Palliative Patient Population Research Articles

Intranasal Therapy in Palliative Care.

In recent years, the use of the intranasal route has been actively explored as a possible drug delivery method in the palliative patient population. There are reports demonstrating the effectiveness of nasally administered medications that are routinely used in patients at the end of life. The subject of this study is the intranasal drug administration among palliative patients. The aim is to summarize currently used intranasal therapies among palliative patients, determine the benefits and difficulties, and identify potential areas for future research. A review of available medical literature published between 2013 and 2023 was performed using online scientific databases. The following descriptors were used when searching for articles: "palliative", "intranasal", "nasal", "end-of-life care", "intranasal drug delivery" and "nasal drug delivery". Out of 774 articles, 55 directly related to the topic were finally selected and thoroughly analyzed. Based on the bibliographic analysis, it was shown that drugs administered intranasally may be a good, effective, and convenient form of treatment for patients receiving palliative care, in both children and adults. This topic requires further, high-quality clinical research.

Feasibility of a physical exercise intervention for patients on a palliative care unit: a critical analysis

BackgroundRecent exercise intervention studies have shown promising results in improving quality of life (QoL) and physical function (PF) in diverse chronic disease and advanced cancer patients. However, the effects of structured exercise in palliative care patients, having different therapeutic needs, lower life expectancies and PFs remain unknown. This study primarily aimed to assess the feasibility of an exercise intervention with follow-up by analysing recruitment numbers, screening procedures, acceptability, preferences, and safety of the exercise intervention as well as retention in follow-up. Our secondary aims related to changes in QoL and PF.MethodsThis study comprised of a one-arm design without a control group. Over 6 months, every in-hospital palliative care unit (PCU) patient was screened for eligibility. Eligible patients were asked to participate in a 2-week exercise intervention consisting of resistance training and/or endurance training with moderate or high intensity based on personal preferences and a 4-week follow-up. Before and after the exercise intervention, QoL and PF were assessed and a qualitative interview after the intervention addressed expectations and experiences of the exercise intervention. For follow-up, patients were provided with information on independent training and after 1 and 4 weeks a QoL assessment and qualitative interview were conducted.ResultsOf 124 patients screened, 10 completed the intervention with an adherence rate of (80 ± 25%), of which 6 patients completed follow-up. Endurance training was the most performed training type and only a few minor adverse events occurred in certain or likely connection to the exercise intervention. While physical QoL and PF measured by arm curl strength and time up and go performance improved, mental QoL and the other PF tests remained unchanged.ConclusionDespite the challenges that were faced in our screening and testing process, that are specific to the palliative patient population with their unique therapeutic requirements and varying mental-/ physical capabilities, we discovered the 2-week exercise intervention to be feasible, safe, and well tolerated by palliative care patients. Moreover, it seems that short-term improvements in QoL and PF are possible. Further full scale studies are required to confirm our findings.Trial registrationThe study was retrospectively registered on 25.01.2022 in the German Clinical Trials Register (DRKS00027861)

Outpatient Palliative Care Service Involvement: A Five-Year Experience from a Tertiary Hospital in Switzerland.

The value of early integration of palliative care has been demonstrated increasingly for the past years in both oncological and nononcological diseases. Outpatient palliative care services might represent a feasible approach to implement supportive care in early disease. In this study, we aimed at evaluating which patients use and benefit from outpatient palliative care services, which symptoms are addressed most, and which support services are installed in this early phase of disease. We retrospectively analyzed the entire patient collective of a recently developed palliative care outpatient clinic within the leading university hospital in Switzerland for a period of five years. Sociodemographics, symptoms, and information on disease as well as patient-reported outcomes were retrieved from the electronic patient files. Demographic and clinical data were analyzed by descriptive statistics between groups and survival was analyzed by means of Kaplan-Meier estimates and log-rank test. We report on 642 consultations of 363 patients between 2016 and 2020. Patients had a mean of 1.8 visits (range 1-10), with n = 340 patients (93.7%) of patients suffering from an oncological disease. Overall symptom load was high, with n = 401 (73.7%) of patient-reported outcomes reporting two or more symptoms. Distress levels of 5 or higher were reported in n = 78 (30.4%) of available patient-reported outcomes. Independent of the origin of primary disease and the length of the disease trajectory, patients were referred to the palliative care service in median only four months before death. We identify high symptom load and distress in the outpatient palliative patient population. Patients benefitted from supportive medication, improvement of ambulatory support systems and advance care planning, and more than one-third of patients remained in follow-up, indicating a good acceptance of the service. Overcoming the overall late referral could, however, further increase the quality of life at earlier stages of disease.

