Terminally-ill Cancer Patients Research Articles

終末期がん患者にベッドサイドで行う末梢挿入型中心静脈カテーテル（PICC）挿入に際して肘窩の穿刺血管別（尺側，正中，橈側）挿入成功率の検討

終末期がん患者にベッドサイドで行う末梢挿入型中心静脈カテーテル（PICC）挿入に際して肘窩の穿刺血管別（尺側，正中，橈側）挿入成功率の検討

The requirement of fentanyl patch in terminally ill patients with cancer.

202 Background: Cancer pain is the most important problem to overcome in terminally ill cancer patients (TICPs). Recently, the fentanyl patch (FP) has been widely used for the treatment of cancer pain. However, the FP requirement largely varies in patients. The purpose of this study was to identify the determinants of the FP requirement in TICPs and propose effective pain relief using a FP. Methods: In a retrospective chart review, we investigated cancer patients who were admitted in our hospital from April 2012 to July 2015 and used FP until their deaths. We examined the time course of FP use in TICPs until death. We used descriptive statistics and a mixed effect model. The primary endpoint of this study was the final dose of FP use (FDFP). Results: Eighty patients were included the analysis. The clinical characteristics were as follows: age (median, range): 64.5 (29-88) years; male/female ratio: 40/40; primary tumor sites: pancreas (n = 33), digestive tract (n = 12), liver and bile duct (n = 7), ovary and uterus (n = 6), hematologic (n = 5), lung (n = 4), head and neck (n = 4), breast (n = 3), and other (n = 6). FDFP was inversely correlated with age (R = -0.272, P < 0.05; Spearman test). The FDFP (mean ± SD) administered in the patients was 3.06 ± 3.20 mg/day (Male/Female: 3.83 ± 4.06/2.29 ± 1.81 mg/day). The FDFP was 4.36 ± 4.32/2.15 ± 1.64 mg/day in patients with/without pancreatic cancer. FDFP was significantly higher in male than in female patients (P < 0.05; student’s t test), and also significantly higher in patients with pancreatic cancer than in patients without pancreatic cancer (P < 0.005; student’s t test). In pancreatic cancer patients, the FP adjustments were more frequent in the last 60 days of life than in patients with other malignancies (P for interaction < 0.001; mixed effect model). Conclusions: We found that younger age, male sex, and pancreatic cancer were risk factors for higher requirement of FP in TICPs. TICPs with pancreatic cancer in particular required more frequent adjustment of FP near death. We should consider quick titration of fentanyl in patients with pancreatic cancer because the pain-relieving action of FP requires time.

終末期がん患者の感染症診療： 何が医療者の意向の差異に繫がるか？

終末期がん患者の感染症診療： 何が医療者の意向の差異に繫がるか？

Clinical Nurses' Perceived or Experienced Obstacles and Supportive Behaviors in Providing Care for Terminally Ill Cancer Patients

Purpose: The purpose of this study was to examine obstacles and supportive behaviors perceived or experienced by clinical nurses providing care for terminally ill cancer patients. Methods: Beckstrand’s survey questionnaire was translated into Korean and verified by an expert committee and through a preliminary study. A survey that used 26 questionnaire items on obstacles and 24 on supportive behaviors, was conducted among 228 registered nurses with more than one year of experience at medical-surgical general wards in a hospital. Results: The highly-perceived and frequently-experienced obstacles in providing care for terminally-ill cancer patients were related to patients’ uncontrollable pain or psychologically unstable family members. The highly-perceived and frequently-experienced supportive behaviors were related to caring family members or having supportive family members. However, nurses’ perceptions or experiences of multiple obstacles and supportive behaviors differed by hospital type, career length, and department. Conclusion: Nurses seem to be in need of training for pain management for terminal cancer patients and of family care in general. Highlyperceived and highly-experienced obstacles or highly-perceived but rarely-experienced supportive behaviors should be intervened without delay considering a hospital type or nurses’ career length.

Burden of inpatient care and treatments in terminally-ill cancer patients: results from a population-based, retrospective study from administrative data in France.

