Palliative Care For Cancer Patients Research Articles

Pain Management for Urological Cancer Patients in Palliative Care

Pain mitigation and therapy is one of the most important medical tasks of the urologist, where patients benefit a lot from the basic concepts of analgesia. However, pain resulting from cancer can be more complex than the one after the surgery. Patients that are not receiving regional analgesia should be administered with intravenous or oral non-opioid analgesics in combination with titration. Slow-release of oral opioids is increasingly being used as part of systemic pain management despite little evidence of their efficacy. Continuous epidural infusion is recommended for pain resulting from extensive retroperitoneal and transperitoneal cancers because of its ability to enhance recovery. Additional pain relief-related approaches such as radiation, psychosocial and spiritual needs of the patients have to be considered. Therefore, a multidisciplinary team of experts is needed to administer etiology-specific pain management and therapeutics. Patients often benefit from multimodal, interdisciplinary pain management techniques comprising psychological and educational approaches, including physiotherapy. This article reviews the pain management techniques for the patients under palliative care. In addition, it presents the cases of urological cancer patients that approach palliative care department of our institution for pain management.

Palliative care consults in oncology: what are we waiting for? A case report.

Palliative care focuses on symptom management and decreased suffering in all aspects of health. Although it has been shown that palliative care improves emotional and clinical outcomes for patients and families, it remains an underutilized specialty particularly in the field of oncology. Involving cancer patients in palliative care can sometimes be confused with the idea of giving up, or losing hope. This is especially true when patients are young. The following case report provides an example of a patient who may have benefited from palliative specialists’ involvement early in his disease, potentially sparing him and his family prolonged, physical, and emotional suffering.

Hjarte-lunge-redning til kreftpasientar i palliativ fase

The criteria for refraining from cardiopulmonary resuscitation in palliative care cancer patients are based on patients' right to refuse treatment and the duty of the treating personnel not to exacerbate their suffering and not to administer futile treatment. When is cardiopulmonary resuscitation futile in these patients? Systematic literature searches were conducted in PubMed for the period 1989-2010 on the results of in-hospital cardiopulmonary resuscitation in advanced cancer patients and on factors that affected the results of CPR when special mention was made of cancer. The searches yielded 333 hits and 18 included articles: four meta-analyses, eight retrospective clinical studies, and six review articles. Cancer patients had a poorer post-CPR survival than non-cancer patients. Survival declined with increasing extent of the cancer disease. Widespread and therapy-resistant cancer disease coupled with a performance status lower than WHO 2 or a PAM score (Pre-Arrest Morbidity Index) of above 8 was regarded as inconsistent with survival after cardiopulmonary resuscitation. Cardiopulmonary resuscitation is futile for in-hospital cancer patients with widespread incurable disease and poor performance status.

Use of palliative care measures to support improved patient outcomes and quality of life.

281 Background: Key public-private quality improvement entities, such as the National Quality Forum (NQF) and the National Priorities Partnership, have identified palliative care measures as being critical for the care of cancer patients. In this study, Avalere sought to understand whether current palliative care measures are adequate to support desired patient outcomes, including quality of life. Methods: Avalere conducted searches of large, national quality measure databases—including the Agency for Healthcare Research and Quality’s National Quality Measure Clearinghouse and NQF—as well as public quality measurement programs to better understand the range of existing palliative care measures and the use thereof. In addition, Avalere augmented this research through a review of the white and grey literature to determine how such measures may be better used to support desired outcomes. Results: Several organizations—most notably the American Society of Clinical Oncology (ASCO); the American Medical Association–convened Physician Consortium for Performance Improvement, with the National Comprehensive Cancer Network and ASCO; and the RAND Corporation—have developed measures addressing palliative care for cancer patients. Several of these measures have been subsequently endorsed by NQF. Despite this, few palliative care measures have been incorporated into national quality measurement programs, outside of ASCO’s proprietary Quality Oncology Practice Initiative (QOPI). Conclusions: While it is widely acknowledged that palliative care measures are critical for the care of cancer patients, particularly as it relates to supporting quality of life, little has been done to ensure such measures are incorporated into national public quality improvement initiatives, such as the Centers for Medicare & Medicaid Services’ Physician Quality Reporting System. As calls for increased use of patient-reported outcomes and other palliative care measures continue to rise, policymakers may need to consider incorporating existing, NQF–endorsed measures, such as those used in QOPI, into public programs.