Scoring Systems May be Effective in Predicting Mortality Associated with Palliative Emergency Gastrointestinal Surgery: A Retrospective Observational Study

BackgroundPalliative emergency gastrointestinal surgery is associated with significant morbidity and mortality and weighing up the benefits and harms during the decision-making may be challenging. There are very few studies on surgery in palliative patient population. The aim of this retrospective study was to evaluate morbidity and mortality after palliative emergency gastrointestinal surgery and the usability of scoring systems in predicting the outcome.MethodsConsecutive adult patients undergoing palliative emergency surgery at a tertiary hospital during the period 2015 to 2016 were included. Pre- and post-operative functional status, morbidity and mortality of patients were assessed. The predictive value of the American Society of Anesthesiologists (ASA) classification, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) and Palliative index (PI) in estimating morbidity and mortality were determined.ResultsA total of 93 patients (age 69 [28–92] years, 51% female) were included. Typical indications for surgery were bowel obstruction (52%) and securing food intake (30%). Pre-operatively two patients (2.2%) were totally dependent in daily activities, while post-operatively the respective share was 34% at discharge from hospital. The incidence of post-operative complications was 37% and 14% died during the hospital stay. One-, three-month and one-year mortality rates were 41%, 63% and 87%, respectively. While ASA score, PI score and ACS NSQIP did not predict post-operative morbidity, both ASA score and ACS NSQIP SRC predicted post-operative mortality.ConclusionsPalliative emergency laparotomy is associated with significant post-operative mortality and morbidity. Scorings, such as ASA score and ACS NSQIP SRC predict mortality in this patient population.

Palliative radiation therapy for patients with orbital and ocular metastases.

Patients with cancer may develop metastases to the orbit causing distressing symptoms. External beam radiation therapy (RT) is an effective palliative treatment for patients with orbital and ocular metastases. The aim of treatment is to preserve vision and to reduce pain. Delivery of 30 to 40 Gy in 2 Fr fractions is a practice in many oncology centres. The aim of this study is to evaluate the outcome of shortcourse palliative radiotherapy in the management of orbital and ocular metastases. A retrospective study to review all patients with orbital metastases treated in 2016 to 2018 were performed. The primary outcomes were a change in visual acuity and tumor response. Secondary outcomes included toxicities of radiotherapy, symptomatic response and survival. Fifteen patients with 19 eyes were included. The most common presenting symptoms were decreased vision, periorbital swelling, and pain. The median follow-up period was 8 months. Visual acuity improved in 11 out of 13 (84.6%) of patients and remained stable in the remaining 2 patients. Partial and complete response (CR) of tumor was observed in 14 out of 15 (93.3%) of patients while one (6.6%) patient had stable disease. The overall response rate (ORR) was 100%. Two (13.3%) patients had grade 2 conjunctivitis. There were no grade 3-4 toxicities and no long-term toxicities observed. The median survival was 9.1 months from diagnosis of choroidal metastases. Short course palliative RT is effective and well tolerated in patients with orbital and ocular metastases. The current review showed that it effectively preserves vision and improves orbital symptoms with minimal radiation-induced toxicity. Short course radiotherapy will help to minimize the traveling time to the hospital and relieve the burden of a long treatment course in this palliative patient population.

