Palliative Situation Research Articles

Dendritic cell-based vaccination of patients with advanced pancreatic carcinoma: results of a pilot study.

Dendritic cell (DC)-based vaccination can induce antitumor T cell responses in vivo. This clinical pilot study examined feasibility and outcome of DC-based tumor vaccination for patients with advanced pancreatic adenocarcinoma. Tumor lysate of patients with pancreatic carcinoma was generated by repeated freeze-thaw cycles of surgically obtained tissue specimens. Patients were eligible for DC vaccination after recurrence of pancreatic carcinoma or in a primarily palliative situation. DC were generated from peripheral blood mononuclear cells (PBMC), loaded with autologous tumor lysate, stimulated with TNF-α and PGE(2) and injected intradermally. All patients received concomitant chemotherapy with gemcitabine. Disease response was the primary endpoint. Individual immunological responses to DC vaccination were analyzed by T cell-based immunoassays using pre- and post-vaccination samples of non-adherent PBMC. Twelve patients received DC vaccination and concomitant chemotherapy. One patient developed a partial remission, and two patients remained in stable disease. Median survival was 10.5 months. No severe side effects were observed. Tumor-reactive T cells could be detected prior to vaccination. DC vaccination increased the frequency of tumor-reactive cells in all patients tested; however, the degree of this increase varied. To quantify the presence of tumor-reactive T cells, stimulatory indices (SI) were calculated as the ratio of proliferation-inducing capacity of lysate-loaded versus -unloaded DC. The patient with longest overall survival of 56 months had a high SI of 6.49, indicating that the presence of a pre-vaccination antitumor T cell response might be associated with prolonged survival. Five patients survived 1 year or more. DC-based vaccination can stimulate an antitumoral T cell response in patients with advanced or recurrent pancreatic carcinoma receiving concomitant gemcitabine treatment.

Palliative Care Situation in Palestinian Authority

Palliative care is a very new concept in Palestine. In fact, it is still not applicable or provided within the Palestinian health care system. However, Al-Sadeel Society had organized a one day workshop in Bethlehem on November 2008 for the health professionals from the governmental and non-governmental sectors to initiate and introduce the idea of palliative care for the first time in Palestine. The general population of Palestine is approximately 2.4 millions (2007), with a life expectancy of 74.3 years of age, the death rate is 3.7 per 1000 population, having 8,910 deaths a year. Deaths due to cancer were 2,305 in five years (1999-2003), where 5,542 new cases were newly diagnosed in the same period. Health services available for cancer patients are hospital units either in patient or day care units. According to the ministry of health (MOH) statistics there are 75 beds in oncology departments in MOH hospitals; represent 2.7% of the total number of beds available, and 60 beds in daily care departments with an occupancy rate at 231.8%. There is no hospice or bereavement follow up care available for patients or their families. Despite the fact that the Palestinian culture is one of the cultures that respect and care for the elderly, but at the end of life, when the load of symptoms is high, most of the patient are care for at hospitals, and usually dye there, because the families are not able to care for their patients, and as there is no system for home care available for the Palestinian patients, and if it is available it is available in limited places and on private bases that are expensive and not affordable to the majority of patients, gross domestic product (GPD) per capita= 1,100 as 2007 estimates). We conducted a needs assessment survey within the only four facilities that provide care for the oncology patients in the West Bank and were filled by the direct health care providers. The results were expressing the fact that there is no palliative care service available for cancer patients or their families, absence of organizations strategic planning for palliative care, No presence of educational resources for palliative care, No presence of communication or consultation to the clergy man, Absence of bereavement support group, no active follow up for the patient and the family, no standards for palliative care service or training programs in palliative care, no home care service for palliative care, absence of community awareness for palliative care And Absence of national standard for palliative care. The recommendations that we can conclude, depending on the needs assessment that we did, and according to the recommendations that come up through the workshop that was organized by Al-Sadeel Society and was attended by key personnel from the Palestinian MOH who summarized the conclusion, are as follows: 1. The need for better quality care for the cancer patient.2. The need for training of health professionals in palliative care.3. The importance of networking and cooperation between the national NGO's and the MOH.4. The need for public awareness regarding the early detection for cancer especially breast cancer.5. The need for national policy and standards for palliative care and opioids legislations.6. The importance of base line data and research. 7. The need for interdisciplinary team work in the issue of cancer. 8. To involve palliative care education within the curriculum of schools of health professions.

