Terminally-ill Cancer Patients Research Articles

Effects of dignity therapy on psychological distress and wellbeing of palliative care patients and family caregivers – a randomized controlled study

BackgroundThis study extended the original Dignity Therapy (DT) intervention by including partners and family caregivers (FCs) of terminally-ill cancer patients with the overall aim of evaluating whether DT can mitigate distress in both patients nearing the end of life and their FCs.MethodsIn this multicenter, randomized controlled trial (RCT), a total of 68 patients with life expectancy < 6 months and clinically-relevant stress levels (Hospital Anxiety Depression total score; HADStot ≥ 8) including their FCs were randomly assigned to DT, DT + (including their FCs), or standard palliative care (SPC) in a 1:1:1 ratio. Study participants were asked to complete a set of questionnaires pre- and post-intervention.ResultsThe coalesced group (DT and DT +) revealed a significant increase in patients’ perceived quality of life (FACIT-Pal-14) following the intervention (mean difference 6.15, SD = 1.86, p < 0.01). We found a statistically significant group-by-time interaction effect: while the HADStot of patients in the intervention group remained stable over the pre-post period, the control group’s HADStot increased (F = 4.33, df = 1, 82.9; p < 0.05), indicating a protective effect of DT. Most patients and their FCs found DT useful and would recommend it to other individuals in their situation.ConclusionsThe DT intervention has been well-received and shows the potential to increase HRQoL and prevent further mental health deterioration, illness burden and suffering in terminally-ill patients. The DT intervention holds the potential to serve as a valuable tool for facilitating end-of-life conversations among terminally-ill patients and their FCs. However, the implementation of DT within the framework of a RCT in a palliative care setting poses significant challenges. We suggest a slightly modified and less resource-intensive version of DT that is to provide the DT inventory to FCs of terminally-ill patients, empowering them to ask the questions that matter most to them over their loved one’s final days.Trial registrationThis study was registered with Clinical Trial Registry (ClinicalTrials.gov -Protocol Record NCT02646527; date of registration: 04/01/2016). The CONSORT 2010 guidelines were used for properly reporting how the randomized trial was conducted.

Potential Drug Interactions in Terminally-Ill Cancer Patients, a Report from the Middle East

This study aims to evaluate the epidemiology of potential drug interactions in terminally-ill cancer patients receiving exclusively supportive care. In this cross-sectional study, during a 6-month follow-up, we considered the medical record of terminally-ill cancer patients referred to palliative care at the cancer center in Isfahan, Iran. Potential drug–drug interactions (DDIs) were assessed by Lexi-Interact ver.1.1 online software. During the study period, 133 terminally-ill cancer patients were recruited. We detected 1678 DDIs with moderate or major severity levels. Among them, 330, 219, 32, 1075, and 51 interactions were categorized in B, C, D, and X drug interactions categories, respectively. One hundred and twenty-two patients (91.73%) encountered at least one potential drug–drug interaction during the end of life care. Mechanistically, most drug–drug interactions (64.5%) were pharmacodynamics. The most frequent pharmacological class of drugs responsible for DDIs were quetiapine (91 cases), oxycodone (87 cases), and sertraline (55 cases). Interaction between oxycodone and sertraline was found to be in the top 10 detected DDIs (13.7%). Our results showed that potentially moderate or major drug–drug interactions often occur among terminally-ill cancer patients and the clinical significance of DDIs should be considered meticulously in the palliative care cancer setting.

“The communication I had with him back then is still stuck in my mind.” Bereaved families of cancer patients’ experiences for end-of-life communication