P008: Care of palliative patients by paramedics in the 911 system

Introduction: Palliative Care aims to relieve suffering and improve the quality of living and dying in patients with life-limiting, progressive conditions. Many patients and families prefer to stay at home at end of life. Despite this, many access 911 in times of apparent crisis. It has been noted in the literature that a well functioning palliative care system includes considering Emergency Medical Services as part of the patients’ circle of care. Training in palliative care is traditionally limited or absent for prehospital clinicians, including Paramedics and Emergency Medical Services Physicians. Furthermore, in our region, there are currently no medical directives available to Paramedics within the 911 system specifically addressing the needs of palliative care patients. Methods: A feasibility study (Expanding Care by Paramedics for Palliative Patients – EC3P) was designed to evaluate implementation of a new palliative care medical directive with trained teams of Paramedics available to respond to 911 calls. As part of this study, a pre-implementation retrospective chart review was performed. Patient care records were screened for “palliative” within the past medical history and text fields. Information about dispatch and scene times, patient demographics, details of patient encounter, and disposition of the patient were recorded. Descriptive statics were used. Results: Data was reviewed for all calls in 2018. Call data was reviewed to exclude those that were pediatric (<18yo) and those whose palliative status was unknown or unclear. There was a total of 318 calls. The majority of the calls (83%) were between 7am and 8pm, with peaks at 10 am and 6pm. The majority were transported to hospital (74%), 16% were transferred to hospital initiated by their palliative care physician, 20% “refused” transport, and 6% were declared dead and not transported. The most common reasons for calling 911 were new symptoms or a sudden worsening of chronic symptoms, followed by needs exceeding caregiver capacity; the third most common was lift assist without apparent injury. Conclusion: Much is unknown about the palliative patient population as it intersects with prehospital emergency care. This study will help provide information needed to guide further research and implementation.

Assessing the credibility and transferability of the patient compassion model in non-cancer palliative populations

BackgroundA lack of evidence and psychometrically sound measures of compassion necessitated the development of the first known, empirically derived, theoretical Patient Compassion Model (PCM) generated from qualitative interviews with advanced cancer inpatients. We aimed to assess the credibility and transferability of the PCM across diverse palliative populations and settings.MethodsSemi-structured, audio-recorded qualitative interviews were conducted with 20 patients with life-limiting diagnoses, recruited from 4 settings (acute care, homecare, residential care, and hospice). Participants were first asked to share their understandings and experiences of compassion. They were then presented with an overview of the PCM and asked to determine whether: 1) the model resonated with their understanding and experiences of compassion; 2) the model required any modification(s); 3) they had further insights on the model’s domains and/or themes. Members of the research team analyzed the qualitative data using constant comparative analysis.ResultsBoth patients’ personal perspectives of compassion prior to viewing the model and their specific feedback after being provided an overview of the model confirmed the credibility and transferability of the PCM. While new codes were incorporated into the original coding schema, no new domains or themes emerged from this study sample. These additional codes provided a more comprehensive understanding of the nuances within the domains and themes of the PCM that will aid in the generation of items for an ongoing study to develop a patient reported measure of compassion.ConclusionsA diverse palliative patient population confirmed the credibility and transferability of the PCM within palliative care, extending the rigour and applicability of the PCM that was originally developed within an advanced cancer population. The views of a diverse palliative patient population on compassion helped to validate previous codes and supplement the existing coding schema, informing the development of a guiding framework for the generation of a patient-reported measure of compassion.