Translation, adaptation and data quality of a Danish version of the Burden Scale for Family Caregivers

The burden of caregiving can have various negative consequences. There is a need for health professionals to be able to measure the burden of caregiving among relatives of end-stage cancer patients in a valid way. The Burden Scale for Family Caregivers (BSFC) has 28 items and was developed as a clinical tool for measuring the self-reported burden among family caregivers caring for a relative at home. To make a standardized translation of the English version of the BSFC into a Danish version and to report data quality in a group of Danish family caregivers caring for palliative care cancer patients. The BSFC was translated following WHO guidelines. Ninety family caregivers of end-stage cancer patients were sent BSFC as part of a larger questionnaire. A total of 75 (83%) returned the questionnaire. Excluding responses with two or more missing items, 58 (64%) participants completed the BSFC. The words 'care', 'caregiving' and 'caregiver' were a challenge to the translators. The item response was moderate with missing answers from 4.0 to 18.7%. For the total sum-score, mean perceived burden amongst participants was low (mean score 23.56 of max 84.00). Cronbach's alpha was 0.91 and average inter-item correlation 0.26. Item-rest correlations ranged from -0.02 to 0.72 and were below 0.40 for seven items. High scores on the BSFC was statistically significantly correlated with the feeling of social isolation (ρ = -0.332, p = 0.013) and with the dyspnoea subscale of the EORTC-QLQ-15-PAL (ρ = 0.322, p = 0.012) but not with poor self-reported health (ρ = -0.036, p = 0.805). The BSFC was translated into Danish and showed problems with some data quality and validity measures. Hence, further psychometric testing on a larger population is needed before the scale can be recommended as a sum-scale for scientific and clinical use.

EL8 - Palliative Care 1: Interventional Radiology in Palliative Care for Cancer

ABSTRACT Background Palliative care is recently recognized as an important aspect of cancer management. Interventional radiology (IR) is an effective treatment option in palliative care for cancer patients. However, IR is not well-known to oncologists and there are few evidences based on prospective studies of IR. Learning objects (i) to review the procedures of IR in palliative care; (ii) to review the results of IR in palliative care; (iii) to discuss the problems of IR as palliative care in clinical practice. Procedures Attractive procedures of IR in palliative care would be introduced as follows: (i) drainage (including shunt) of accumulated fluids; (ii) metallic stent placement for obstruction; (iii) vertebroplasty or radiofrequency ablation (RFA) for cancer pain relief; (iv) repair of leakage or bleeding. Results There were some retrospective reports, but few prospective studies in IR as palliative care. Japan Interventional Radiology in Oncology Study Group (JIVROSG) was organized in 2002 and has been conducted several prospective studies. In particular, phase I/II study of percutaneous vertebroplasty (PVP) as a palliative care (JIVROSG-0202) demonstrated the efficacy of PVP to relive pain due to malignant vertebral compression fractures (Ann Oncol 2009) and PVP was approved for this indication in December 2009. Issues and solutions for IR in clinical practice First, IR in palliative care has been still not well known to medical staff and cancer patients. So, we have joined the meeting of Japanese Society of Palliative Medicine and other various meetings recently to present the important role of IR in palliative care. Secondly, there are not enough interventional radiologists who can perform these IR procedures. Therefore, patients have to be transferred to special hospitals as our hospital for IR. Indication of IR and duration of hospitalization have been informed to neighboring hospitals. Also, educational program for IR procedure should be established. Finally, since IR is an important palliative treatment as well as medical therapy and psychological care, it is better to be integrated in multidisciplinary approach to cancer patients.

Abstract PL03-03: Disparities in cancer palliative care for medically underserved populations.