PurposeCommunication with family members is important to end-of-life care for patients with cancer. It is an interactive engagement between terminally-ill cancer patients and their families through which they expand their mutual understanding to cope with losses and find meaning in death. This study aimed to describe the experiences of end-of-life communication between patients with cancer and their family members in South Korea.MethodsThis is a qualitative descriptive study using in-depth semi-structured interviews. Ten bereaved family members with end-of-life communication experience with terminal cancer patients were recruited through purposive sampling. Data were analyzed using qualitative content analysis.ResultsA total of 29 constructed meanings, 11 sub-categories, and the following 3 categories were derived: “Offering a space for patients to reminisce and reflect,” “Building a bond,” and “Reflections on what we need.” End-of-life communication primarily centered on the patients, with families struggling to share their stories with them. Although the families coped well, they also regretted the lack of meaningful communication with the patients, indicating a need for support to facilitate effective end-of-life communication.ConclusionThe study highlighted concrete communication for finding meaning at the end-of-life for cancer patients and their families. We found that the families have the potential to communicate appropriately to cope with the patients’ end-of-life. Nevertheless, end-of-life presents a unique challenge in which families require adequate support. Given the increasing number of patients and families dealing with end-of-life care in hospitals, healthcare providers should be mindful of their needs and help them cope effectively.

Differences in Fentanyl Requirements in Terminally Ill Cancer Patients

Cancer pain is a significant issue in terminally ill cancer patients (TICPs). The fentanyl patch (FP) is used extensively for treating cancer pain, but FP requirements vary between patients. We aimed to identify determinants of FP requirements in TICPs and propose effective pain relief using a FP. In a retrospective chart review, we investigated cancer patients admitted to our hospital from April 2012 to July 2015 and used FP until death. The time course of FP use in TICPs until death was examined. The primary endpoint was the final dose of FP use (FDFP). In total, 79 patients were included the analysis. FDFP was inversely correlated with age (R= −0.262, p = 0.20; Spearman test). FDFP tended to be higher in males than in females and was significantly higher in patients with pancreatic cancer than in patients without pancreatic cancer (p = 0.017; Welch’s test). FP adjustments were more frequent in the last 60 days of life in patients with pancreatic cancer than in patients with other malignancies (P for interaction = 0.002; mixed effect model). In conclusion, younger age, and pancreatic cancer were associated with higher FP requirements in TICPs. TICPs with pancreatic cancer required more frequent FP adjustment near death.

Drug Choice for Hyperactive Delirium in Terminally-Ill Cancer Patients: A Nationwide Survey

Delirium is a prevalent neuropsychiatric condition in patients with cancer that increases in patients prior to death. 1 Lawlor PG Gagnon B Mancini IL et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med. 2000; 160: 786-794 Crossref PubMed Scopus (598) Google Scholar Delirium is a distressing symptom for patients with cancer, caregivers, and medical staff. 2 Bush SH Lawlor PG Ryan K et al. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018; 29: iv143-iv165 Abstract Full Text Full Text PDF Scopus (66) Google Scholar Therefore, the management of delirium would lead to an improvement in the quality of life of cancer patients and their caregivers.

Prognostication of the Last Days of Life.

Accurate prediction of impending death (i.e., last few days of life) is essential for terminally-ill cancer patients and their families. International guidelines state that clinicians should identify patients with impending death, communicate the prognosis with patients and families, help them with their end-of-life decision-making, and provide sufficient symptom palliation. Over the past decade, several national and international studies have been conducted that systematically investigated signs and symptoms of impending death as well as how to communicate such a prognosis effectively with patients and families. In this article, we summarize the current evidence on prognostication and communication regarding the last days of life of patients with cancer, and future directions of clinical research.

Developing an integrated model of community-based palliative care into the primary health care (PHC) for terminally ill cancer patients in Iran

BackgroundPatients with cancer commonly experience pain and suffering at the end of life days. Community-based palliative care can improve the quality of life of terminally-ill cancer patients and provide them with a merciful death. The purpose of this study was to develop an integrated model of community-based palliative care into PHC for terminally ill cancer patients.MethodThis study is a health system research (HSR) that was conducted in three phases from October 2016 to July 2020. In the first phase, dimensions of community-based palliative care were explored in patients with cancer using qualitative methods and conventional content analysis. In the second phase, a scoping review was carried out to complete the collected data from the qualitative phase of the study. Based on the collected data in the first and second phases of the study, a preliminary draft of community-based palliative care was developed for patients with cancer based on the framework of the World Health Organization. Finally, the developed model was validated using the Delphi technique in the third phase of the study.ResultsData analysis indicated that providing community-based care to patients with cancer is influenced by the context of care. According to the developed model, patients are identified as terminally ill, and then are referred to the local comprehensive health center in a reverse manner. After patients’ referral, they can receive appropriate healthcare until death by the home care team in relation to the comprehensive health center based on the framework of primary healthcare.ConclusionsThis model was developed based on the current Iranian healthcare structure and the needs of terminally ill cancer patients. According to the model, healthcare is provided in a reverse manner from the subspecialty centers to patients’ homes in order to provide easy access to palliative care. It is suggested to use this model as a pilot at the regional level.

