Palliative Situation Research Articles

The Diagnosis and Treatment of Ampullary Carcinoma.

Ampullary or papillary carcinoma is a malignant tumor arising from the mucosa in the region of the major duodenal papilla, also known as the ampulla of Vater. Uniform treatment recommendations are lacking both for the adjuvant situation and for palliative care. A selective literature search was carried out in PubMed in order to identify the most informative publications concerning the epidemiology, clinico-pathological background, and surgical and medical treatment of this condition. Ampullary carcinoma has an incidence of 0.5 to 0.9 per 100 000 persons and a poor prognosis, with a 5-year survival rate of 41% to 45% for locally confined and 4% to 7% for metastatic disease. Most such tumors are of an intestinal or a pan - creaticobiliary immunohistochemical subtype; the latter has a worse prognosis (median survival, 72-80 vs. 33-41 months). Targeted treatment is not yet available for either subtype, nor is there enough scientific evidence available for the formulation of specific therapeutic recommendations in either the adjuvant or the palliative situation. The treatment of choice for ampullary carcinoma is radical oncological resection of the head of the pancreas with systematic lymphadenectomy. Five-year overall survival is between 10% and 75% depending on the stage. No definitive recommendation for adjuvant therapy can be given. Palliative therapy can be oriented to the published treatment strategies for cancer of the colon, pancreas, and bile duct. The current state of the evidence on the treatment of ampullary carcinoma is poor. Therapeutic decisions should be discussed in an interdisciplinary tumor board and should, in our opinion, take the histological subtype into account.

Prise en charge nutritionnelle d’une patiente âgée obèse atteinte de sclérose latérale primitive

A patient in a nursing home suffered from primary lateral sclerosis (PLS), which is a slowly progressive neuromuscular disease, in her case, very disabling. She gradually developed obesity. The possibility of an underlying sarcopenia was eliminated, and the weight gain was explained by very low physical activity and especially uncontrolled snacking. In the absence of treatment for PLS, the patient was considered to be in a palliative situation. Invoking respect for her quality of life, she refused to moderate her snacking. The only recourse was to provide dietary advice to the patient, the teams and her family. This clinical case highlights the difficulty of nutritional assessment and management of people with neurological and neuromuscular diseases.

SOP—pain therapy for tumour patients in a palliative care situation

SOP—pain therapy for tumour patients in a palliative care situation

Alloplastic reconstruction of the mandible after subtotal mandibulectomy for medication-related osteonecrosis of the jaw: An update of the method.

Reconstruction of continuity defects following osteonecrosis in multimorbid patients is challenging. In all cases of the predescribed palliative treatment method for alloplastic mandible reconstruction, plate fractures were detected in follow-up. We hypothesized that a modification could avoid these fractures, leading to stable long-term results. This retrospective study compares the original method with a modification using single, laser-sintered CAD-CAM plates instead of manually bent miniplates. The predescribed shuttering technique was used to reconstruct the mandible in its original shape with bone cement. Uneventful wound healing was observed in 86% of the cases after modification of the method. No implant or plate fracture occurred. The presented method should be considered as a treatment option for mandible reconstruction in elderly, multimorbid patients in palliative situations. The results of this study suggest that the modification of the method leads to significantly improved long-term stability. Donor site morbidity is avoided with this method of palliative surgery.

Contribution of collegial support meetings (CSM) in the management of complex situations of patients with advanced cancer.

Collegial support meetings (CSM) have been set up in the Gustave Roussy Cancer Center for inpatients whose complex care requires a multi-professional approach involving many participants: oncologists but also health-caregivers, a member of the palliative care team, an intensivist, and a psychologist. This study is aimed at describing the role of this newly multidisciplinary meeting implemented in a French Comprehensive Cancer Center. Each week, the health-caregivers decide which situations should be examined, depending on the difficulty of a case. The discussion goes on to include the goal of treatment, the intensity of care, ethical and psychosocial issues, and the patient's life plan. Finally, to obtain feedback from the teams, a survey has been distributed to assess the interest in the CSM. In 2020, 114 inpatients were involved, and 91% were in an advanced palliative situation. During the CSMs, 55% of the discussions focused on whether to continue specific cancer treatment-29% about whether to continue invasive medical care-50% about optimizing supportive care. We estimate that between 65 and 75% of CSMs influenced further decisions. Death occurred during the hospitalization for 35% of the patients that were discussed. The lapse of time between last chemotherapy and death was 24days (IQR, 28.5). CSMs were well received, since 80% of the teams find these meetings useful. CSMs reach conclusions for medical and nursing staff involved, in order to improve the management of inpatients with cancer in advanced palliative situation and to define the better goals of care.