Abstract An underserved population refers to a group of people who, for a variety of reasons, do not have equal access to health and health care services. In the United States and across the globe, examples of underserved populations are the poor or the near-poor who are uninsured or under-insured, minorities, immigrants (including undocumented immigrants), and those with mental health and/or medical multimorbidity. As a consequence of being underserved, disparities exist in terms of specific differences in the development of disease or specific syndromes and health outcomes. If you then add the dimension of value judgment, specifically the notion that health and relief of suffering is a fundamental human right, and that individuals with the same needs and preferences ought to experience a fair distribution of health resources and outcomes regardless of social standing, then the concept of health equity comes to light. Just as terms like disparity and underserved and inequity can be confusing, so it is with palliative care as it pertains to cancer patients. This term is often linked to hospice care, pain and symptom management and supportive oncology. The World Health Organization succinctly defines palliative care as an approach to care. It is an approach that improves the QOL of patients and their families facing the problems associated with life threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. The palliative care workforce applied to cancer patients varies and ranges from trained local caregivers and community volunteers to allied health professionals to highly trained providers with or without special training or credentials in palliative care. In practice, the key dimensions of delivering on this comprehensive, interdisciplinary approach include communication, cultural competency, pain and symptom management, and integrated systems and teamwork. The root of disparities and health inequity in regards to the delivery of palliative care in cancer patients can be understood by examining both the palliative care workforce and these specific dimensions in detail. Relevant palliative care outcomes worthy of examination for disparity and health equity include the availability of palliative care programs and specialists, the availability and appropriate use of opioid analgesics and associated teaching, early integration of palliative care with active cancer treatment, utilization of hospice, place of death according to patient preference, trust and therapeutic alliance with healthcare providers, racial/ethnic concordance between patients and providers, level of stress and burnout among the palliative care providers, level of aggressiveness in end-of-life care including use of resuscitation and intensive care units, patient understanding and acknowledgement of terminal illness, and use of advanced directives to guide end-of-life care. Across one or more of these relevant outcomes, there are both disparities and health inequities that have been noted according to geography (rural vs. urban vs. other, low-income countries versus others), race/ethnicity, comorbidity (HIV/AIDS, mental illness including substance abuse), immigration status, sexual orientation, gender, and age group. Improving palliative cancer care and eliminating healthcare inequities in this realm will require efforts at multiple levels, including governmental policies, community engagement and advocacy, professional organizations, and the level of individual institutions, programs, and providers. Priority areas for attention are the availability and distribution of palliative care resources for care delivery as well as research, and the size, diversity, and skill level of the workforce applied to delivering this important approach to care. Citation Format: Michael J. Fisch. Disparities in cancer palliative care for medically underserved populations. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr PL03-03.

Treatment monitoring and mortality risk adjustment in anaemic Jehovah's Witnesses

Management of anaemic Jehovah's Witness (JW) patients, who refuse blood transfusion on religious grounds, is challenging. In the published literature, there are few cohort studies that consider causes of mortality in isolation and are lacking in their predictive power. This does not allow clinicians to monitor treatment progress of severely anaemic JW patients and adjust their risk of mortality. The study aims to develop an anaemia-related mortality risk prediction instrument. This retrospective cohort study evaluated anaemia-related mortality risk factors of JW patients. JW patients were identified from the records of four major public hospitals in the Auckland and Midlands regions of New Zealand (North Shore, Auckland City, Middlemore and Waikato hospitals) for the period 1998 to 2007 inclusive. The inclusion criteria were age ≥15 years and severe anaemia (haemoglobin concentration ≤80 g/L). Palliative care cancer patients were excluded. Anaemia-related risk factors of mortality for JW patients were identified, weighted and used to construct a mortality risk predictive score (the Hamilton Anaemia Mortality Risk Score (Hamilton AMRS)). This permitted stratification of JW patients into mortality risk groups according to their Hamilton AMRS. It is shown that patients with Hamilton AMRS of 0 to 2 had 4% mortality, patients with Hamilton AMRS of 3 to 4 had 29% mortality, patients with Hamilton AMRS of 5 had 40% mortality and patients with Hamilton AMRS of ≥6 had 67% mortality. The Hamilton AMRS allows treatment monitoring of anaemic JW patients and adjustment of their risk of mortality.

