Integrating POLST into palliative care guidelines: a paradigm shift in advance care planning in oncology

Because predicting and outlining guidance for all possible scenarios is difficult, advance directives are rarely sufficiently precise to dictate patient preferences in specific situations as a disease progresses. Nonetheless, advance care planning is an essential process that should begin at the time of diagnosis, if not already initiated, to ensure that all patient and family rights are preserved. Communicating effectively with the patient and family and having the patient designate a surrogate decision-maker are critical. Attention must be paid to resolving conflicts among patient values and preferences and those of family and the health care team. Patient-centered goals for care and expectations should be elicited at first assessment and reassessed frequently as conditions change. As a disease progresses, advance directives are rarely precise enough to predict all possible scenarios and outline guidance for care. Therefore, for patients with advanced metastatic cancer and a potential life expectancy of less than 1 year, converting patient-centered treatment goals into actionable medical orders while the patient maintains capacity is a more effective way to ensure that patient preferences are honored. Physician Orders for Life-Sustaining Treatment (POLST) and similar medical order forms provide explicit direction about resuscitation status ("code status") if the patient is pulseless and apneic. POLST also includes directions about additional interventions the patient may or may not want. A decade of research in Oregon has proved that the POLST Paradigm Program more accurately conveys end-of-life preferences that are more likely to be followed by medical professionals than traditional advance directives alone.     

Pretreatment oral health care interventions for radiation patients

Individuals undergoing head and neck radiation treatments and cytotoxic chemotherapy for cancer are at risk for a variety of deleterious oral side effects. This added potential for oral problems places the cancer patient in a special category for oral health care management. Pretreatment intervention regimens directed at the supporting tissues of the teeth can effectively remove dental calculus deposits and cementum-imbedded bacterial toxins and reverse the inflammatory state of the periodontium back to normal. A variety of patient-applied fluoride agents are extremely effective in preventing severe radiation-associated dental decay, which is likely to occur after salivary gland dysfunction. Deficiencies in current patient management protocols and areas of current research are noted. Two essentials for a successful patient management program are emphasized: early referral of the patient to a knowledgeable dental team to ensure pre-cancer treatment oral health care intervention and long-term maintenance, and a family-oriented education and motivation program to enhance patient understanding and compliance.     

Psychosocial Care of the Cancer Patient

The diagnosis and treatment of cancer are events that confront the patient, family, physician, and other members of the health care team. Each stage of the illness, from diagnosis to death, is characterized by individual psychosocial tasks and problems. The authors develop specific guidelines that phsycians can use for the psychosocial assessment of and intervention with the cancer patient. The overall goal is to provide the patient with hope balanced with reality of al stages of the disease. Methods are given for assessment and intervention at four specific points in the disease: (1) the initial meeting between patient and physician, (2) the completion of treatment, (3) the time when treatment fails, and (4) the terminal stage. The benefits of psychosocial assessment and intervention for the patient, family, and health care team are discussed.     

The Role of Advocacy in Cancer Research: Not a Monster

The 1990s, the decade of advocacy, have produced many changes in the dynamic of the cancer patient and his or her surroundings. I write from the perspective of the female patient, specifically the woman with breast cancer, since it is this patient and survivor group that has had the most dramatic impact. Among the relationships that now have new dimensions are that of the patient and her physician, the patient and her insurer, the patient and her government, and the patient and the media. Evolving along with these, for both common and unrelated reasons, are the relationships of the physician and the insurer, the medical profession and the advocate, the oncology researcher and his or her traditional sources of funding, and the physician and the media.     

Problem-Solving Model in Radiology for Medical Students

Current undergraduate medical education is criticized for not preparing physicians to be independent thinkers. The rapid development of new imaging techniques and the problem of escalating medical costs call for efficient patient management, The development of algorithms in imaging work-up of patient problems is an excellent example of problem solving or medical decision making. The senior elective in radiology at our institution incorporates this type of problem-solving session. Small groups (15–25 students) with faculty guidance discuss 5–6 common patient problems to develop an investigative plan in imaging. Algorithms are thus developed by the group, but not presented for memorization. Small changes are then made in the case history so that the students are forced to make new hypotheses and generate a modified algorithm. Correlative costs are included. Flexibility and initiative in development of patient management algorithms are stressed.     

Familial adenomatous polyposis, hereditary nonpolyposis colon cancer, and familial risk: what are the implications for the surgeon?

Recent advances in the understanding of the molecular biology of colorectal cancer have resulted in many new implications for surgeons. To continue providing sound patient care, surgeons must familiarize themselves with associated issues that include genetic counseling and its role in patient and family management. Issues related to genetic counseling are reviewed in this article. Recommendations for surgical therapy and surveillance methods are summarized for each of the hereditary syndromes. Failure to use these patient management tools in an effective way may be a source of future litigation.     

Conflits d’intérêts et éthique médicale

Since the majority of people have various interests in their life, many conflicts are between the patient and himself/ herself. The physician has to help the patient to realize the different parts of his/her interest in order to choose autonomously at the best for amedical decision. Listening to the patient and many exchanges between him/her and the doctor allow to elucidate the best way to obtain the good or the least evil for the patient.     