Percutaneous transhepatic ultrasound-guided gallbladder aspiration: Still a safe option for gallbladder decompression in patients at high surgical risk.

Cholecystitis generally warrants immediate cholecystectomy; however, high-risk patients require non-surgical options for gallbladder decompression. The continuous evolution of endoscopic techniques makes it difficult for clinicians tochoose the best technique for high-risk patients. Here we aimed to show that percutaneous transhepatic gallbladder aspiration, a technique that has fallen into disuse, is a safe and rapid method for gallbladder decompression. In our local database, we identified 48 patients who had undergone transhepatic punctures of the biliary system,34 of whom were excluded because they had received bile duct punctures. The remaining 14 patients had received gallbladder punctures, of whom 9 were considered eligible for analysis. Cases were retrospectively analyzed for technical success, complications, and individual outcomes. Our analysis included 9 patients (3 female, 6 male; median age, 51 years; range, 32-84 years). Underlying malignancy was found in 5 patients, while 4 were in a palliative situation. Underlying infection was found in 8 cases. All punctures were technically successful without complications. In all patients, individual therapy goals were met,including clinical stabilization in palliative situations, stabilization before liver surgery, exclusion of gallbladder empyema and infection in gallbladder hydrops, and avoidance of gallbladder rupture. The white blood cell counts at the day of punction were significantly reduced one week after the puncture (p=0.023). When selecting an appropriate technique for high-risk patients, clinicians should remember that gallbladder aspiration is a feasible and successful bedside procedure in patients at high surgical risk, which does not require an experienced endoscopist.

Evolution of parenteral nutrition practices in a comprehensive cancer center: Comparative audits

Malnutrition affects 20% to 70% of oncology patients depending on the patient's age, type and stage of cancer. Two audits were carried out in 2016 and 2019 to evaluate the practice of Parenteral Nutrition (PN). Records of adult medical inpatients who received PN between January 1, 2018 and April 30, 2019 were retrospectively analysed. Twenty criteria were defined. We conducted a statistical analysis to compare the two audit data. Between January 1, 2018 and April 30, 2019, 86 hospitalizations with a PN prescription were analysed. Of the 69 patients, 66% were female, the mean and median age was 60 years. These were most often medical oncology patients in palliative care. Gynecological and digestive tumors were the two main tumor localization. Bowel obstruction and palliative care management were the two main reasons for hospitalization. Nutritional assessment, amount of energy prescribed, monitoring, and duration of PN remain with poor results. Our study seems to show improvements in the relevance of PN indications, the prescription, and monitoring in patients due to the computerization of prescription and training of professionals. PN remains often prescribed in exclusive palliative situations. We need to continue our improvements, particularly for the initial clinical and biological assessment, and the monitoring. It requires a referral team to improve management of patients treated with PN.

What does the general and abdominal surgeon need to know about oncologically oriented radiotherapy?

Radiotherapy is an integral component of most modern multimodal tumor treatment concepts, both in palliative and curative situations and intentions. This also applies to many tumor entities relevant in general as well as abdominal surgery. This can give rise to new challenges in the context of the daily clinical routine and interdisciplinary tumor conferences. Practice relevant overview, based on selective references from the current scientific literature in medicine and own experiences obtained in daily work, for the oncological surgeon on radiotherapy-associated options for visceral tumor lesions. Aparticular focus is on rectal cancer, esophageal cancer, anal cancer and liver metastases. Anarrative review is given. In total neoadjuvant therapy it is possible to avoid resection in rectal cancer if a good response is achieved and close monitoring can be provided. In esophageal cancer neoadjuvant chemoradiotherapy followed by resection can be considered the therapeutic regimen of choice for all suitable patients. If surgery is not an option, definitive chemoradiotherapy is an appropriate and favorable alternative, especially with respect to squamous cell carcinoma. Even taking the latest data on the topic into account, definitive chemoradiotherapy remains undisputedly recommended for anal cancer. Liver tumors can be locally ablated by stereotactic radiotherapy. Close cooperation between disciplines in the context of tumor therapy remains essential for the best possible treatment and outcome of patients.

Emergency medical services and palliative care: a scoping review

ObjectivesThe aim of this study was to map existing emergency medical services (EMS) and palliative care literature by answering the question, what literature exists concerning EMS and palliative care? The...

"I Needed to Know, No Matter What I Do, I Won't Make It Worse"-Expectations and Experiences of Last Aid Course Participants in Germany-A Qualitative Pilot Study.