9527 Background: Over the past decades, dramatic changes in the treatment of advanced cancer have raised concerns regarding the quality of end-of-life care in terminally-ill patients. However, Earl...

Preferences for Aggressive End-of-life Care and Their Determinants Among Taiwanese Terminally Ill Cancer Patients

Studies on factors influencing preferences for aggressive end-of-life (EOL) care have focused predominantly on preferred goals of EOL and seldom comprehensively incorporate patients' predisposing, enabling, and need factors into their analyses. The aim of this study was to investigate the determinants of preferences for a wide range of aggressive EOL care from the aforementioned factors. A cross-sectional survey was conducted using a convenience sample of 2329 terminally ill cancer patients recruited from 23 hospitals throughout Taiwan. Among these Taiwanese terminally ill cancer patients, 8.2% preferred prolonging life as their goal for EOL care. When combining those who wanted and those who were undecided as wanting that specific treatment, 27.9% preferred cardiopulmonary resuscitation when their life was in danger, and 36.0%, 27.3%, 24.3%, and 26.7% preferred to receive care at intensive care unit, cardiac massage, intubation, and mechanical ventilation support, respectively. Those at risk of preferring aggressive EOL care were men, younger than 45 years, married, diagnosed within 6 months, and with comorbidity and their physician had not accurately disclosed their prognosis or discussed EOL care issues to/with them. Few Taiwanese terminally ill cancer patients preferred to prolong life as their goal for EOL care, cardiopulmonary resuscitation when their life was in danger, and life-sustaining treatments at EOL. Preferences for aggressive EOL care are determined by patients' predisposing, enabling, and need factors. Terminally ill cancer patients at risk of preferring aggressive EOL care should receive interventions to help them appropriately weigh the burdens and benefits of such aggressive treatments.

OA24 Support for terminally-ill cancer patients: perceptions of religious leaders about end-of-life spiritual care in lagos, nigeria.

Religious leaders are well respected in most Nigerian communities and are often called in to provide support for terminally-ill patients. Many Nigeria communities still view cancer as a stigmatised disease. This study sought to elicit the perceptions of Christian and Islamic religious leaders and explore problems associated with their involvement in end-of-life care for cancer patients. Participants were recruited among 114 religious leaders. Four focus group discussion sessions were then conducted with open-ended questions on previous involvement in end-of-life care of cancer patients and whether they would like to do more. There were thirty (30) willing participants in all. The discussions were audiotaped, transcribed and coded using the NUDIST software. Ninety of the respondents (62%) would not be involved in end-of-life care. This is because of the fear of peer pressure. The responses could be classified under three major themes were identified: (1) Care supposed to be provided by all religious leaders (2) End-of-Life care in institutions are safer (3) End-of-Life care consumes time. Statements made by respondents include "I will fall out with many if I am found ministering to dying patients". We observe that peer pressure played an important role in the acceptability of end-of-life activities in this group. This could be used in the positive light in designing interventions.

Meta-Analysis of Current Status of Prognostic Awareness in Advanced/ Terminally Ill Cancer Patients

ABSTRACT Aim: Only advanced/terminally ill cancer patients who are aware of their prognoses can participate in discussions about their end-of-life (EOL) treatments and make the decisions that meet their preferences. Despite the abundant literature on this topic, no systematic estimates of prognostic awareness in these patients are available. Methods: The literature on prognostic awareness in cancer patients was systematically reviewed from 1990 to 2013. The pooled proportions of cancer patients’ awareness, accurate awareness, and completely accurate awareness of prognosis were calculated. Differences in weighted estimate for prognostic awareness and accurate (accurate and completely accurate) prognostic awareness were compared on stage of cancer by meta-regression. Results: The literature search retrieved 38 articles for meta-analysis. Most cancer patients were aware of their prognoses (pooled estimates of 65.0%, 95% confidence interval (CI): 59.0%-70.6%, range: 8.8-100%), but only about half accurately understood their prognoses (46.8%, 95% CI: 38.6%- 55.1%, range: 8.8-78.2%), and less had completely accurate awareness (37.6%, 95% CI: 28.2%- 48.0%, range: 0-73.5%). Meta-regression analysis indicated that stage of cancer did not impact on prognostic awareness but terminally ill cancer patients were more accurately aware of their prognoses than those with advanced cancer, or cancer at heterogeneous stages (53.4%, 41.2%, 34.1%, respectively, p = 0.010). Conclusions: Most cancer patients were aware of their prognoses but substantially less accurately or completely, accurately understand their prognoses. As death approached when prognostic disclosure becomes more relevant, terminally ill cancer patients were more accurately aware of their prognoses than cancer patients at other stages. Further research and interventions should focus not only on prognostic awareness but also on facilitating accurate prognostic awareness to improve EOL care in accordance with patients’ wishes. Disclosure: All authors have declared no conflicts of interest.

