- or undertreatment ( 9 , 10 ). Within palliative surgery and other invasive specialty areas, specifi c concerns include the risks of major morbidity and mortality associated with many cancer-specifi c treatment approaches and the impact of decreased or severely restricted decision-making capacity among patients, especially those who are frail and elderly. The diversity of ethnic, cultural, and religious backgrounds of patients experiencing life- threatening illness at older ages adds further complexity to the provision of acceptable and optimal cancerrelated care. The fact that the Medicaid-insured nursing home patients studied by Bradley et al. ( 11 ), as reported in this issue of the Journal, had a preponderance of late and unstaged disease, high mortality within a few months of diagnosis, low hospice utilization, and little cancer-directed treatment is of concern, and future studies should further examine these issues. Timely cancer treatment and the alleviation of symptoms have the potential to extend life and enhance the quality of survival. Especially noteworthy are the fi ndings that 1) relative to patients aged 86 years and older (the fastestgrowing segment of the US population), patients aged 76 – 80 years and 81 – 85 years were less likely to be diagnosed with late or unstaged cancer at diagnosis; and 2) compared with patients with breast cancer, patients with colorectal, lung, prostate, and other cancers were more likely to be diagnosed with late or unstaged cancer. These results in particular underscore the fact that within the overarching category of “older survivors”, complexities related to early detection and management of the disease increase with age. In addition, some cancers other than breast cancer tended to have been diagnosed relatively late in this study, highlighting the need for vigilance toward possible cancer-related symptoms for some common cancers. These fi ndings also might refl ect the impact of established guidelines and practices relating to mammograms, as opposed to inconsistencies regarding prostate-specifi c antigen testing, colonoscopy, and screening for lung cancer.

Feeling like a burden: Exploring the perspectives of patients at the end of life

The issue of caregiver burden within the context of end-of-life care has received considerable attention. Less focus has been directed at the corresponding issue of care recipients’ perceptions of being a burden to others, referred to as “self-perceived burden”. The purpose of this interpretative phenomenological study was to gain a better understanding of self-perceived burden from the patient's perspective. Fifteen patients (ten women, five men) from Ottawa, Canada, receiving palliative care for advanced cancer were interviewed. Participants’ experiences of self-perceived burden were reflected in two major interrelated categories. “Concern for Others” included the physical, social, and emotional hardships participants believed they were creating for others, as well as concerns about the future and likely effect of their death on those around them. “Implications for Self” reflected feelings of responsibility for causing hardships to others, resulting in distress and a diminished sense of self. A third category, “Minimizing Burden”, was also identified, which described coping strategies used by participants to alleviate the burden on others and to reduce the negative impact on themselves. These categories and themes are discussed from the perspective of social psychology theory pertaining to the maintenance of equity in relationships.

Spiritual Pain among Patients with Advanced Cancer in Palliative Care

The large body of empirical research suggesting that patients' spiritual and existential experiences influence the disease process has raised the need for health care professionals to understand the complexity of patients' spiritual pain and distress. The current study explores the multidimensional nature of spiritual pain, in patients with end-stage cancer, in relation to physical pain, symptom severity, and emotional distress. The study combines a quantitative evaluation of participants' intensity of spiritual pain, physical pain, depression, and intensity of illness, with a qualitative focus on the nature of patients' spiritual pain and the kinds of interventions patients believed would ameliorate their spiritual pain. Fifty-seven patients with advanced stage cancer in a palliative care hospital were interviewed by chaplains. Overall, 96% of the patients reported experiencing spiritual pain, but they expressed it in different ways: (1) as an intrapsychic conflict, (2) as interpersonal loss or conflict, or (3) in relation to the divine. Intensity of spiritual pain was correlated with depression (r = 0.43, p < 0.001), but not physical pain or severity of illness. The intensity of spiritual pain did not vary by age, gender, disease course or religious affiliation. Given both the universality of spiritual pain and the multifaceted nature of pain, we propose that when patients report the experience of pain, more consideration be given to the complexity of the phenomena and that spiritual pain be considered a contributing factor. The authors maintain that spiritual pain left unaddressed both impedes recovery and contributes to the overall suffering of the patient.