The need to care for a loved one in a palliative state can lead to severe physical as well as psychological stress. In this context, Last Aid courses have been developed to support caring for relatives and to stimulate the public discussion on death and dying. The purpose of our pilot study is to gain an understanding of the attitudes, values, and difficulties of relatives caring for a terminally ill person. A qualitative approach was used in form of five semi-structured guided pilot interviews with lay persons who recently attended a Last Aid course. The transcripts of the interviews were analyzed following Kuckartz's content analysis. Overall, the interviewed participants have a positive attitude toward Last Aid courses. They perceive the courses as helpful as they provide knowledge, guidance, and recommendations of action for concrete palliative situations. Eight main topics emerged during analysis: expectations regarding the course, transfer of knowledge, reducing fear, the Last Aid course as a safe space, support from others, empowerment and strengthening of own skills, and the improvement needs of the course. In addition to the expectations before participation and the knowledge transfer during the course, the resulting implications for its application are also of great interest. The pilot interviews show initial indications that the impact, as well as supportive and challenging factors regarding the ability to care for relatives to cope, should be explored in further research.

Pain Management in Palliative Care

Patients in the palliative phase of a disease often suffer from pain, which leads to a significant reduction in quality of life. Since in most cases there is a progression rather than an improvement of the disease over time, pain therapy must also be dynamically adapted. Due to accompanying symptoms and the physical burden of the disease, treatment of pain is often difficult. In the palliative situation, pain should not only be understood as an excitation of nociceptors but is rather also an expression of mental stress. In this article, we would like to give an overview of the available drugs, application methods and alternative treatment options. Specifically, the article is divided into the following subsections: non-opioid analgesics, opioids, co-analgesics, patient-controlled analgesia procedures, neuraxial and peripheral regional anesthesia procedures, neurolysis, supportive therapies and palliative sedation. Thus, when treating palliative patients, the focus should not only be on the one symptom of pain, but, in the sense of the bio-psycho-social model, a multimodal oriented treatment of the patient with all his symptoms, also including his relatives, must be carried out.

Sarcopenia remaining after intensive nutritional feeding support could be a criterion for the selection of patients for surgery for oesogastric junction adenocarcinoma.

Sarcopenia is recognized as a negative prognostic factor in several cancers. The aim of this study was to investigate the impact of nutritional support with feeding jejunostomy (FJ) on the occurrence of sarcopenia and how it may affect postoperative short-term outcomes and long-term survival outcomes in patients undergoing esophagectomy for oesogastric junction adenocarcinoma (OJA). Patients with OJA were included. The presence of sarcopenia was determined using cutoff values of the total cross-sectional muscle tissue measured on CT scan. We analyzed risk factors for sarcopenia occurrence and the impact of preoperative sarcopenia on postoperative results, overall survival and disease-free survival. A total of 124 patients were eligible for analysis. Ninety-one patients underwent surgery after chemotherapy, and 72 of them received preoperative FJ. Among the 91 patients, 21 patients (23.0%) were sarcopenic after preoperative chemotherapy. Multivariate analysis showed that FJ is a protective factor against sarcopenia occurrence. Overall survival was significantly different between sarcopenic and nonsarcopenic patients (median survival=33.7 vs. 58.6 months, respectively, p=0.04), and sarcopenia occurrence was an independent risk factor for overall survival in patients who underwent surgery (HR=3.02; CI 95% 1.55-5.9; p<0.005). Subgroup analyses showed no differences in overall survival between patients who presented sarcopenia despite nutritional prehabilitation with a FJ and patients excluded from surgery in palliative situations (median survival=21.9 vs. 17.2 months, respectively, p=0.46). The persistence of sarcopenia after preoperative chemotherapy despite renutrition with FJ could be a selection factor to propose curative surgery for OJA.

Challenges developing an electronic patient-reported outcome measurement for palliative home care: A qualitative interview and focus group study

Background: Patient-reported outcome measures have the potential to improve outcomes, quality, and effectiveness of care. Digital use of patient-reported outcome measures could be an option to foster implementation in palliative care. The Palli-MONITOR study focused on developing and testing an electronic patient-reported outcome measure in specialised palliative home care. As part of this study, we examined setting-specific challenges for the development of the measure. Aim: We aimed to identify and explore challenges for the development of electronic patient-reported outcome measures as standardised assessment in specialised palliative home care. Design: Qualitative approach with semi-structured interviews and focus groups. Data were thematically analysed using the framework method. Setting/Participants: Patients and professionals from five German palliative home care teams. Results: Patients described potential problems in using electronic questionnaires due to their deteriorating health. Answering the electronic questionnaire encouraged patients to reflect on their current palliative situation, which was partly perceived as burdensome. Identified concerns and questions regarding the future roll-out of electronic patient-reported outcome measurement addressed the process of receiving and using the provided information in clinical care routine. Challenging factors on organisational and structural level were the potential undermining of the established 24-h emergency call system and the potential use for patients. Conclusions: Our results provide a multifaceted picture of challenges developing electronic systems for patient-reported outcome measurement in palliative home care on the individual and organisational level. The study underpins the benefit of stakeholder involvement creating digital health innovations and emphasises the importance to therefore mind setting specific culture.