Opioids for Cancer Pain

Palliative care is an emerging topic in Turkey within recent years. Currently, there are only few number of palliative care services across the country and majority of the centers are pain control units. Morphine consumption rate per capita is low, accessibility and availability of morphine products are also limited. One of the main headings of Turkish Cancer Control Programme 2009-2015 is palliative care and a serial palliative care unit implementation with continuous training programmes is planned to be finalized until 2015. This article reviews the current palliative care situation in Turkey, opioid availability in Turkey and also briefly summarizes Pallia-Turk Project which is unique with respect to many different aspects for implementation, and can be a good model for many other countries that still did not have such an implemented palliative care program.

Success and Failure of Primary Medical, Nonoperative Management In Breast Cancer

Nonoperative but systemic therapy as first-line management is offered to some patients with breast cancer (BC) who have assumed limited life expectancy, such as older women or those who have distant metastases at initial presentation. We evaluated rates of and predicting factors for success and failure of this therapy approach. Seventy-five patients who were initially treated only systemically, and cases in which local control while avoiding surgery was the intended long-term therapy goal were analyzed. Additionally, two stage-dependent subgroups were distinguished (A: stage I-III, n = 31; B: stage IV, n = 44). Failure of therapy was defined as when secondary surgery had to be performed due to locoregional progression or in case of no surgery when severe locoregional clinical signs/symptoms were observed during the further course. Patients in group A were older than those in group B (81 vs. 67.5 years; P < 0.001) and showed an increased survival (5-year rates: 40.2% vs. 24.3%). In 24 patients of the entire cohort (32%), secondary surgery had to be performed; surgery was performed more often in group A (58.1% vs. 13.6%). In the cases in which no surgery was performed (n = 51), 11 women (21.6%) suffered from severe locoregional symptoms in the palliative situation (A: n = 1; B: n = 10). Although the presence of stage IV was a significant factor for therapy success (odds ratio (OR), 2.59; 95% confidence interval (CI), 0.95-7.05; P = 0.039), skin involvement was associated with failure of therapy (OR, 3.57; 95% CI, 1.16-11.11; P = 0.031). Nonoperative treatment may be offered to selected patients with BC who have assumed limited life expectancy. These women must be openly informed that this approach is not successful in nearly half of the cases.

Pediatric Resident Comfort Level in Palliative Care Situations and the Need for Formal Training During Residency (770)