Clinical outcomes of hypofractionated radiation therapy for choroidal metastases: Symptom palliation, tumor control, and survival

PurposeExternal beam radiation therapy (RT) is an effective palliative treatment for patients with choroidal metastases and is aimed at preserving vision and obtaining local tumor control. Delivery of 30 to 40 Gy in 2-Gy daily fractions is a standard approach at many centers. This study reports the outcomes of a hypofractionated schedule of 20 Gy in 5 fractions in this palliative setting. Methods and materialsWe conducted a retrospective review of patients who were treated with RT (20 Gy in 5 fractions) for choroidal metastases between January 1999 and November 2012. The primary outcome measures were change in visual acuity and tumor response. Secondary outcomes included toxicities of RT, tumor control, and overall survival (OS) from diagnosis of choroidal metastases. Univariate and multivariable Cox regression modeling was used to investigate the predictors for OS. ResultsFifty-five patients with 71 affected eyes were included. Decreased vision was the presenting symptom in 43 eyes (61%). Visual acuity improved from a median of 20/70 at baseline to 20/40 at last follow-up and remained stable or improved in 56 eyes (80%). Tumor regression was observed in 64 eyes (91%) with complete response in 47 eyes (67%). Local progression occurred in 4 eyes (6%). The median survival after diagnosis of choroidal metastases was 13 months. No acute complications were observed in 49 patients (89%). Mild acute toxicities included transitory dryness in 5 patients and episcleritis in 1 patient. Cataracts, retinopathy, optic neuropathy, pigmentary maculopathy, and neovascular glaucoma developed in 4 eyes (6%), 1 eye, 7 eyes (10%), 5 eyes (7%), and 1 eye, respectively. No variables were statistically significantly associated with OS. ConclusionsA short fractionation schedule of 20 Gy in 5 fractions is a well-tolerated treatment that effectively preserves vision and gains local tumor control for many patients with choroidal metastases. This hypofractionated approach would help reduce the burden of a longer treatment course in this palliative patient population.

Outcomes of hypofractionated palliative radiotherapy for choroidal metastases.

194 Background: External beam radiotherapy (RT) is an effective palliative treatment for choroidal metastases aimed at preserving vision and obtaining local tumor control. Delivery of 30-40 Gy in 2 Gy daily fractions is a standard approach in many centers. At our center, a shorter, more convenient schedule of 20 Gy in 5 fractions has been used in this palliative setting. This study reports the efficacy and toxicity of this hypofractionated RT approach. Methods: We conducted a retrospective review of patients treated in the Ocular Oncology clinic at Princess Margaret Cancer Center who received RT (20 Gy in 5 fractions) for choroidal metastases between January 1, 1999 and November 30, 2012. Primary outcome measures were change in visual acuity and tumor response. Secondary outcomes included toxicities of RT, tumor control, and overall survival from the date of choroidal metastases diagnosis. Results: A total of 55 patients with 71 involved eyes were included. Decreased vision was the presenting symptom in 43 eyes (61%). Visual acuity improved from a median of 20/70 to 20/40 between baseline assessment and last follow-up, and remained stable or improved in 56 eyes (80%). On ultrasound, tumor regression was observed in 64 eyes (91%) with complete response in 47 eyes (67%). Metastases progressed in 4 eyes (6%) despite RT with 1 eye requiring enucleation. Median survival after diagnosis of choroidal metastases was 13 months with estimated overall survival at 1, 2, and 3 years to be 50% (36-62), 23% (12-35), and 8% (3-18), respectively. Forty-nine patients (89%) did not experience any acute complications. Mild acute toxicities included transitory dryness in 5 patients and episcleritis in 1 patient. Cataracts developed in 4 eyes (6%), retinopathy in 1 eye, optic neuropathy in 7 eyes (10%), pigmentary maculopathy in 5 eyes (7%), and neovascular glaucoma in 1 eye. Conclusions: A short fractionation schedule of 20 Gy in 5 fractions is a well-tolerated treatment that effectively preserves vision and gains local tumor control for many patients with choroidal metastases. This hypofractionated approach would help reduce the burden of a longer treatment course in this palliative patient population.