United States Acculturation and Cancer Patients’ End-of-Life Care

BackgroundCulture shapes how people understand illness and death, but few studies examine whether acculturation influences patients’ end-of-life treatment preferences and medical care.Methods and FindingsIn this multi-site, prospective, longitudinal cohort study of terminally-ill cancer patients and their caregivers (n = 171 dyads), trained interviewers administered the United States Acculturation Scale (USAS). The USAS is a 19-item scale developed to assess the degree of “Americanization” in first generation or non-US born caregivers of terminally-ill cancer patients. We evaluated the internal consistency, concurrent, criterion, and content validity of the USAS. We also examined whether caregivers’ USAS scores predicted patients’ communication, treatment preferences, and end-of-life medical care in multivariable models that corrected for significant confounding influences (e.g. education, country of origin, English proficiency). The USAS measure was internally consistent (Cronbach α = 0.98); and significantly associated with US birthplace (r = 0.66, P<0.0001). USAS scores were predictive of patients’ preferences for prognostic information (AOR = 1.31, 95% CI:1.00–1.72), but not comfort asking physicians’ questions about care (AOR 1.23, 95% CI:0.87–1.73). They predicted patients’ preferences for feeding tubes (AOR = 0.68, 95% CI:0.49–0.99) and wish to avoid dying in an intensive care unit (AOR = 1.36, 95% CI:1.05–1.76). Scores indicating greater acculturation were also associated with increased odds of patient participation in clinical trials (AOR = 2.20, 95% CI:1.28–3.78), compared with lower USAS scores, and greater odds of patients receiving chemotherapy (AOR = 1.59, 95% CI:1.20–2.12).ConclusionThe USAS is a reliable and valid measure of “Americanization” associated with advanced cancer patients’ end-of-life preferences and care. USAS scores indicating greater caregiver acculturation were associated with increased odds of patient participation in cancer treatment (chemotherapy, clinical trials) compared with lower scores. Future studies should examine the effects of acculturation on end-of-life care to identify patient and provider factors that explain these effects and targets for future interventions to improve care (e.g., by designing more culturally-competent health education materials).

Palliative Radiotherapy for Terminally-Ill Cancer Patients: Lack of Usefulness or Lack of Knowledge?

Copyright: © 2012 Rozzi A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The most important aim of palliative care is to provide adequate palliation for cancer patients with end-stage disease whose lifeexpentancy is about six months or less. Beyond pharmacological interventions, radiotherapy represents a valuable therapeutic option in this setting.

Survival prediction for terminally ill patients with cancer: Revision of palliative prognostic score with incorporation of delirium.