Objectives 1. Gain knowledge about the perceptions of palliative care physicians and trauma surgeons regarding the role of family members in facilitating and/or constraining optimum care of SICU patients. 2. Gain understanding of the underlying socioemotional dynamic shaping family impact on processes of care in the SICU. 3. Gain awareness of the importance of integrating patientfamilies into the changing landscape of the SICU, capitalizing on family’s strengths, and moderating family distress. Background. The role of palliative care in intensive care unit (ICU) is growing. Previous research investigated the interface of palliative and surgical providers caring for surgical ICU (SICU) patients. Little is known, however, about providers’ perspectives on family members of ICU patients. Research objectives. In this presentation we examine palliative and surgical physicians’ perceptions of the role of family in facilitating and/or constraining optimum care of SICU patients presenting with sudden advanced illness (SAI). Methods. We conducted face-to-face interviews with a total of 16 palliative and surgical attending physicians at theUniversity of Alabama at BirminghamHospital, an academicLevel-1TraumaCenter. We queried respondents about experiences with patients presenting with SAI, asking providers to describe a typical case. Using qualitative methods, we analyzed interview texts for emerging themes characterizing physicians’ experiences with family members of SAI patients. We used physicians’ exemplary quotes to operationalize themes. Results. We identified three interrelated, crosscutting themes enabling or interfering with optimal care for SICU patients: (1) the primacy of emotions in the family’s processing the patient’s situation, (2) the relevance of knowledge in the family’s comprehension of the patient’s condition, and (3) the salience of expectations in the family’s management of the patient’s care Conclusion. Providing holistic care to patients and families with SAI can be challenging. Family members function as both patient advocates and physician antagonists. Navigating the complex needs of SICU patients and family involves collaboration of palliative and surgical physicians and requires tools for assisting family members with processing, understanding, and managing the severity of the patient’s condition. Implications for research, policy, or practice. As collaborations between palliative care and surgical providers become the norm, understanding the role of family members in the SICU will take on increased importance. Research in this area can lead to the development of educational modules for providers and psychosocial interventions for family members.

Writing for Publication: Disseminating the Wisdom of Palliative Care (P20)

patients and families? This workshop with explore the dimensions of hope and how it affects the care we provide for our patients. The art and science of hope will be explored through participant discussion in large and small group formats; an empirically-based presentation on hope; a 55-word story writing exercise; a panel discussion of hope and hopelessness; and a presentation of evidencebased communication techniques that strengthen hope and the empowerment of patients, families, and clinicians in the face of life threatening and challenging palliative medicine situations. Participants will have a chance to practice the communication skills in dyads.

Qualité de vie et transfusion en cancérologie: revue de la littérature

Blood transfusion's repercussions on quality of life are less well studied in cancer research, and rarer in palliative situation. It is necessary to look for studies dealing with anaemia to estimate its effects. In curative palliative situation, the situation is similar to that of curative stage patients. It is necessary landing quickly for anaemia to assure the patient's quality of life. Blood transfusion and more recently erythropoïesis-stimulating agents are effective treatments. In advanced palliative stage, transfusion improves symptoms (weakness and dyspnoea bound anaemia) and the patients’ well being. The treatment choice must be individual and has to follow an ethical behaviour in respect with the legislation.

Das Konzept der chronischen Erkrankung in der Palliativbehandlung onkologischer Patientinnen: Schweizer Daten und Fakten zu Mamma- und Ovarialkarzinom

In the last years, incurable oncologic diseases have become increasingly viewed as chronic disease processes. In order to evaluate the treatment course of a chronic disease and to demonstrate whether the concept of a palliative oncologic situation as a chronic disease can be translated into practice, it is essential to give an overview of the entire course of the disease (i.e. from the first diagnosis of recurrence/metastases to death). There are only few reports regarding this approach in the international literature. We present Swiss long-term data (1990-2007) for breast and ovarian cancer and demonstrate drawbacks and opportunities of an exact retrospective data collection and analysis. When an incurable disease which requires periodic therapy cycles to control progressive course and symptoms is increasingly treated with a strategy that permits stabilization and uses regimens that have limited cumulative toxicity with particular consideration of quality of life, then the requirements of a chronic disease management have been fulfilled.

Palliative Treatment and Palliative Care

I think there are substantial problems with the description of the therapeutic options in palliative settings on the final page of the article. Palliative therapy and palliative care are often confused, and that is the case for this article. In order to avoid the distinction, which is obviously either not known or too difficult or not desired, the wording used is that of “palliative situations.” If palliative medical ideas are indeed concealed in such “palliative situations,” the fundamental principles of palliative care are conspicuously absent. To focus only on interventional procedures (such as pleural puncture, pleurodesis, or endoscopic procedures) does not do justice to palliative care in any shape or form. This is regrettable-and more so, because a large proportion of patients with carcinoma of the bronchus dies from their tumor and palliative care approaches should be used in this setting. The authors do not mention the benefits of rehabilitation measures at all. Prevention, however, is mentioned. If the authors had actually conducted a comprehensive literature search, such as was done in setting out the S3 guideline for Germany, they would have discovered that rehabilitation measures-for example, an aerobic endurance training program-are extremely suitable for improving patients’ performance in the shortest time, and thus improving their quality of life to a measurable degree. This means that two crucial strategies in the management of lung cancer patients were omitted.