Oral Chemotherapy in Patients with Hematological Malignancies—Care Process,Pharmacoeconomic and Policy Implications

Patients with hematologic malignancies are increasing being prescribed oral anticancer medications (OAMs) and/or biologics. These newer targeted OAMs are associated with a host of practical and pharmacoeconomic implications for patients and healthcare providers. Issues such as safety, procurement challenges, and the need for proactive involvement of all stakeholders to optimize adherence for successful use of these agents are increasingly being recognized. The current reactive model is negatively impacting the patient experience through delays in care, financial toxicity, and decreased safety. It also impacts the healthcare providers in the form of lost revenue and staff burnout due to labor-intensive procurement and patient financial assistance burdens. In this review, we describe some of the issues identified and discuss potential strategies to improve patient access, minimize healthcare burden, and review current policy initiatives and patient advocacy efforts to reduce financial toxicity.     

Are DNA Flow Cytometry Measurements Providing Useful Information in the Management of the Node-Negative Breast Cancer Patient?

The appropriate management of the breast cancer patient with early stage disease is a controversial, frustrating issue. If laboratory tests could accurately predict tumor behavior, however, the clinician and patient would be greatly aided in their treatment decisions. Although imperfect, there are several new and significant factors that can be used to predict patient prognosis; the most promising and well studied of these factors are DNA flow cytometry measurements. There are at least two estimates of tumor aggressiveness that we can obtain from DNA flow cytometry: one is an estimate of the tumor DNA content or ploidy and the other is an estimate of the tumor proliferative capacity. These measurements have their greatest clinical impact in the node negative patient predicting for relapse-free survival and overall survival. Estimates of proliferative capacity are independent predictors of patient prognosis. Estimates of DNA content are at times controversial and yet still are helpful in distinguishing prognostic subgroups of proliferative activity and may have additional clinical relevance. This discussion will summarize the data obtained from DNA flow cytometry measurements supporting their use as clinically important markers of prognosis in the node-negative patient.     

New hurdles for translational research

New guidelines for the collection and use of human tissues for research will impose new requirements on researchers to seek ethical approval and patient consent. This extends to the use of surplus tissue, such as breast cancer excision biopsies, which, until recently, have been regarded as having been 'abandoned' by the patient. This article argues that some of these new constraints provide hurdles to translational research that are unnecessary for patient protection. This is particularly significant when emerging technologies are expected to elicit major advances in clinical cancer research.     

Algorithms for prostate-specific antigen recurrence after treatment of localized prostate cancer

Nomograms are devices that predict outcome probabilities for the individual patient. Herein we discuss their strengths and limitations, focusing on responses to several frequently asked questions about nomograms. We believe these tools are useful and necessary for patient counseling, follow-up scheduling, and clinical trial design and analysis.     

Die zukünftige Rolle der Pflegenden in der Onkologie

The innovative developments in oncology have a great impact on patient care and on the nurses themselves. The implied rationing of nursing care leads to increased risks for the patients and the nurses. This problematic situation should be approached as follows: nurses with advanced clinical experience are to be integrated in daily practice; evidence-based continuing education courses for patient counseling and patient education are to be implemented. The framework for nursing is adapted to the patients’ needs and the internationally acknowledged criteria for magnet hospitals will also be recognized and put into practice in Europe.     

In vivo dosimetry during external photon beam radiotherapy

In this critical review of the current practice of patient dose verification, we first demonstrate that a high accuracy (about 1-2%, 1 SD) can be obtained. Accurate in vivo dosimetry is possible if diodes and thermoluminescence dosimeters (TLDs), the main detector types in use for in vivo dosimetry, are carefully calibrated and the factors influencing their sensitivity are taken into account. Various methods and philosophies for applying patient dose verification are then evaluated: the measurement of each field for each fraction of each patient, a limited number of checks for all patients, or measurements of specific patient groups, for example, during total body irradiation (TBI) or conformal radiotherapy. The experience of a number of centers is then presented, providing information on the various types of errors detected by in vivo dosimetry, including their frequency and magnitude. From the results of recent studies it can be concluded that in centers having modern equipment with verification systems as well as comprehensive quality assurance (QA) programs, a systematic error larger than 5% in dose delivery is still present for 0.5-1% of the patient treatments. In other studies, a frequency of 3-10% of errors was observed for specific patient groups or when no verification system was present at the accelerator. These results were balanced against the additional manpower and other resources required for such a QA program. It could be concluded that patient dose verification should be an essential part of a QA program in a radiotherapy department, and plays a complementary role to treatment-sheet double checking. As the radiotherapy community makes the transition from the conventional two-dimensional (2D) to three-dimensional (3D) conformal and intensity modulated dose delivery, it is recommended that new treatment techniques be checked systematically for a few patients, and to perform in vivo dosimetry a few times for each patient for situations where errors in dose delivery should be minimized.     