Preferences on the Timing of Initiating Advance Care Planning and Withdrawing Life-Sustaining Treatment between Terminally-Ill Cancer Patients and Their Main Family Caregivers: A Prospective Study.

Background: The Western individualistic understanding of autonomy for advance care planning is considered not to reflect the Asian family-centered approach in medical decision-making. The study aim is to compare preferences on timing for advance care planning initiatives and life-sustaining treatment withdrawal between terminally-ill cancer patients and their family caregivers in Taiwan. Methods: A prospective study using questionnaire survey was conducted with both terminally-ill cancer patient and their family caregiver dyads independently in inpatient and outpatient palliative care settings in a tertiary hospital in Northern Taiwan. Self-reported questionnaire using clinical scenario of incurable lung cancer was employed. Descriptive analysis was used for data analysis. Results: Fifty-four patients and family dyads were recruited from 1 August 2019 to 15 January 2020. Nearly 80% of patients and caregivers agreed that advance care planning should be conducted when the patient was at a non-frail stage of disease. Patients’ frail stage of disease was considered the indicator for life-sustaining treatments withdrawal except for nutrition and fluid supplements, antibiotics or blood transfusions. Patient dyads considered that advance care planning discussions were meaningful without arousing emotional distress. Conclusion: Patient dyads’ preferences on the timing of initiating advance care planning and life-sustaining treatments withdrawal were found to be consistent. Taiwanese people’s medical decision-making is heavily influenced by cultural characteristics including relational autonomy and filial piety. The findings could inform the clinical practice and policy in the wider Asia–Pacific region.

Efficacy and Safety of Subcutaneous Levetiracetam Injection for Terminally-ill Cancer Patients: A Case Report

【緒言】終末期がん患者に対して，痙攣発作の治療を目的とした抗痙攣薬の使用は臨床現場において稀でなく，経口および静脈投与不可能な症例への治療選択が求められることは少なくない．われわれは終末期がん患者で末梢血管の確保ができない症例に対してレベチラセタム（LEV）注を皮下注射した症例を3例経験したため報告する．【症例】3症例の年齢は83，75，82歳で，LEV皮下注射の投与時期は予後1カ月程度であった．3例ともLEVを点滴静脈から皮下へ投与経路変更した事例である．LEV皮下注射の実施後，痙攣の増悪や注射部位反応，その他の有害事象は確認できなかった．【考察】末梢血管確保の不可能な終末期がん患者においてLEVの皮下注射は痙攣発作の治療の選択肢の一つとなり得ると考える．

Thoughts of Expert Nurses About Daily Life Assistance of Terminally-Ill Cancer Patients Considering Safety and Comfort

Thoughts of Expert Nurses About Daily Life Assistance of Terminally-Ill Cancer Patients Considering Safety and Comfort