e19552 Background: The validated Palliative Prognostic (PaP) score predicts survival in terminally-ill cancer patients and is calculated on the basis of dyspnea, anorexia, Karnofsky Performance Status, clinical prediction of survival, total white blood count and lymphocyte rate. The impact of delirium is known but was not incorporated in the original PaP score. Our aim was to incorporate information on delirium into this score. Methods: The study was based on a retrospective series of 361 terminally-ill cancer patients. The main endpoint was overall survival. We used the ‘validation by calibration’ approach proposed by van Houwelingen et al. and later adapted by Miceli et al. to obtain a score revision with inclusion of a new variable. A new model is fitted including the original score and the new variable as covariates; the model parameter estimates are then used to calculate the partial score for the new variable and the revised cutoffs to define the prognostic categories. Results: The prognostic contribution of delirium was confirmed as statistically significant (p<0.001) and the variable was incorporated into the PaP score (D-PaP score) accordingly. With such a revision, 30 day survival in the three risk groups (A>70%, B 30-70%, C<30%) was 83% (95% Confidence Interval CI 77-90), 50% (95% CI 42-58) and 9% (95% CI 3-15) vs 87% (95% CI 80-93), 51% (95% CI 44-59) and 16% (95% CI 8-24) obtained using the original PaP score. PaP and D-PaP score classifications were in accordance in 292 patients (80.9%). Seventeen (4.7%) patients were switched to a group with a less favorable prognosis and 52 (14.4%) were switched to a more favorable prognostic group. The frequency of patients with delirium, 14 (10.1%) and 37 (25.9%) in groups A and B, sharply increased to 48 (60.8%) in group C. The overall prognostic performance of the revised score was better than that obtained with the original one. Conclusions: The model validation and revision was carried out by modifying the cut-off values used for prognostic grouping without affecting the partial scores of the original PaP score. The revision improved the performance of the original PaP score whilst maintaining its key feature of simplicity.

Effectiveness and long term safety of gabapentin in the management of neuropathic pain of terminally-ill cancer patients

終末期がん患者の神経障害性疼痛に対するガバペンチンの鎮痛効果, 適切な投与方法, 安全性を明らかにするため, 200X年11月から200X＋2年10月に淀川キリスト教病院ホスピスでがんに伴う神経障害性疼痛に対しガバペンチンを投与した患者の観察研究を行った. numerical rating scale (NRS)で疼痛評価し, 投与前, 1週間後, 維持投与時のNRSをWilcoxonの符号付順位和検定で比較検討した. 調査を開始した44名中19名が投与終了まで調査可能で, 投与期間平均52.0日, 死亡まで平均67.2日であった. 1週間後の投与量は平均358 (200～1,200) mg/日, 維持投与開始は平均11.6日, 維持投与量は平均463 (200～2,400) mg/日で男性620 mg/日, 女性289 mg/日であった. NRSの平均値は投与前5.7, 1週間後 2.1 (p＜0.001), 維持投与時1.9 (p＜0.001)で, 有意に低下した. 57.9％で副作用を認め, 眠気52.6％, せん妄5.3％, 振戦5.3％であった. ガバペンチンを少量から副作用に注意して調整することで, がんに伴う神経障害性疼痛に対し鎮痛効果が得られ, 終末期でも長期間安全に投与可能である. Palliat Care Res 2011; 6(1): 101-108

Applying Inhaled Furosemide for Refractory Breathlessness in Terminally-ill Cancer Patients - Based on Seminar of Palliative Medicine Research Group, The Korean Academy of Family Medicine -

Applying Inhaled Furosemide for Refractory Breathlessness in Terminally-ill Cancer Patients - Based on Seminar of Palliative Medicine Research Group, The Korean Academy of Family Medicine -

Applying Inhaled Furosemide for Refractory Breathlessness in Terminally-ill Cancer Patients - Based on Seminar of Palliative Medicine Research Group, The Korean Academy of Family Medicine -

Breathlessness is a frequent and distressing symptom in terminal cancer patients. Refractory breathlessness is defined as a state that does not respond to conventional disease-specific therapy with an exclusion of reversible underlying causes, and the main classes of symptomatic drug treatments include opioids and benzodiazepines. Korean Family Medicine Palliative Medicine Research Group discussed two terminal cancer patients in whom severe breathlessness with different causes were treated with inhalation of nebulized furosemide, which is an emerging option of palliative treatment. It still remains unclear how it becomes effective or how much it is effective, therefore, its routine use seems to be somewhat early. Nevertherless, if a patient with intractable breathlessness does not have a marked obstructive airway lesion, its use should be considered. Based on the discussion in the seminar, we want to share our experience of the application of inhaled furosemide with ot her palliative care practitioners and strongly recommend further research on this topic in the future. (Korean J Hosp Palliat Care 2010;13:252-256)

A Palliative Care Intervention in Forgiveness Therapy for Elderly Terminally Ill Cancer Patients