Invasive Palliative Interventions

In palliative cancer care situations, invasive palliative interventions are frequently considered. The perception of invasiveness has a wide range and is subjective. A structured palliative care approach can guide decisional processes. It may contain 6 key elements: (1) multidimensional and multiprofessional assessment patients current priorities, (2) quality of current symptom management for the potential target intervention, (3) documentation of potential reasons to reduce symptomatic medications, (4) cautious judgment if patients' potential clinical benefit can be extrapolated from published evidence, (5) a decisional process for the considered intervention (e.g., the 7 P's model: priority, price, probability, prognosis, progression, prevention, preferences), and (6) agreement on the goal of the intervention before the invasive intervention. The examples of pleural effusion and parenteral nutrition are briefly emphasized. Oncologists may be competent to foster patients' participation in decision making and to use available specialist palliative care competencies and those of other professions.

Aktuelle Therapieoptionen bei rezidivierenden Kopf-Hals-Tumoren

Recurrent disease is one of the main reasons for the persistently poor prognosis of squamous cell carcinoma of the head and neck (HNSCC; European 5-year survival, 42%). The main treatment option for primary and secondary malignancy as well as recurrent disease is surgical therapy. If R0 resection (resection margin >5 mm) for a primary tumor is not viable, survival probability is reduced by 50%. In recurrent or secondary tumors with R1- or -2 resection or in the presence of non-resectable metastases, a palliative situation results in more than 80% of cases. In the case of surgery following radiotherapy or radiochemotherapy, attention should be paid to the criteria for salvage surgery (tissue perfusion, fibrosis, wound healing) and the procedure adapted to focus on functionality. In the case of relapse, primary surgery can potentially be supplemented with adjuvant therapy protocols such as (re-) irradiation, as well as possibly with chemotherapeutic agents or targeted therapies. Interdisciplinary collaboration and case discussions should take place in the context of a tumor board.

Bendamustine and cetuximab as an alternative therapeutic option for recurrent head and neck squamous cell carcinoma.

e16029 Background: The risk of recurrence in patients with squamous cell cancer of the head and neck (SCCHN) is high. In general, the therapeutic options after failure of a standard cisplatin-based chemotherapy ± radiotherapy are extremely limited due to the prior intensity of therapy and/or the reduced physical condition of the patient. As a monotherapeutic drug even in relapsed SCCHN cetuximab has shown activity. Also there are reports of the activity of bendamustin in relapsed SCCHN. Because of the moderate toxicity profile of bendamustine, we used it as a combination partner to cetuximab. In this highly palliative situation after failure of standard therapy in inoperable patients we treated 28 patients with the combination of cetuximab and bendamustine. Methods: We administered cetuximab in a starting dose (day 0) of 400 mg/m2, from day 8 subsequently weekly 250 mg/m2 till a progressive disease had to be observed. Bendamustine (Day 9, 10) 100 mg/m2 in a three week cycle also till progression. Results: So far, this therapy seems to be highly effective, so after 26 weeks 10 patients showed a partial response, 10 patients a stable disease and 8 patient was progressive. The therapy has been well tolerated (grade I/II rash symptoms by cetuximab), hematological grade III/IV toxicities were not observed. Conclusions: Similar therapeutic results have not been observed by us before and thus should be investigated further. No significant financial relationships to disclose.