Referral Patterns of Patients for Palliative Radiation Therapy in British Columbia: A Comparison Between Rural and Urban Family Physicians

BackgroundPrevious studies have shown that palliative radiation therapy (PRT) is often underused, especially in rural and remote settings despite evidence supporting its effectiveness in managing symptoms from advanced or metastatic cancer. PurposeTo identify factors which influence family physicians (FPs) in British Columbia (BC) to refer patients for PRT at the BC Cancer Agency (BCCA) and to compare referral patterns between FPs in rural and urban areas. Methods and MaterialsA total of 1,001 questionnaires were sent to all FPs practicing in rural areas and randomly to FPs in urban areas (351 and 650, respectively). Rural and urban areas were chosen based on our previous study of utilization rates of PRT in BC. The questionnaire was adapted from a previously validated survey, and was used to obtain information on referral practices of FPs in BC. FPs who did not practice family medicine or where 80% of their practice was spent with either obstetrical or pediatric patients were excluded. ResultsThe overall response rate was 33% (44% rural vs. 28% urban). Rural FPs were more involved in both palliative care and metastatic cancer management of their patients (88% vs. 74%; P = .01 and 58% vs. 39%; P = .01). No difference was observed in the FPs' awareness of the BCCA's Radiation Oncology Program. The most significant factors influencing an FP to refer a patient for PRT were: poor functional status, inconvenience to travel and life expectancy. A higher proportion of rural FPs had 10 years or less of experience in family practice than the urban FPs (P = .03). There was no significant difference in the formal training or additional training between the rural and urban FPs. ConclusionsThis study found that FPs practicing in rural areas were more involved in palliative management of their patients and participated more in the care of patients with advanced or metastatic cancer than those in urban areas. They also more commonly referred patients for palliative radiotherapy than their urban counterparts. The reported factors that influenced rural and urban FPs to refer were patients' functional status and life expectancy, combined with uncertain benefit and potential side effects of radiotherapy. More than twice as many FPs from rural compared to urban areas were influenced by perceived inconvenience to travel for palliative radiotherapy. After controlling for potential confounding factors, FP awareness of the radiotherapy program, high participation in advanced, metastatic, or palliative care of cancer patients, formal training in radiation oncology, and additional training in palliative care were all associated with an increased probability of ever referring for palliative radiotherapy.

Dietary energy density, inflammation and energy balance in palliative care cancer patients

Diet energy density is correlated with energy intake in patients with advanced cancer. Little information is available about the effects of energy density on energy balance, nor about the influence of other factors, such as systemic inflammation and disease stage. We assessed whether dietary energy density or energy intake predict energy balance over 4 months in patients with advanced cancer. We examined also the influence of systemic inflammation and survival time. Energy balance was calculated from the change in body energy content by repeated dual-energy X-ray scans in 107 patients for a total of 164 4-month measurement periods. A linear mixed model was used to investigate relationships between diet energy density (kcal/g), energy intake (kcal/day) and energy balance with systemic inflammation and survival as covariates. In an unadjusted model, the energy density of solid food and energy intake were positive predictors of energy balance (P < 0.03). A 1-SD increase in energy density and energy intake increased energy balance by 38 and 41 kcal/day, respectively. The total diet energy density did not predict energy balance (P > 0.05). Survival was positively (P < 0.001), and systemic inflammation negatively (P = 0.005) associated with energy balance. Only energy intake remained a significant predictor of energy balance after adjustment for survival and inflammatory status. Dietary energy density is positively associated with energy balance in patients with advanced cancer. Relations between energy intake, energy density and energy balance are affected by systemic inflammation. Thus, targeting systemic inflammation may be important in nutritional interventions in this patient group.