Palliative care is now considered an essential part of end-of-life care, yet little research examines the efficacy of interventions addressing the psychological treatment of dying patients. Forgiveness therapy has been shown to be effective in improving psychological well-being and may provide a valuable addition to a terminal cancer patient's overall treatment plan. This study experimentally tested the effectiveness of a four-week forgiveness therapy in improving the quality of life of elderly terminally ill cancer patients. Participants (n = 20) were randomly assigned to a forgiveness therapy group or to a wait-list control group, which received forgiveness therapy in the second four-week period. All participants completed instruments measuring forgiveness, hope, quality of life, and anger at pre-test, post-test 1, and post-test 2. The forgiveness therapy group showed greater improvement than the control group, with one-tailed t-tests, on all measures. After receiving forgiveness therapy, participants in both forgiveness treatment conditions demonstrated significant improvements on all measures. The aggregated effect size was large. The four-week forgiveness therapy demonstrated psychological benefits for elderly terminally ill cancer patients and thus may be an appropriate addition to the treatment plan for terminal cancer patients.

Dying cancer patients talk about euthanasia

Within developed nations, there is increasing public debate about and apparent endorsement of the appropriateness of euthanasia as an autonomous choice to die in the face of intolerable suffering. Surveys report socio-demographic differences in rates of acceptance of euthanasia, but there is little in-depth analysis of how euthanasia is understood and positioned within the social and moral lives of individuals, particularly those who might be considered suitable candidates—for example, terminally-ill cancer patients. During discussions with 28 such patients in Australia regarding medical decisions at the end of life, euthanasia was raised by 13 patients, with the others specifically asked about it. Twenty-four patients spoke positively of euthanasia, 19 of these voicing some concerns. None identified euthanasia as a currently favoured option. Four were completely against it. Endorsement for euthanasia was in the context of a hypothetical future or for a hypothetical other person, or temporally associated with acute pain. Arguments supporting euthanasia framed the issue as a matter of freedom of choice, as preserving dignity in death, and as curbing intolerable pain and suffering, both of the patient and of those around them. A common analogy featured was that of euthanising a dog. These arguments were typically presented as self-evident justification for euthanasia, construed as an appropriate choice to die, with opposers positioned as morally inferior or ignorant. The difficulties of ensuring ‘choice’ and the moral connotations of ‘choosing to die,’ however, worked to problematise the appropriateness of euthanising specific individuals. We recommend further empirical investigation of the moral and social meanings associated with euthanasia.

Canadian oncologist communication about prognosis disclosure with their terminally-ill patients

6554 Background: Prior research indicates that oncologists are reluctant to discuss prognosis (prog) with their terminally-ill cancer patients (tcp), yet physician attitudes have not been well described. Methods: We surveyed Canadian medical oncologists' (mo) self-reported behaviors, beliefs and attitudes regarding prog communication (comm) with their tcp. Following a pre-notification letter, surveys were mailed to a systematic sample of 335 mo with Canadian addresses listed in the 2005 ASCO and RCPSC Members Directory. Results: Surveys were mailed with a $5 cash incentive in April, 2006. 196 surveys were completed and returned (59% response rate). Median age of respondents (res) is 44 (29–73); 66% men; 54% at university affliated institution. Res have practiced a median 11 years (1- 43) and see a median 45 (6–300) patients/week. Answering yes or no, 99% of res say their usual practice is to tell their tcp they will eventually die of their disease. Choosing from closed-ended responses: 34% say they always discuss prog, 50% discuss prog only after asking their tcp if they want the information, and 16% discuss it only if their tcp ask for the information. 34% say they always or usually communicate a timeframe as to when death may occur and 50% sometimes, rarely, or never give a timeframe. If they do not tell a tcp their prog, 19% always, 22% usually, 28% sometimes, and 24% rarely or never tell family or friends. 92% are always or usually satisfied with their prog comm. 92% say their tcp are always or usually satisfied with the comm. 96% believe prog comm education should be part of cancer-care training. 40% say such education was either absent or inadequate during their training. Older mo(<45y) were less likely to report always/usually telling their tcp timeframe re prog (OR=0.69; p=0.02) as were those who did not receive training (OR=0.35; p<0.00). Qualitative data has also been collected about: clinical factors affecting mo prog comm, associated emotions, and examples of recent prog comm. Conclusions: Almost all Canadian mo report that they tell their tcp that they have a known life-ending prog. When they do not tell their tcp they frequently tell family or friends. Most Canadian mo say they provide a prognostic timeframe to their tcp re: time left to live. No significant financial relationships to disclose.