Voriconazole susceptibility of yeasts isolated from the mouths of patients with advanced cancer

The in vitro activity of voriconazole was compared with those of fluconazole and itraconazole against 270 clinical isolates of yeasts from the mouths of patients receiving palliative care for advanced cancer. A broth micro-dilution assay as described by the National Committee for Clinical Laboratory Standards was employed for determination of MICs. Of the 270 isolates, 206 (76 %) were fluconazole sensitive and 64 were fluconazole resistant. Voriconazole showed more potent activity than either fluconazole or itraconazole, including against some isolates resistant to both fluconazole and itraconazole. However, for fluconazole-resistant isolates, the MICs of itraconazole and voriconazole were proportionally higher than for the fluconazole-susceptible isolates, suggesting cross-resistance. Voriconazole may be a useful additional agent for the management of oral fungal infections caused by strains resistant to fluconazole and itraconazole, but susceptibility cannot be assumed and in vitro MIC determination is recommended prior to its use.

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

Structured interview assessment of symptoms and concerns in palliative care.

Assessment in palliative care requires a multidimensional review of physical symptoms and psychosocial concerns in a format appropriate for patients with advanced illness. In this study, we describe the initial development and validation of a structured interview for assessing common symptoms and concerns faced by terminally ill individuals. We constructed a 13-item Structured Interview for Symptoms and Concerns (SISC) based on a review of end-of-life issues and administered it to 69 patients receiving palliative care for advanced cancer. Along with the interview, each participant completed visual analog scales (VAS) addressing the same constructs. Test-retest and interrater reliability were determined, as was the concordance between interview ratings and VAS scores. Overall, the interview items had excellent interrater reliability (intraclass correlations were > 0.90) and at least moderate temporal stability (test-retest correlations ranged from 0.50 to 0.90). Concurrent validity was evident in the good concordance between interview items and VAS measures (correlations were > 0.70). The SISC was also sensitive to individual differences between subgroups of participants who did or did not meet diagnostic criteria for anxiety or depressive disorders. This study demonstrates that structured interviews provide a reliable and valid approach to assessment in palliative care and may be an appropriate alternative for some research applications.

Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.

In jurisdictions that permit euthanasia or physician-assisted suicide, patients with cancer comprise the largest group to die by these methods. We investigated the personal attitudes toward these practices of patients receiving palliative care for advanced cancer. Seventy patients (32 men and 38 women; median survival, 44.5 days) took part in a survey using in-depth semistructured interviews. The interviews were audiotaped for transcription and content analysis of themes. Most participants (73%) believed that euthanasia or physician-assisted suicide should be legalized, citing pain and the individual's right to choose as their major reasons. Participants who were opposed to legalization cited religious and moral objections as their central concerns. Forty (58%) of the 69 participants who completed the entire interview also believed that, if legal, they might personally make a future request for a hastened death, particularly if pain or physical symptoms became intolerable. Eight of these individuals (12%) would have made such a request at the time of the interview. These 8 participants differed from all others on ratings of loss of interest or pleasure in activities, hopelessness, and the desire to die (Ps<.02). They also had a higher prevalence of depressive disorders (P<.05). However, they did not differ on ratings of pain severity. Many patients with advanced cancer favor policies that would allow them access to both euthanasia and physician-assisted suicide if pain and physical symptoms became intolerable. For patients who would actually make requests for a physician-hastened death, however, psychological considerations may be at least as salient as physical symptoms.

Palliative Care in Advanced Cancer

Palliative Care in Advanced Cancer

"Are you depressed?" Screening for depression in the terminally ill.

This study compared the performance of four brief screening measures for depression in a group of terminally ill patients. The methods included 1) a single-item interview assessing depressed mood, 2) a two-item interview assessing depressed mood and loss of interest in activities, 3) a visual analog scale for depressed mood, and 4) the Beck Depression Inventory-Short Form. Semistructured diagnostic interviews for depression were administered to 197 patients receiving palliative care for advanced cancer. The interview diagnoses served as the standards against which the screening performance of the four brief screening methods was assessed. Single-item interview screening correctly identified the eventual diagnostic outcome of every patient, substantially outperforming the questionnaire and visual analog measures. Brief screening measures for depression are important clinical tools for terminally ill patients. For diagnostic purposes, however, they do not approach the validity of a single-item interview that asks, in effect, "Are you depressed?"

Psychosocial aspects of palliative care in advanced cancer

One hundred patients with advanced cancer referred to a palliative care service were evaluated for psychosocial distress using a standard questionnaire. A high incidence of emotional upset, financial distress, and home-care problems was found. Psychosocial distress is common among patients (and their families) with advanced cancer and may have a significant impact on provision of optimal care. Community services are often inadequate, A dedicated palliative care service employing a multidisciplinary approach can best provide care. We make specific recommendations about how to combat psychosocial distress using specific administrative and management techniques.