Patient-controlled analgesia in palliative care - Concepts and practical aspects

Patient-Controlled Analgesia (PCA) involving the use of on-demand subcutaneous or intravenous opioids offers patients greater autonomy in managing pain. In palliative situations, this method allows a continuous background infusion rate of opioids and allows a patient to self-administer a pre-set bolus dose of opioids. Indications for PCA are moderate to severe pain that is not relieved by 3rd level analgesics administered in oral ore transdermal route or by intermittent injections. PCA prescription, programming, initiation, and safety monitoring require the vigilance of a trained interdisciplinary team. PCA is safe and effective on hospice inpatients and outpatients and encourage their return or their stay at home.

Pneumologie meets Onkologie

Lung cancer is common and associated with a high mortality. After major therapeutic advances in the palliative situation of non-small cell lung cancer (NSCLC), new therapeutic concepts including immunotherapy and targeted tumor therapy have now also reached the curative stages. Osimertinib and atezolizumab have recently been approved under certain conditions in adjuvant therapy after complete tumor resection. In addition, the first approval of a neoadjuvant immunochemotherapy in Germany is expected soon. In the palliative therapy setting, comprehensive molecular pathological diagnostics on oncogenic mutations are required. Many drugs addressing these targets are now available predominantly for first line therapy but also although less for second line therapy. If there are no possibilities to address driver mutations, immunotherapy and immunochemotherapy are available depending on the programmed death ligand 1 (PD-L1) status. Overall, these new therapeutic options have already significantly improved therapy tolerability and the prognosis of lung cancer. Specific side effects must be considered. For small cell lung cancer (SCLC), palliative immunochemotherapy provides a moderate improvement in the prognosis. The introduction of lung cancer screening by low-dose computed tomography (CT) in Germany is to be expected in the coming years. The advantages are a relative reduction in lung cancer mortality of approximately 20% with a number needed to screen of 250. The disadvantage is particularly the expected number of false positive findings. A screening program must be established as a structured and quality assured procedure.

The APSY-SED study: protocol of an observational, longitudinal, mixed methods and multicenter study exploring the psychological adjustment of relatives and healthcare providers of patients with cancer with continuous deep sedation until death

BackgroundSince 2016, France is the only country in the World where continuous deep sedation until death (CDSUD) is regulated by law. CDSUD serves as a response to refractory suffering in palliative situations where the patients’ death is expected to occur in the following hours or days. Little is known on the psychological adjustment surrounding a CDSUD procedure for healthcare providers (HCPs) and relatives. Our study aims to gather qualitative and quantitative data on the specific processes behind the psychological adjustment of both relatives and HCPs, after the administration of CDSUD for patients with cancer.MethodsThe APSY-SED study is a prospective, longitudinal, mixed-methods and multicenter study. Recruitment will involve any French-speaking adult cancer patient for who a CDSUD is discussed, their relatives and HCPs. We plan to include 150 patients, 150 relatives, and 50 HCPs. The evaluation criteria of this research are: 1/ Primary criterion: Psychological adjustment of relatives and HCPs 6 and 13 months after the death of the patient with cancer (psychological adjustment = intensity of anxiety, depression and grief reactions, CDSUD-related distress, job satisfaction, Professional Stress and Professional experience). Secondary criteria: a)occurrence of wish for a CDSUD in patients in palliative phase; b)occurrence of wish for hastened death in patients in palliative phase; c)potential predictors of adjustment assessed after the discussion concerning CDSUD as an option and before the setting of the CDSUD; d) Thematic analysis and narrative account of meaning-making process concerning the grief experience.DiscussionThe APSY-SED study will be the first to investigate the psychological adjustment of HCPs and relatives in the context of a CDSUD procedure implemented according to French law. Gathering data on the grief process for relatives can help understand bereavement after CDSUD, and participate in the elaboration of specific tailored interventions to support HCPs and relatives. Empirical findings on CDSUD among patients with cancer in France could be compared with existing data in other countries and with results related to other medical fields where CDSUD is also conducted.Trial registrationThis protocol received the National Registration Number: ID-RCB2021-A03042-39 on 14/12/2021.