1435P - The Charateristics of Palliative Care in a Rural European Region

ABSTRACT The palliative care unit Landshut is one of the few centres accredited by the ESMO serving in a rural area (Lower Bavaria, Germany). It is part of the Network for Oncology and Palliative Care Medicine Landshut (Onkologisches und Palliativmedizinisches Netzwerk Landshut) which has been accredited 2010 by the ESMO as Designated Centre of Integrated Oncology and Palliative Care and the DGHO in 2011. The Network aims to improve the palliative care service with regard to the special needs of the rural cancer population. Data regarding palliative care of tumor patients in rural areas of Europe are lacking. In December 2010, a continuous data acquisition for patients on the palliative care unit located at the Hospital Landshut-Achdorf was started. We now present a cross sectional data analysis. Between December 2010 and March 2012, 499 patients were admitted for the first time to the palliative care unit. The majority of these patients were living outside the town boundaries, mainly in small villages. 84% of the patients were diagnosed with a solid tumour, 6% with a haematological malignancy, and 10% had a non-malignant disease. Before their first admission, 50% of the patients were treated with opioids, 44% of the patients had a central venous port system, 4% a gastric tube, and 10% had received parenteral nutrition. The most frequent symptoms leading to admission were reduced general health status (43%), uncontrolled pain (20%), dyspnoea (14%), nausea (8%), confusion (3%), and insufficient social support (3%). 48% of the patients died during the first admission. The mean time of hospitalization was 11 ± 7 days. After discharge from hospital, 37% were cared for by themselves or family members, 23% were visited by a community nurse or other nursing services, 19% were cared for by the outpatient palliative care program, 14% were admitted to a nursing home, 4% were transferred to another ward, and 3% to the hospice which had opened as recently as January 2012. Detailed data of the hospitalized palliative patients are presented and further discussed regarding the special needs of the growing rural palliative patient population. Disclosure All authors have declared no conflicts of interest.

Description of a Tertiary Swiss University Hospital Palliative Population Based on the International Classification of Disease (ICD): A Retrospective Pilot Study

The factors for assessing the utilization rate of a palliative care service are various and complex. Several authors have described different methods to address this problem. McNamara and colleagues have proposed criteria to determine "minimal," "mid-range," and "maximal" palliative population estimates. In order to evaluate the utilization of our intrahospital palliative care consult team (PCT), it appeared necessary to better describe and define the population who dies in our institution, a Swiss university hospital. The goal of this pilot study was to determine what percentage of patients who died in our hospital over a 4-month period in 2007 was seen by the palliative care consult team (PCT), using "minimal" and "maximal" population estimates. The hospital database was searched for all adult patients who died during that period and the "maximal" and "minimal" populations determined. The PCT's database was searched to identify those patients who had been seen by the PCT. The charts of a random sample of patients who did not initially meet the "minimal" criteria were hand searched. A total of 294 adult deaths were reported: 263 (89%) met the "maximal" criteria and 83 (28%) met the "minimal" criteria initially. The random search of 56 charts of the 180 patients who did not meet the "minimal" criteria revealed that 21 (38%) should have been included in the "minimal" population. The PCT saw 67/263 (25.5%) of the "maximal" palliative patient population and 56/151 (37.1%) of the "minimal" palliative population. This study highlights the usefulness of the method proposed by McNamara and colleagues to determine palliative populations. However, it also illustrates an important limitation of the "minimal" estimate and reliance on the accuracy of the cause of death as noted on the death certificate. A strategy to address this limitation is suggested. The "maximal" estimate suggests that the PCT is being underutilized.

Review of telephone follow-up experience at the Rapid Response Radiotherapy Program

To review the feasibility of telephone follow-up following a 3-year experience from 1999 to 2001 at the Rapid Response Radiotherapy Program as a prospective radiotherapy outcome assessment of symptom palliation. Patients referred for palliative radiotherapy for symptom control from 1999 to 2001 were asked to rate symptom distress using the Edmonton Symptom Assessment System (ESAS) at initial consultation. Patient demographics and analgesic consumption were recorded. Telephone follow-up interviews were conducted with all patients who received radiotherapy during weeks 1, 2, 4, 8, and 12 after radiotherapy using the ESAS and an analgesic diary. Clinic follow-up visits were conducted only if necessary. Between January 1999 and December 2001, 830 patients received palliative radiotherapy. Of these patients, 260 (31.3%) died during the 12-week follow-up period. The percentage of surviving patients responding to the telephone interview ranged from 48.2% (week 12) to 56.6% (week 4) during the 12-week study. Telephone follow-up is a feasible tool for prospective outcome assessment of symptom palliation in metastatic cancer patients. Telephone follow-up is recommended for outcome assessment of symptom relief when it can achieve the same purpose as clinic follow-up. Data collection remains a challenge in the palliative patient population. Further studies are required to determine how well other methods of maximizing data collection, such as through the use of caregivers, can provide reliable and accurate information.