Specialized Rural Pain Clinics: Lessons for a Small Country like Lebanon

Background: People with chronic pain and who live in rural communities often lack access to pain specialists. They end up relying on primary care providers who may be less prepared to deal with their conditions. Purpose: The purpose of this study is to survey the existence of specialized pain clinics/services in rural Lebanon. It also aims at highlighting the importance of the existence of such clinics/services rurally. Method: A review of the literature about pain in Lebanon was conducted using PubMed, Medline, Google Scholars, and Research Gate. Another search was conducted using Google Maps to locate any specialized pain clinics in the rural areas. The Lebanese Society for Pain Medicine was also contacted for information about the distribution of specialized pain clinics/services in Lebanon. Results: Our results showed that the total number of pain clinics/services in Lebanon is ten. They are distributed as follows: Five in Greater Beirut including Metn (50%), one in North Lebanon (10%), two in South Lebanon (20%), one in Beqaa (10%), and one in Mount Lebanon (Chouf, Aley, Kesrouan/Jbeil) (10%). The majority (90%) of these services are hospital-based and are governed by the Anesthesia Departments. Moreover, a comprehensive palliative care approach towards pain management in terminally-ill cancer and non-cancer patients is still lacking nationwide. Conclusion and implications: Rural Lebanon is still significantly underserved as far as the existence of specialized pain clinics is concerned. This calls for a quick interference by the health officials considering the fact that a significant proportion of Lebanese people live in the rural areas. In parallel, the international approaches to palliative care for chronic pain should be adopted. Lastly, an alternative to out-of-pocket payment for the consultation fees and treatments should be taken into consideration

T-cells "à la CAR-T(e)" - Genetically engineering T-cell response against cancer.

The last decade will be remembered as the dawn of the immunotherapy era during which we have witnessed the approval by regulatory agencies of genetically engineered CAR T-cells and of checkpoint inhibitors for cancer treatment. Understandably, T-lymphocytes represent the essential player in these approaches. These cells can mediate impressive tumor regression in terminally-ill cancer patients. Moreover, they are amenable to genetic engineering to improve their function and specificity. In the present review, we will give an overview of the most recent developments in the field of T-cell genetic engineering including TCR-gene transfer and CAR T-cells strategies. We will also elaborate on the development of other types of genetic modifications to enhance their anti-tumor immune response such as the use of co-stimulatory chimeric receptors (CCRs) and unconventional CARs built on non-antibody molecules. Finally, we will discuss recent advances in genome editing and synthetic biology applied to T-cell engineering and comment on the next challenges ahead.

Characteristics of Breakthrough Pain and Its Impact on Quality of Life in Terminally Ill Cancer Patients.

Purpose. This study aimed to characterize breakthrough pain (BTP) and investigate its impact on quality-of-life (QoL) in terminally-ill cancer patients. Similarities and differences between high and low predictable BTP were also tested. Methods. Secondary analysis of a multicenter longitudinal observational study included 92 patients at their end-of-life. BTP was assessed with a short form of the Italian version of the Alberta Breakthrough Pain Assessment Tool. QoL was assessed with the Palliative Outcome Scale (0-40). Patients were stratified by self-reported BTP predictability into unpredictable BTP (never or rarely able to predict BTP) and predictable BTP (sometimes to always able to predict BTP). Results. In all, 665 BTP episodes were recorded (median 0.86 episodes/day). A median duration of 30 minutes and a median peak intensity score of 7 out of 10 were reported. Time to peak was <10 minutes, 10 to 30 minutes, and ≥30 minutes in 267 (41.1%), 259 (39.9%), and 30 (4.6%) of the episodes, respectively. Onset of relief occurred after a median of 30 minutes. Time to peak (P < .001) and duration (P = .046) of BTP was shorter in patients with predictable pain (n = 31), who usually were younger than those with unpredictable pain (P = .03). The mean (SD) QoL score was 14.6 (4.6). No difference in QoL between patients with predictable and unpredictable BTP was found (P = .49). Conclusions. In terminally-ill cancer patients, BTP is a severe problem with a negative impact on QoL and has different characteristics according to its predictability.

Effects of Oral Rinse with Hangeshashinto Alone and Hangeshashinto with Honey for Oral Discomfort in Terminally-ill Cancer Patients

Effects of Oral Rinse with Hangeshashinto Alone and Hangeshashinto with Honey for Oral Discomfort in Terminally-ill Cancer Patients

The Circadian Rhythm of Breakthrough Pain Episodes in Terminally-ill Cancer Patients.