Palliative and Hospice Care in Nursing Homes: Discrepancies Between Theoretical Framework and Everyday Practice

Despite the existence of a legislative framework, palliative care and hospice support in nursing homes vary widely. Although most nursing homes have palliative care concepts by now, they are rarely integrated into everyday practice. This study aims to examine differences in palliative and hospice care and to determine the causes of discrepancies between theoretical framework and everyday practice. Based on a pilot project, in depth structural and process analyses of two nursing homes in urban and rural areas in North Rhine-Westphalia were conducted. In addition, three nursing homes of an extended group of providers as well as an expert advisory board was included to minimize (provider-) specific characteristics and to expand findings. Although the proportion of palliative residents and their average age was comparable, analyses revealed significant differences between the nursing homes regarding the palliative length of stay (213.2 days vs. 88.6 days) as well as the mortality rate of palliative residents among all death cases (26% vs. 63.6%). Furthermore, internal processes within the nursing homes differed vastly despite similar concepts and procedural instructions. As a result, palliative care formally started at an earlier stage in nursing home X. Besides that, the identification of palliative care situations, as well as communication, organizational processes and the inclusion of cooperation partners, took place without fixed structures and was based on the subjective handling of staff members in both facilities. It turns out to be challenging for nursing homes to implement theoretical framework into everyday practice. To facilitate this process, aside from practicable assessments, defined responsibilities and organizational support, financing concepts at health policy level need to be established.

L’infirmière en pratique avancée au sein d’un service de soins de support : le chainon manquant ?

Cancer has become a chronic disease thanks to therapeutic evolutions and justifies the early integration of supportive care in the management. The Advanced Practice Nurse (APN) was created to respond to the increase in the number of patients followed in the long term. The objective of this study is to identify the place and expected missions of an APN within a multidisciplinary supportive care team. A qualitative study by semi-directed interview using a previously developed interview grid was carried out with 14 health professionals (doctors, nurses and health managers) working in a supportive care service in three Cancer Centres. The role expected by the participants is based on the optimisation of patients' follow-up, the integration of supportive care into the care pathway, the improvement of the relationship with the town, and the development of nursing leadership in the establishment. At the same time, the potential arrival of an APN as a change agent in a supportive care service is a source of fears. The APN seems to be a real link in the institutional organisations facilitating the link between the professionals of the institution and with the professionals of the territory. The identification of the origins of the fears expressed should enable work to be done to facilitate the integration of the APN into specific support care services, particularly for patients in palliative situations.

La consultation médicale en urgence dans le parcours du patient en oncologie

Medical emergencies are defined at the medical level, whereas the use of emergency consultations is decided by the patient. Urgent oncology cares are specific due to clinical, therapeutic, technic and psychologic complexity. This descriptive retrospective study about 142consultations carried out at the unplanned medical unit, with an analyse of demographics, clinical characteristics, reason for medical appeal, deployed resources and oncological pathway for six months. Breast (48%) and lung (21%) cancer are the most common. 68% of patients present with a disease at a non-curative stage and 83% have received a cancer treatment within the previous two months. Pain is the main reason for consultation (19). 91% of patients benefit from diagnostic and therapeutic procedures. At three month, half of patients use an emergency system again. At six months, the tumour progression rate is 54%. The mortality rate is 33% regardless of the risk of immediate aggravation. The use of emergency consultation mainly concerns patients in a palliative situation, sometimes announcing the change of the trajectory towards the advanced phase. The organization of the emergency care pathway should evolve to better consider the needs of this population, by formalizing longitudinal monitoring, collaboration with palliative care teams and coordination with care providers in the city.

Strahlentherapie endokriner Tumoren

BackgroundEven with the advent of new systemic therapy options, radiotherapy keeps its place for the treatment of endocrine and neuroendocrine tumors. The advancement of radiotherapy technology has enabled its advent into the treatment of rare tumor entities.Materials and methodsA selective PubMed search was performed and national and international guidelines were taken into consideration.ResultsEndocrine and neuroendocrine tumors are rarely treated by definitive radiotherapy. For anaplastic thyroid carcinomas and aggressive pituitary tumors, radiotherapy represents a cornerstone of multimodal treatment. Locally advanced neuroendocrine tumors (NET) can be treated with concomitant radiochemotherapy. Stereotactic ablative radiotherapy is applied in oligometastatic cases. In palliative situations, radiotherapy is successfully used for symptom relief.ConclusionDespite advances in systemic therapy options for treatment of endocrine and neuroendocrine tumors, the field of radiation therapy continues to offer a broad spectrum of therapies from curative to palliative situations, including oligometastasis. The decision for radiotherapy treatment should be made by a multidisciplinary team.