Palliative radiotherapy at the end of life: A critical review

Answer questions and earn CME/CNE When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life. CA Cancer J Clin 2014;64:295–310. © 2014 American Cancer Society.     

Improving cancer care at the end of life

Excellent care for cancer patients and their families should extend throughout the illness, and should include care provided at the end of life. Recent evidence, including a report from the Institute of Medicine, has emphasised that major reform is needed to improve relief of pain, other symptoms, and psychosocial care. This paper reviews the critical necessity for reform in end-of-life care for the field of oncology and the major educational efforts required to ensure that oncology professionals can respond to this need.     

Waiting for the platelet count to rise: negotiating care at the end of life

Oncologists play a crucial role in enabling patients at the end of life and their families to decide whether the burden of chemotherapy is worth the benefit. Using language that displays their concern for providing ongoing care and that does not mistakenly imply withholding of effective therapies can ease the transition off chemotherapy. Providing accurate, timely prognostic information; exploring patients' hopes, goals, and values; helping them resume meaningful activities; meeting their health care proxies and discussing the advance care plan with them can all enhance the relationship with patients at the end of life and ease fears of abandonment.     

Palliative care team at general hospital

Some three hundred thousand patients die from cancer in a year, most of whom end their lives at a general hospital. Considering this situation, the general hospital has to provide palliative care and make up interdisciplinary Palliative Care Team (PCT). Since April 2002, we established a PCT at Akita City Hospital. Our PCT educated doctors and nurses for palliative care medicine and established a system for palliative care. For example, the assessment sheet of cancer pain is useful for treatment of pain and to equally recognize the patient's condition by each team. The PCT provides support for doctors and nurses in the general unit. We general doctors must learn more about how to provide palliative care medicine for at least cancer pain as well as cancer treatment. A team approach is needed for all cancer patients.     

Couples therapy at end of life

This study reports on a preliminary uncontrolled study of a treatment for couples in which one partner is diagnosed with a terminal illness. In this study nine couples, in which one partner was diagnosed with a terminal illness and had less than 18 months to live, were offered eight sessions of couples therapy. Follow-up data were available for six couples. Two patients died during treatment and a third patient moved out of the area prior to completing the follow-up assessment. Significant decreases were seen in the patients' distress about dying and the frequency of partners' worry about their partner dying. Improvements were also seen in relationship quality. While the size of the study precludes generalizing these findings to a larger population, this study supports further exploration of couples therapy as a potentially useful adjunct to end of life care.     

Patterns of care at end of life for people with primary intracranial tumors: lessons learned

To determine the variability in processes of care in the last 6 months of life experienced by patients dying of primary intracranial tumors and potential predictors of place of death, a death-backwards cohort was assembled using historical data and 1,623 decedents were identified. 90 % of people had ≥1 admission to an acute care hospital and 23 % spent ≥3 months of their last 6 months of life in acute care. 44 % had ≥1 ER visits and 30 % were admitted ≥1 times to ICU. Only 18 % had a home visit by a physician. 10 % died at home but 49 % died in hospital, while 40 % died in a palliative care facility. Age, comorbidities, and being diagnosed with grade 4 astrocytoma were associated with greater burden of care. Level of care burden and age were associated with higher odds of dying in a treatment intensive place of death, being diagnosed with grade 4 astrocytoma had opposite effect. Despite valuable research efforts to improve the treatment of primary intracranial tumors that focus on biology, refinements to surgery, radiation, and chemotherapy, there is also room to improve aspects of care at the end of life situation. An integrative approach for this patients’ population, from diagnosis to death, could potentially reduce the care burden in the final period on the health care system, patient’s family and improve access to a better place of death.     

Support of cancer patients' spiritual needs and associations with medical care costs at the end of life

BACKGROUND:

Although spiritual care is associated with less aggressive medical care at the end of life (EOL), it remains infrequent. It is unclear if the omission of spiritual care impacts EOL costs.

METHODS:

A prospective, multisite study of 339 advanced cancer patients accrued subjects from September 2002 to August 2007 from an outpatient setting and followed them until death. Spiritual care was measured by patients' reports that the health care team supported their religious/spiritual needs. EOL costs in the last week were compared among patients reporting that their spiritual needs were inadequately supported versus those who reported that their needs were well supported. Analyses were adjusted for confounders (eg, EOL discussions).

RESULTS:

Patients reporting that their religious/spiritual needs were inadequately supported by clinic staff were less likely to receive a week or more of hospice (54% vs 72.8%; P = .01) and more likely to die in an intensive care unit (ICU) (5.1% vs 1.0%, P = .03). Among minorities and high religious coping patients, those reporting poorly supported religious/spiritual needs received more ICU care (11.3% vs 1.2%, P = .03 and 13.1% vs 1.6%, P = .02, respectively), received less hospice (43.% vs 75.3% ≥1 week of hospice, P = .01 and 45.3% vs 73.1%, P = .007, respectively), and had increased ICU deaths (11.2% vs 1.2%, P = .03 and 7.7% vs 0.6%, P = .009, respectively). EOL costs were higher when patients reported that their spiritual needs were inadequately supported ($4947 vs $2833, P = .03), particularly among minorities ($6533 vs $2276, P = .02) and high religious copers ($6344 vs $2431, P = .005).

CONCLUSIONS:

Cancer patients reporting that their spiritual needs are not well supported by the health care team have higher EOL costs, particularly among minorities and high religious coping patients. Cancer 2011;. © 2011 American Cancer Society.     

Palliative care for colorectal cancer

Most patients with stage IV colorectal cancer have a poor prognosis,but numerous palliative modalities are available today.When a cure is no longer possible, treatment is directed toward providing symptomatic relief. The data leave little doubt that surgical resection may provide good palliation. Although resection has been the mainstay of palliative care, an individualized multidisciplinary approach, which may involve both surgical and nonsurgical modalities, is probably the best current option.     

Palliative care workshop primarily aimed for physicians and nurses in order to improve the care of the end-of- life homecare patient

Since 2008, we held a palliative care workshop primarily aimed for physicians, who engaged in clinical practice for cancer treatment. In order to improve the end-of-life stage patient care at home, we made all sorts of efforts not only for physicians, but we also made a workshop available for healthcare professionals to participate. There were more than 60 people participated the workshop: our 20% of physicians and 24% of nurses, 13% of nearby hospital and clinic physicians, 12% of pharmacists and 17% of nurses. According to our questionnaire survey, more than 90% of the participants were satisfied with the workshop. Only 8% of the participants expressed that the workshop was rather difficult. From our analysis of the results, it was clear that we attained a high level of participants' satisfaction.