Fulminante Duodenalblutung als Erstmanifestation eines neuroendokrinen Pankreaskopfkarzinoms

A 73-year-old male patient presented with upper gastrointestinal bleeding. The reason was an arterial hemorrhage from a duodenal tumor that could only be stopped by an angiographic intervention. In the further staging, there was evidence for a neuroendocrine carcinoma of the pancreatic head with infiltration of the duodenum and hepatic metastases. Due to good differentiation (G1) a systemic biotherapy with octreotide LAR was induced. After recurrent bleeding with arrosion of a branch of the superior mesenteric artery, a duodenum-preserving pancreatic head resection was performed. Afterwards, the systemic therapy was changed to a palliative chemotherapy with streptozotocin and 5-fluorouracil due to local progression of the disease and a Ki-67 index of 4% in the primary tumor. In about 0.7% of patients with neuroendocrine tumors, the lesion is located in the pancreas. At this site these entities are very heterogeneous. The majority are nonfunctional tumors without secretion of bioactive substances and the associated symptoms. About 60% of the patients present with advanced metastasized disease. The therapy depends on the local spread and histological grading as well as symptoms of the patient. The only curative option represents surgical resection. However, even in a palliative situation, there can be benefit for the patient in case of a tumor mass reduction of > 90%. Alternative therapies in the palliative situation are somatostatin analogs, a classic systemic chemotherapy, or locoregional interventional procedures.

Outcome of sinonasal melanoma: Clinical experience and review of the literature

Primary sinonasal malignant melanoma (SNMM) is a rare clinical entity. There is neither a classification nor a staging system nor an evidence-based treatment concept established. Our objective was to find potential risk factors predicting the outcome. Twenty-five patients with histologically confirmed SNMM were consecutively included and retrospectively analyzed. Staging methods were nasal endoscopy, CT, MRI, and positron emission tomography (PET) scan. Patients were selected for a curative or palliative concept. All patients had postoperative follow-up with control-MRI at 3 and 6 months. Restaging was performed when local recurrence occurred. Nineteen patients underwent primary surgery with curative intention; in 16 cases with tumor free margins. Thirteen patients (68%) had transnasal endoscopic surgery, 4 lateral rhinotomy, and 2 transfacial approach with orbital exenteration. Six patients (32%) had palliative therapy and 7 patients (37%) had adjuvant radiotherapy. Despite radical operations, 6 patients (37%) showed local recurrence and 8 patients (50%) developed distant metastasis. In 2 patients with incomplete surgery, regional metastasis was noted. The median disease-free interval was 18 months, and the median overall survival rate was 23 months. SNMMs of the ethmoid and maxillary sinuses have a worse prognosis than other localizations in the nasal cavity; infiltration into the skull base, orbit, or facial soft tissue correlates with a very poor outcome corresponding to the palliative situations. Furthermore, local recurrence insinuates aggressive disease with short survival rate. A main difference from its cutaneous counterpart seems to be a primary tendency to hematogenic spread. Further research is needed to confirm these findings.

Sinnhaftigkeit und Dauer von palliativer Chemotherapie in Bezug auf die Lebensqualität betroffener Patienten

I am reporting on a 74-year-old female patient with primary pulmonary and hepatic metastatic colon cancer. In the course of three-and-a-half years the patient decided to receive multiple cycles of palliative chemotherapy, irradiation of the liver and of the upper body. As a result of the extended anti-tumour therapy, remissions of the advanced cancer disease could be achieved repeatedly, which lead to a substantial increase of the patient's quality of life. This case shows that even in an advanced palliative situation the goal of a multimodal treatment is to curb disease progression and to extend the life and increase quality of life of the patient.

Treatment of malignant pleural effusion: consequent talc pleurodesis shows best results

Objectives: Many patients suffering from malignant diseases have pleural effusion. This often causes dyspnoea and worsens the quality of life extremely. Therefore the aim of this study was to show an effective way to treat the malignant pleura effusion in these palliative situations.