Opioid therapy must be adjusted to the rhythm of a cancer patient’s pain to ensure adequate symptom control at the end of life (EOL). However, to-date no study has explored the rhythm of breakthrough pain (BTP) episodes in terminally-ill cancer patients. This prospective longitudinal study was aimed at verifying the existence of a circadian rhythm of BTP episodes in terminally-ill cancer patients. Consecutive adult cancer patients at their EOL treated with long-acting major opioids to control background pain (Numeric Rating Scale ≤ 3/10) were recruited from two Italian palliative care services. Using a personal diary, patients recorded the frequency and onset of BTP episodes and the analgesic rescue therapy taken for each episode over a 7-day period. Rhythms identified in BTP episodes were validated by Cosinor analysis. Overall, 101 patients were enrolled; nine died during the study period. A total of 665 BTP episodes were recorded (average of 7.2 episodes, mean square error 0.8) per patient, with 80.6% of episodes recorded between 8:00 a.m. and 12:00 a.m. At Cosinor analysis, a circadian rhythm of BTP episodes was observed, with a Midline Estimating Statistics of the Rhythm (MESOR) of 1.5, a double amplitude of 1.8, and an acrophase at 12:30 p.m. (p < 0.001). Oral morphine was the most frequent analgesic rescue therapy employed. In terminally-ill cancer patients, BTP episodes follow a circadian rhythm; thus, tailoring the timing of opioid administration to this rhythm may prevent such episodes. This circadian rhythm of BTP episodes in terminally-ill cancer patients should be confirmed in larger samples.

Distinct Patterns of Conjoint Symptom Distress and Functional Impairment in the Last Year of Life Predict Terminally Ill Cancer Patients' Survival

Context/ObjectivesOur study addressed important knowledge gaps about trajectories of distinct conjoint symptom-functional states, that is, patterns for different levels of combined symptom distress and functional impairment, over cancer patients' last year and their ability to predict survival. MethodsWe identified distinct symptom-functional states and explored their changes over 317 terminally ill cancer patients' last year by a transition model using hidden Markov modeling. These distinct symptom-functional states' ability to predict current survival probability, measured in the previous assessment, was evaluated by multivariate Cox regression models. ResultsWe identified five worsening, conjoint symptom-functional states: 1) mild symptom distress with high functioning, 2) moderate symptom distress with mild functional impairment, 3) severe symptom distress with moderate functional impairment, 4) moderate symptom distress with severe functional impairment, and 5) profound symptom distress and functional impairment. Trajectories of these five states differed substantially by direction (downward vs. upward) and speed. Participants in States 1–4 had substantially lower risk of subsequent death than those in State 5 (adjusted hazard ratios [95% CI] ranged from 0.048 [0.028–0.081] to 0.434 [0.316–0.579]). The risk of subsequent death differed significantly between patients in any two distinct symptom-functional states, except between those in States 3 and 4. ConclusionOur identification of five distinct symptom-functional states and their unique transition patterns and prediction of mortality provides all stakeholders with guides for end-of-life care. Goals of end-of-life care should change toward palliative care and effective symptom management for patients with at least moderate symptom distress and substantial functional impairment.

Coping Styles and Life Satisfaction in Palliative Care.

Background:Patients in palliative care suffer variously due to underassessment of needs and suboptimal intervention, coupled with lack of access to palliative care. This study attempts to identify effective coping strategies which lead to life satisfaction, among those afflicted with terminal cancer.Materials and Methods:This observational, cross-sectional study was carried out among terminally-ill cancer patients undergoing palliative care. Cancer patients receiving palliative care who give consent and were aged 18 years or older were included in the study. Those with cognitive deficits, delirium, or psychosis were excluded from the study. COPE scale, Temporal Satisfaction with Life Scale, and sociodemographic Performa were administered and analyzed. Pearson's r correlation coefficient test and multiple linear regression analyses were used to evaluate correlation and effect of coping strategies on life satisfaction.Results:Religious coping was the most frequently used coping strategy by patients, followed by acceptance. Females showed higher problem-focused coping, whereas males had higher emotion-focused and avoidant coping strategies. Females manifested more religious coping. Males showed more acceptance of their illness. Those without a partner had significantly higher emotion-focused coping strategies and higher religious coping. Income, social support, and problem-oriented coping were positively related to quality of life. Life satisfaction showed significant negative correlation with denial, substance use, and venting utilized as coping methods.Conclusion:Problem-focused coping (religious coping and acceptance) was found to be more effective than other methods. Patients in palliative care could be instructed for the use of problem-focused coping. Such training might enhance their life satisfaction, helping them experience greater control over the course of illness.