Noncancer Palliative Care

Little is known about the picture of patients receiving palliative care in the acute care setting. The study was conducted in a medical center in Taiwan. Cancer palliative care (CPC) was performed for terminal do-not-resuscitate (DNR) patients with advanced cancers. Noncancer palliative care (NCPC) was performed for DNR patients who did not fulfill the criteria of CPC. Of the 1379 consecutive admissions, 258 patients were identified, with 193 (74.8%) requiring NCPC and 65 (25.2%) requiring CPC. The NCPC patients were older and had lower Charlson comorbidity index (2.6 vs 8.6, P &lt; .001) than CPC patients and had poorer consciousness and more organ failure than CPC patients when recognized. Many noncancer patients without access to specialist palliative care services were treated in the acute care setting with delayed recognition.

Nutritional support and quality of life in cancer patients undergoing palliative care

In palliative care, the nutrition provided has to be tailored to the patient's needs, enhancing patient comfort and quality of life (QoL). We conducted a literature search to review methods of measuring QoL, and modalities of nutritional intervention and their influence on QoL of cancer patients in palliative care. Original papers published in English were selected from PubMed database by using the search terms, palliative medicine, cancer, nutrition and quality of life. Specific tools that are particularly recommended to assess QoL in a palliative care setting are reviewed. The main goal in palliative care is to maintain oral nutrition by providing nutritional counselling. Enteral nutritional support showed inconsistent effects on survival and QoL. An evidence-base for parenteral nutrition is still lacking. Ethical considerations concerning provision of food and hydration in end-of-life care are discussed. Nutritional status should be assessed early and regularly during treatment using appropriate tools. In the particularly acute context of palliative care, optimal patient management requires adequate education and counselling to patients and families. Meaningful interactions between the patient, caregivers and medical team would also increase the chance of resolving nutrition-related issues and help to fulfil each patient's specific nutritional needs and thus improve the QoL.

52 Examining the Effect of the Case Management Model on Patient Results in the Palliative Care of Cancer Patients

52 Examining the Effect of the Case Management Model on Patient Results in the Palliative Care of Cancer Patients

Acupuncture for the treatment of cancer pain: a systematic review of randomised clinical trials

Controlling cancer-related pain is an important component in the palliative care of cancer patients. The objective of this review was to assess the effectiveness of acupuncture for treating cancer pain. Fourteen databases were searched from their inception through April 2011. Randomised clinical trials (RCTs) were included if acupuncture was used as the sole treatment or as a part of a combination therapy for cancer pain. Studies were included if they were controlled with a placebo or controlled against a drug-therapy or no-treatment group. The Cochrane criteria were used to assess the risk of bias. A total of 15 RCTs met our inclusion criteria. All of the included RCTs were associated with a high risk of bias. The majority of acupuncture treatments or combination therapies with analgesics exhibited favourable effects compared with conventional treatments in individual studies. However, a meta-analysis suggested that acupuncture did not generate a better effect than drug therapy (n = 886; risk ratio (RR), 1.12; 95% CI 0.98 to 1.28; P = 0.09). The comparison between acupuncture plus drug therapy and drug therapy alone demonstrated a significant difference in favour of the combination therapy (n = 437; RR, 1.36; 95% CI 1.13 to 1.64; P = 0.003). The results of this systematic review provide no strong evidence for the effectiveness of acupuncture in the management of cancer pain. The total number of RCTs included in the analysis and their methodological quality were too low to draw firm conclusions. Future rigorous RCTs will be necessary to assess the clinical efficacy of acupuncture in this area.

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...

Revolving scheme/cash round scheme at hospice Africa Uganda

IntroductionHospice Africa Uganda (HAU) was started as a catalyst to encourage the spread of palliative care for cancer patients and later also those with HIV/AIDS to improve their quality of...