Taking care of terminally-ill patients at home — the economic perspective revisited

End-of-life care can be delivered in a variety of settings, whereby the majority of terminally-ill cancer patients prefer to die at home. The aim of our study is to evaluate health services utilisation during the last year of life, and to compare terminally ill patients who have received home-specialised palliative care services (HSPCS) with patients who died receiving home non-specialised palliative care services. The study included 120 and 515 patients, respectively, who died between 1999—2000. Age and gender distribution were similar in both groups. During the last year of life, mean health services cost per person among the HSPCS group was lower by more then 30% (P < 0.005). The median cost per patient was as low as one-fifth in the last month. Men and the older age group of 65 and above, cost significantly less compared with women and younger patients, respectively, regardless of provider setting. The main differences in health services utilisation were in hospitalisations and oncology treatments (P < 0.01 and P < 0.05, respectively). Palliative Medicine 2007; 21 : 537—541

Pattern of electrolyte abnormalities among cancer patients referred to palliative care: a review of 750 patients

Background: Electrolyte abnormalities, especially when severe, may increase the symptomatic burden on the terminally-ill cancer patients. This study aimed at determining the pattern of electrolyte abnormalities in hospitalized cancer patients at the time of their referral to a palliative care team.Methods: We retrospectively reviewed the medical records of hospitalized adult cancer patients upon their first referral to a palliative care team. The study period covered 25 months. The electrolytes studied included potassium, sodium, calcium and magnesium. The most abnormal value observed on the day of referral ± 7 days is taken as the value of interest for a particular electrolyte for a given patient. The degree of abnormality in the level of electrolytes is classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events, Version 3.0.Results: From 1137 referrals, 750 (66%) patients were eligible for the study. Among these, 590 (79%) had at least one electrolyte abnormality and 163 (22%) had 3 or more electrolyte abnormalities. About 38% of patients had at least one electrolyte abnormality of grade 3 or 4. The most prevalent electrolyte abnormalities were hyponatraemia (59%), hypomagnesaemia (42%), hypokalaemia (41%) and hypercalcaemia (23%). Conclusions: Electrolyte abnormalities are common and often severe among cancer patients referred to palliative care. Further studies are warranted to correlate between electrolyte abnormalities and the clinical presentation of palliative care cancer patients and the potential impact of routine assessment and management of such abnormalities on their overall well-being.

Spirituality and religion in terminally ill patients with cancer

19587 Background: The importance of spirituality and religion in coping with a terminal illness is becoming increasingly recognised. We aimed to assess the relation between spiritual well-being, religiosity, depression, and end-of-life despair in terminally-ill cancer patients. Methods: One hundred forty three terminally ill cancer patients with a life expectancy of less than 6 months were interviewed with a series of standardised instruments, including the FACIT Spiritual Well-Being Scale, a religiosity index similar to those used in previous research, the Hamilton depression rating scale, the Memorial Symptom Assessment Scale and the Duke-UNC Functional Social Support Questionnaire. Results: A strong negative association was observed between the FACIT Spiritual Well-Being scale and the HDRS, but no such relationship was found for religiosity. Similar patterns were observed for the FACIT subscales, finding a strong negative association between the meaning and peace subscale (which corresponds to the more existential aspects of spirituality) and HDRS scores, whereas a positive, albeit nonsignificant, association was observed for the faith subscale (which corresponds more closely to religiosity). Conclusions: These results suggest that the beneficial aspects of religion may be primarily those that relate to spiritual well-being rather than to religious practices per se. Spiritual well-being offers some protection against end-of-life despair in those for whom death is imminent. The area of spiritual work is fertile ground for further investigation, especially interventions aimed at improving spiritual health and general quality of life among terminally ill patients with cancer. No significant financial relationships to disclose.