Early integration of palliative care services with standard oncology care for patients with advanced cancer

Answer questions and earn CME/CNE Scientific advances in novel cancer therapeutics have led to remarkable changes in oncology practice and longer lives for patients diagnosed with incurable malignancies. However, the myriad options for treatment have established a culture of cancer care that has not been matched with a similar availability of efficacious supportive care interventions aimed at relieving debilitating symptoms due to progressive disease and treatment side effects. Accumulating data show that the introduction of palliative care services at the time of diagnosis of advanced cancer leads to meaningful improvement in the experiences of patients and family caregivers by emphasizing symptom management, quality of life, and treatment planning. In this review article, the rationale and evidence base for this model of early palliative care services integrated into standard oncology care are presented. In addition, the implications and limitations of the existing data to 1) elucidate the mechanisms by which early palliative care benefits patients and families; 2) guide the dissemination and application of this model in outpatient settings; and 3) inform health care policy regarding the delivery of high‐quality, cost‐effective, and comprehensive cancer care are discussed. CA Cancer J Clin 2013;63:349‐363. ^© 2013 American Cancer Society, Inc.     

Spiritual well‐being of Italian advanced cancer patients in the home palliative care setting

This study evaluates the spiritual well‐being (SpWB) in very advanced cancer patients assisted by the home palliative care program of ANT Foundation, a no‐profit Italian organisation. SpWB was assessed by the Functional Assessment of Chronic Illness Therapy–Spiritual Well‐Being Scale (FACIT‐Sp12), including Meaning, Peace, and Faith subscales. The quality‐of‐life (QoL) was evaluated by using the Functional Assessment of Cancer Therapy‐General scale. Questionnaires were distributed to 1,055 patients and 683 were compiled and evaluable for analysis. The mean scores of FACIT‐Sp12 as well as of QoL were notably lower than reference values for cancer survivors. The FACIT‐Sp12 score was higher in patients with less impaired Karnofsky Performance Status, fully participating in religious rituals and living in central Italy. A high Pearson's correlation was found between QoL and FACIT‐Sp12 (r = .60), Peace (r = .71) and Meaning (r = .52), while it was marginal for Faith (r = .27). The hierarchical regression analysis showed that FACIT‐Sp12 is a significant predictor of QoL. The study suggests that Italian patients with advanced cancer assisted by expert multi‐professional teams in the home palliative care setting have a low level of SpWB thereby highlighting the need for the integration of spiritual support as part of comprehensive cancer care.     

Pediatric palliative care in the community

Answer questions and earn CME/CNE Early integration of pediatric palliative care (PPC) for children with life‐threatening conditions and their families enhances the provision of holistic care, addressing psychological, social, spiritual, and physical concerns, without precluding treatment with the goal of cure. PPC involvement ideally extends throughout the illness trajectory to improve continuity of care for patients and families. Although current PPC models focus primarily on the hospital setting, community‐based PPC (CBPPC) programs are increasingly integral to the coordination, continuity, and provision of quality care. In this review, the authors examine the purpose, design, and infrastructure of CBPPC in the United States, highlighting eligibility criteria, optimal referral models to enhance early involvement, and fundamental tenets of CBPPC. This article also appraises the role of CBPPC in promoting family‐centered care. This model strives to enhance shared decision making, facilitate seamless handoffs of care, maintain desired locations of care, and ease the end of life for children who die at home. The effect of legislation on the advent and evolution of CBPPC also is discussed, as is an assessment of the current status of state‐specific CBPPC programs and barriers to implementation of CBPPC. Finally, strategies and resources for designing, implementing, and maintaining quality standards in CBPPC programs are reviewed. CA Cancer J Clin 2015;65:315–333. © 2015 American Cancer Society.     

Research with families in palliative care: conceptual and methodological challenges

Conducting research with families of individuals receiving palliative care is challenging. Issues contributing to the challenge include defining the family, determining the unit of analysis in the level of inquiry, and identifying pathways to knowledge about the family. The purpose of this paper is to provide an overview of the major conceptual and methodological issues facing family researchers in general, with an aim to examining how these issues impact researchers studying families of individuals receiving palliative care.     

Barriers to accessing palliative care for pediatric patients with cancer: A review of the literature

Although many of the 16,000 children in the United States diagnosed who are with cancer each year could benefit from pediatric palliative care, these services remain underused. Evidence regarding the barriers impeding access to comprehensive palliative care is dispersed in the literature, and evidence specific to pediatric oncology remains particularly sparse. The purpose of the current review was to synthesize the existing literature regarding these barriers and the strategies offered to address them. The authors completed a literature search using the PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science databases. In total, 71 articles were reviewed. Barriers to accessing pediatric palliative care were categorized according to the 4 levels of a modified socioecological model (ie, barriers related to policy/payment, health systems, organizations, and individuals). Major themes identified at each level included: 1) the lack of consistent and adequate funding mechanisms at the policy/payment level, 2) the lack of pediatric palliative care programs and workforce at the health systems level, 3) difficulties integrating palliative care into existing pediatric oncology care models at the organizational level, and 4) the lack of knowledge about pediatric palliative care, discomfort with talking about death, and cultural differences between providers and patients and their families at the individual level. Recommendations to address each of the barriers identified in the literature are included. Cancer 2018;124:2278‐88 . © 2018 American Cancer Society.     