Dietary energy density is associated with energy intake in palliative care cancer patients

Diet energy density (ED) is associated with energy intake (EI) in cancer patients. There is limited information on the influence of patient characteristics on this association, potentially hampering individual tailoring of dietary treatment in clinical practice. We studied the relation between ED (kcal/g) and EI (kcal/kg body weight per day), using a mixed linear model estimating both overall and individual intercept and slopes with patient characteristics as covariates. Age, sex, body mass index (BMI), tumor type, tertiles of survival, weight loss, hypermetabolism, low muscle mass, low serum albumin, inflammation, handgrip strength, and fatigue were entered in the model, and significant effects were retained (p < 0.05). Dietary intake was obtained from 251 food records (995 days) in a group of unselected palliative care cancer patients. ED and EI were calculated for each day including all food and beverages. Mean EI was 25.8 kcal/kg/day. Age, BMI, fatigue, and survival were negatively associated and hypermetabolism was positively associated with EI. Effect estimates (1 SD) were: -1.9 kcal/kg/day for age, -3.8 kcal/kg/day for BMI, -1.5 kcal/kg/day for fatigue, and 1.1 kcal/kg/day for hypermetabolism. For tertiles of survival, the effect was -4.3 kcal/kg/day for 1st and -2.6 kcal/kg/day for 2nd, as compared to 3rd tertile. After adjustment, ED was still positively associated with EI with an overall effect of 4.5 kcal/kg/day per 1 SD. Age, BMI, fatigue, survival, and hypermetabolism are associated with EI, but do not substantially influence the association between ED and EI in palliative care cancer patients.

Systematic Review of Rehabilitation Intervention in Palliative Care for Cancer Patients

Aim: Despite the gradually growing recognition of the importance of rehabilitation for cancer patients, the absolute level of awareness about rehabilitation still seems to be low in the field of cancer care, particularly in the field of palliative care for cancer patients. Methods: We carried out a systematic review of the literature pertaining to rehabilitation intervention in palliative care for cancer patients, using the medical literature database Pub Med. The key words were “cancer,” “palliative care,” and “rehabilitation.” The search was confined to interventional studies, and review papers, case reports and papers whose main text was in a language other than English despite being appended with an English abstract were excluded. Results: While the literature search yielded 604 published papers based on the keywords, only 8 were eligible for inclusion in this study, demonstrating the scarcity of published studies on this topic. The interventions used in these published studies placed emphasis on mental approaches rather than physical approaches based on the tradition of rehabilitation medicine. Intervention often involved group care rather than separate care for individual patients. Conclusions: This review demonstrates the scarcity of high-evidence-level studies well founded on oncology, and provides a direction for future studies on this subject.

Palliative care for cancer patients who experience self-perceived burden: suggestions from an qualitative study for bereaved family members

終末期がん患者はしばしば家族や医療者に対する負担感(self-perceived burden)を経験するといわれている. 負担感を和らげるためのケアが必要とされる一方で, どのようなケアが望ましいかを実証した研究はほとんどない. 本研究では, 終末期がん患者の感じている負担感の実態と, 患者の負担感を和らげるために必要なケアを調査するために, 28名のがん患者の遺族を対象に半構造化面接を行った. 内容分析の結果, 「がん患者の負担感の内容」(例: 下の世話をしてもらうのがつらい), 「がん患者が行っていた負担感に対するコーピング」(例: 家族の仕事や予定を優先するようにいう), 「家族の気持ちと対応」(例: 患者の遠慮は家族への思いやりの表れだと思った), 「患者の負担感に対して必要なケア」(例: ことさら何かを強調するのではなく, 自然な言葉がけをする)が抽出された. 収集された患者の負担感を和らげるためのケアの有用性の評価が今後の重要な課題である.

Palliative Cancer Patients’ experience of Physical Activity

Results from pilot studies indicate that palliative cancer patients report increased well-being and less fatigue after physical activity. This study aimed to explore how palliative cancer patients experienced physical activity. A qualitative design with semi-structured interviews was used. Eleven palliative cancer patients over 18 years old with different diagnoses and Eastern Cooperative Oncology Group Scale performance status levels of between 1 and 3 were interviewed. Four main themes emerged: routines of everyday life, less fatigue, professional guidance, and hope. The first theme comprised two categories: something to do, and being together with others in a similar situation. The theme professional guidance also comprised two categories: the physiotherapist as tutor, and the physiotherapist as motivator. Some cancer patients in palliative care who participated in physical activity experienced less fatigue and enhanced energy. Physical activity helps to bring structure to everyday life and gives a feeling of hope for the future.