The representitativeness of patient position during the first treatment fractions

BACKGROUND: During external radiotherapy daily or even weekly image verification of the patient position might be problematic due to the resulting workload. Therefore it has been customary to perform image verification only at the first treatment fraction. In this study it is investigated whether the patient position uncertainty at the initial three treatment fractions is representative for the uncertainty throughout the treatment course. METHODS: Seventy seven patients were treated using Elekta Synergy accelerators. The patients were immobilized during treatment by use of a customized VacFix bag and a mask of AquaPlast. Cone beam CT (CBCT) scans were performed at fractions 1, 2, and 3 and at the 10th and 20th treatment fractions. Displacements in patient position, translational and rotational, have been measured by an image registration of the CBCT and the planning CT scan. The displacements data are evaluated retrospectively and the effect of Action Level (AL) image verification protocols based on sessions 1, 2, 3 are simulated. The resulting overall patient position uncertainties of the different protocols are evaluated at the 10th and 20th fractions. RESULTS AND CONCLUSIONS: The differences between the addressed protocols are shown to be very small compared to the overall increase in patient position uncertainty during the treatment course. Thus the main problem in achieving the smallest possible uncertainty for the overall treatment is not the selection of 'the best' image verification protocol for the initial three fractions. The main challenge is that the overall patient position uncertainty increases during the treatment course. Information about the patient position during the first three fractions is therefore not representative for the overall patient position. For these types of patients and immobilization equipment it would consequently be an advantage to reduce the number of image verification sessions during the initial fractions and then compensate with additional imaging sessions during the remaining treatment course.     

Palliative home care

Palliative home care supports the quality of life (QOL) of a patient and family as a whole. Team care is an effective method corresponding to the various needs of the patient and family. Cooperation of various types of professions can meet the need for high-quality outpatient medical care. Social work serves as a coordinator of the care team. One of its important tasks in palliative home care is support of the patient discharge procedure from the hospital. Discharge from the hospital must be carried out before the patient's condition worsens. Prompt support of the discharge is indispensable so that the patient may spend substantial time with high QOL at home. Palliative home care means care for the dying. Therefore, spirituality issues are important. Palliative home care must respect and understand the spirituality of the patient and family. The patient can be discharged from the hospital in peace when there is general support for the physical, psycho-social and spiritual needs of both patient and family.     

An approach to ADL expansion for home pediatric patient with artificial respirator

A home pediatric patient with artificial respirator has little chance to go out. The primary reasons are as follows: (1) Lack of experience in controlling the situation by the family when artificial respirator related troubles occur. (2) Whenever the patient wants to go out, no caregiver is available for assistance. (3) Going-out is just a psychological burden for the patient and family. (4) Availability of receiving institutions for a patient who needs an emergency care. Hence, a caregiver should improve not only the patient's ADL but also establishes a system that provides a satisfactory care for the patient and family. In doing so, the caregiver's role is important more than ever.     

Patient choice for cancer treatment: towards a shared-decision model?

The process of medical decision implies the elaboration of a choice between alternatives. Who has the choice? The doctor? The patient? Both? That depends on the particular characteristics of the patient and of the tumour, but also of the characteristics of the doctor and of his approach of medical discipline. For that reason, we planned first to remind some principles. In our analysis, the patient-doctor's relationship ties with environment, culture and habits. Philosophical principles, moral, and models of the relation between patient and doctor concern first part. In the second part, these ideas are compared with our routine practice: surveys about patients' needs, the obstacles for complete information and participation, studies on patients' preferences. The authors' analysis is that we are going inescapably towards shared decision-making taking into account the patients preferences. This evolution is not only tied with ethical principles, but with medical reason, i.e. the variability of patients' preferences led to tailor the treatment to the individual patient especially when benefit is limited. Of course, the applicability of a shared model depends on the particular situation of the patient and of his demand. It is all the easier as the consequences of the treatment are well known the riks tiny and distant. In the classical paternalistic model, there is no choice for the patient because the doctor(s) give the treatment. In the ideal model of the shared decision, doctor and patient progress together towards medical decision, in this case, the patient is not alone facing a choice, and in all cases, he is never alone.     

Experiences of Family Caregivers of Cancer Patients Receiving Chemotherapy

Background: Cancer is a disease which affects not only patients but also their families physically and emotionally. The purpose of this study was to determine the needs, challenges and ways of coping of caregivers of cancer patients. Materials and Methods: In the study, a phenomenological approach was used. Data were collected through semi-structured individual interviews. The study sample comprised 16 family members providing care for a cancer patient. Results: The study findings are grouped under four main themes: the impact of caregiving, masking feelings, experienced challenges and expectations, and coping. During the caregiving process, patient relatives are affected physiologically, psychologically and socially. It was determined that patient relatives hid their feelings and avoided talking about the disease for fear that they might upset the patient, and that they had difficulty in coping with the patient’s reactions during the treatment process. Family members had difficulties arising from the health system, hospital conditions and treatment in addition to ransportation and financial problems. Support is very important in coping, but it was determined that some of the relatives of patients did not receive adequate support. Patient relatives expect that health care professionals should provide them with more information about their patient’s condition and the course of the disease that their patients should be dealt with by the physicians specialized in cancer, and that psychological support should be provided both for them and for their patient. Conclusions: During the caregiving process, family members are faced with many difficulties and they exhibit different coping behaviors which health care professionals should take into account.