Symptom control and palliative care content of abstracts presented at the Canadian Association of Radiation Oncologists annual meetings.

Half of all patients referred for radiotherapy are treated with palliative intent. Recent emphasis has been placed on the importance of symptom control and palliative care (SCPC) in the radiation oncology community. The purpose of this study was to determine the number of abstracts relating to SCPC presented at the annual Canadian Association of Radiation Oncologists (CARO) meetings, and whether this number has increased over time. SCPC abstracts presented at CARO from 1992 through 2002 were counted. Abstracts were included if they described a patient population with advanced or metastatic cancer treated with palliative intent. Abstracts were then categorized as reporting treatment outcomes, health services research, descriptive studies or literature reviews. Radiation treatment sites were recorded. An average of 6.7% (60/892; range 0-16.2%) of all abstracts presented at CARO from 1992 through 2002 pertained to SCPC. There was a significant increase in the proportion of SCPC abstracts accepted over time ( P=0.0012). Descriptive studies accounted for 46.7%, treatment outcomes 31.7%, health services research 13.3%, and literature reviews 8.3% of the SCPC abstracts. Bone metastases (48.3%), primary lung tumors (11.7%), and brain metastases (10.0%) were the most common treatment sites. Of all the SCPC abstracts, 45% came from dedicated palliative radiotherapy clinics. SCPC research is poorly represented at the annual CARO conferences. Research in this field should be promoted as the palliative patient population represents a large component of radiotherapy clinical practice. The recent emergence of dedicated palliative radiotherapy clinics should continue to increase palliative radiotherapy research.

Communicating with metaphor: a dance with many veils.

Health practitioners face many challenges when caring for and communicating with dying persons. As truth-tellers, we search for ways to communicate with honesty, sensitivity, and compassion. Creative use of language is one aspect of caring. Metaphorical communication can be a healing modality, one consistent with communication as an art. This article suggests that metaphor is a powerful and sensitive form of language that offers a range of characteristics particularly suitable for the art and the challenge of communicating with dying people. Metaphor, as figurative language, provides a permissible way of saying one thing and meaning another. It allows us to share a truth without the glare of reality. This author contends that metaphor is mysterious, creative, invitational, safe, open to interpretation, respectful and playful. The creative and judicious use of metaphor provides health care practitioners with many veils--veils that shield the dying from the glare of their prognosis, veils particularly valuable and suited in communicating with our palliative patient population.

A Reliability and Validity Study of the McMaster Quality of Life Scale (MQLS) for a Palliative Population

The McMaster Quality of Life Scale (MQLS) was developed to measure the quality of life in a palliative patient population. This paper describes the tool and its psychometric properties. Palliative stage patients could assess their condition using this tool (r = 0.84; 95% Cl 0.76-0.94). Although ratings by different raters (patient, family, staff) were correlated, systematic differences were found by source of rating, which suggests that proxy rating (substituting family or staff ratings for a patient rating) should be avoided. The MQLS was sensitive to changes in the patient's quality of life. Neither age nor sex of patient influenced total score obtained. Persons close to death rated their quality of life as being poorer than those who were alive at the end of the data collection period. People who needed to have the MQLS read to them rated their quality of life somewhat lower than patients who could complete the task by themselves. Staff-rated MQLS scores correlated significantly with the staff-rated Spitzer Quality of Life Index. This study suggests the MQLS is a reliable and valid measure of quality of life during the palliative phase.