Understanding the Role of Spirituality and Faith in Relation to Life Expectancy and End of Life Experience in Terminally-ILL Cancer Patients

Understanding the Role of Spirituality and Faith in Relation to Life Expectancy and End of Life Experience in Terminally-ILL Cancer Patients

Talking About Death With Terminally-Ill Cancer Patients: What Contributes to the Regret of Bereaved Family Members?

ContextTalking about death is an important issue for terminally-ill cancer patients and their families. Little is known about how often and which bereaved families regret not having talked about death with their deceased loved one. ObjectivesTo explore the prevalence of a regret of not having talked about death with a deceased loved one among bereaved family members of adult cancer patients, and to systematically explore factors contributing to their regret. MethodsWe conducted a nationwide survey of 999 bereaved families of cancer patients admitted to 133 inpatient hospices in Japan and surveyed families' regret on talking about death. Exploratory analyses identified the underlying structures of process, option, and outcome subscales of factors contributing to regret. ResultsAmong 678 bereaved families (response rate 68%), 224 (33%) regretted not having talked about death sufficiently, whereas 40 (5.9%) conversely regretted having talked about death. Three process factors (“prognostic disclosure to patient” [β = 0.082, P = 0.039], “upsetting of patient and family” [β = 0.127, P = 0.001], and “family's sense of uncertainty about when to act based on terminal awareness” [β = 0.141, P = 0.000]) and an outcome factor (“having achieved a good death” [β = −0.152, P = 0.000]) contributed to the regret of talking insufficiently. ConclusionA third of bereaved families of adult cancer patients regretted not having talked about death sufficiently. Clinicians may minimize this regret by facilitating a shared understanding of the disease and prognosis, advising families explicitly when to talk based on terminal awareness, providing continuous emotional support, and validating their decision on talking about death.

Effect of the Sedative Combination of Ketamine, Morphine and Midazolam on the Quality-of-Life in the Final Days of Terminally Ill Cancer Patients

Background: Sedation in terminally-ill cancer patients is typically used to alleviate symptoms of physical distress during the last week of life, in order to allow patients to achieve serenity. These include pain, as well as respiratory, neuropsychiatric, and gastrointestinal symptoms. The purpose of this study is to investigate the effect of the sedative protocol containing ketamine, midazolam, and morphine (KMM) on symptoms of terminally-ill cancer patients at the end-of-life, as well as on consciousness level, and overall survival. Methods and Findings: This retrospective study included terminally-ill cancer patients (>18 years) who completed cancer-specific treatment and received KMM upon hospitalization. Medical records were reviewed. The symptoms were classified according to their severity before and during treatment. Control of debilitating symptoms and level of consciousness during the hospitalization was clinically evaluated. Results: The study included 30 patients (10 males; mean age, 55 years). Range doses were: 0.1-1 mg/kg, 0.05-0.5 mg/kg, and 0.5-5 mg/kg daily, for ketamine, midazolam, and morphine, respectively. The mean survival was 4.6 days (therefore, analyses focused on the first 3 days). A statistically significant decrease in pain was achieved on the first day of treatment (P<0.0001). Further improvement was sustained through the following 2 days (P=0.022). An improvement in respiratory, gastrointestinal, and neuropsychiatric symptoms was reported (P=0.033). A significant decline in consciousness level was observed with time. The initial pain level (before administrating KMM) was negatively associated with survival. Conclusions: The KMM protocol is an effective method in controlling pain and providing relief from respiratory, neuropsychiatric, and gastrointestinal symptoms. No KMMassociated complications were identified. Further research is warranted.