Use and comprehension of complementary and alternative medicine in breast cancer patients: Results from cognitive interviews

Introduction Studies about the use of complementary and alternative medicine (CAM) show that oncological patients and, among these, most often women, frequently use CAM. However, prevalence of CAM use differs greatly between different studies. The patients’ understanding of CAM (e.g. what exactly constitutes homeopathy) is rarely investigated. Materials and methods This study involves 2 steps: (1) surveying female breast cancer patients in a neoadjuvant, adjuvant or palliative treatment situation. A total of 172 patients returned the questionnaire concerning their CAM use plus EORTC-QLQ; (2) cognitive interviews were performed with 17 patients within the framework of validating the questionnaire. By using the think aloud technique , difficulties in understanding the questionnaire were examined, and the comprehension of CAM methods was explicitly probed. Qualitative content analysis was applied to the data and more themes emerged from the cognitive interviews besides validation issues. These results will be presented here. Results Patients use CAM for both cancer-specific (e.g. prevention of relapse) and non-specific reasons (e.g. general well-being). Some patients reported preferring conventional medicine for the cancer-specific therapy, but integrated CAM as a means of general support. Comprehension of CAM modalities was often vague, e.g. the term “homeopathy” was repeatedly used as a generic term for CAM. Most interviews demonstrated that the allocation of different CAM modalities was unclear. In some cases we evidenced considerable contradictions, e.g. an extensive adjustment of nutrition that was not described as keeping a specific diet. Discussion A significant lack in patients’ comprehension as to what exactly is a feature of which CAM modality might be a cause of the variability of CAM use seen in different studies. The fact that many patients are not well informed about CAM methods often prescribed by different therapists demonstrates the risk of interactions between CAM modalities among themselves and with conventional medicine. Conclusion Regarding the integration of CAM and conventional medicine many patients wish for and implement themselves, their comprehension of CAM modalities and modes of action plays an important role. Being aware of this is crucial in order to ensure a patient-centred treatment.

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation.

BackgroundToday, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest.MethodsDuring a period of 2 years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate.ResultsEighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48 h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol.ConclusionsStrategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or “Do not attempt resuscitation” orders should be more readily available and should be adhered to more closely.

Pharmakotherapie für Alterspatienten. Allgemeine Grundsätze und die Behandlung der Agitiertheit im Speziellen

The biggest problem of gerontopharmaceutic therapy is polypharmacy, because it potentiates side effects and malcompliance. Best practice today includes instruction of long time patients in medication self management, which includes regular use of detailed taken medication lists. In gerontopharmaceutic therapy the following substances should be avoided: anticholinergics, dopamin receptor stimulants, long acting oral antidiabetics, benzodiazepine (other then for substitution in low dose dependency, in anaesthesia or in palliative situations) and neuroleptics (other then for psychotic symptoms). In unspecific agitation with or without dementia the measure of first choice is adaption of the milieu, which may be supported by the prescription of a sedative non tricyclic antidepressive medication.

The need for hospital-based neonatal palliative care programs in Saudi Arabia

The terms palliative care, supportive care, and comfort care are used to describe individualized care that can provide a dying person the best quality of life until the end. The term “end-of-life care” is also used in a general sense to refer to all aspects of care of a patient with a potentially fatal condition. While the concept of palliative care is not new, it has only recently been applied to the neonatal population. To the best of our knowledge, none of the neonatal intensive care units (NICUs) in Saudi Arabia have adopted a neonatal program for palliative care. We believe the main reason is lack of knowledge of such programs and the fear of being accused of being heartless and cruel by providing comfort care for dying babies. Comfort care begins with the diagnosis of a life-threatening/terminal condition, and continues throughout the course of illness regardless of the outcome. In this perspective, our aim is to introduce these programs for caregivers in the NICUs in Saudi Arabia. For this purpose, we have reviewed the current recommendations in establishing neonatal palliative care programs and discussed some of the social and religious aspects pertaining to this issue.