Nutritional support and quality of life in cancer patients undergoing palliative care

PREVOST V. & GRACH M.-C. (2012) European Journal of Cancer Care21, 581-590 Nutritional support and quality of life in cancer patients undergoing palliative care In palliative care, the nutrition provided has to be tailored to the patient's needs, enhancing patient comfort and quality of life (QoL). We conducted a literature search to review methods of measuring QoL, and modalities of nutritional intervention and their influence on QoL of cancer patients in palliative care. Original papers published in English were selected from PubMed database by using the search terms, palliative medicine, cancer, nutrition and quality of life. Specific tools that are particularly recommended to assess QoL in a palliative care setting are reviewed. The main goal in palliative care is to maintain oral nutrition by providing nutritional counselling. Enteral nutritional support showed inconsistent effects on survival and QoL. An evidence-base for parenteral nutrition is still lacking. Ethical considerations concerning provision of food and hydration in end-of-life care are discussed. Nutritional status should be assessed early and regularly during treatment using appropriate tools. In the particularly acute context of palliative care, optimal patient management requires adequate education and counselling to patients and families. Meaningful interactions between the patient, caregivers and medical team would also increase the chance of resolving nutrition-related issues and help to fulfil each patient's specific nutritional needs and thus improve the QoL.     

Systematic versus on-demand early palliative care: A randomised clinical trial assessing quality of care and treatment aggressiveness near the end of life

AimEarly palliative care (EPC) in oncology has shown sparse evidence of a positive impact on patient outcomes, quality of care outcomes and costs.Patients and methodsData for this secondary analysis were taken from a trial of 207 outpatients with metastatic pancreatic cancer randomly assigned to receive standard cancer care plus on-demand EPC (standard arm) or standard cancer care plus systematic EPC (interventional arm). After 20 months' follow-up, 149 (80%) had died. Outcome measures were frequency, type and timing of chemotherapy administration, use of resources, place of death and overall survival.ResultsSome indices of end-of-life (EoL) aggressiveness had a favourable impact from systematic EPC. Interventional arm patients showed higher use of hospice services: a significantly longer median and mean period of hospice care (P = 0.025 for both indexes) and a significantly higher median and mean number of hospice admissions (both P < 0.010). In the experimental arm, chemotherapy was performed in the last 30 days of life in a significantly inferior rate with respect to control arm: 18.7% versus 27.8% (adjusted P = 0.036). Other non-significant differences were seen in favour of experimental arm.ConclusionsSystematic EPC showed a significant impact on some indicators of EoL treatment aggressiveness. These data, reinforced by multiple non-significant differences in most of the other items, suggest that quality of care is improved by this approach.This study is registered on ClinicalTrials.gov (NCT01996540).     

Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward

BACKGROUND.

Acute palliative care units (APCUs) are gaining popularity in tertiary care centers. In this study, the authors examined the impact of opening an APCU on administrative outcomes for a general oncology ward (GOW) at a comprehensive cancer center.

METHODS.

The GOW database was reviewed for 3 periods: June 2000 through May 2002 (before the APCU opened), June 2002 through May 2004 (transitional period, including APCU opening in a temporary location), and June 2004 through May 2006 (after opening of the APCU). Data were extracted on demographics, reasons for admission, admission type, waiting time for admission, length of stay (LOS), overstay (>2 days over expected LOS), death rate, and discharge destination. Linear regression analysis and the Cochran‐Armitage test were used for data analysis.

RESULTS.

There were 5340 admissions: The median patient age was 60 years, and 55% of patients were women. The most common primary cancers were head and neck (22%), gynecologic (21%), gastrointestinal (13%), and lung (12%). There were significant trends on the GOW in decreased admissions for palliative care (12.2%, 9.6%, and 7.9%, respectively, for the 3 periods; P < .0001), fewer inpatient deaths (11.4%, 8.6%, and 6.1%, respectively; P < .0001), and fewer patients with prolonged waits for a bed on a palliative care unit (3.4%, 3%, and 1.7%, respectively; P = .002). Admissions increased for interventions (10.4%, 17.3%, and 22.5%, respectively, for the 3 periods; P < .0001) and for chemotherapy (6.8%, 6.6%, and 9.7%, respectively; P = .001).

CONCLUSIONS.

After the opening of an APCU at the authors' cancer center, the GOW experienced a decrease in administrative endpoints related to palliative and end‐of‐life care and an increase in endpoints related to cancer‐directed interventions. Prospective studies with clinical endpoints will be required to determine whether this specialization of inpatient care improves quality of life, quality of death, and psychosocial well being. Cancer 2008. © 2008 American Cancer Society.     

End of life care

This module presents background and encourages personal reflection and learning on end of life care terminology, concepts and ethics for all healthcare staff working with adult cancer patients. Consideration is given to resuscitation issues, communication skills competence and end of life care pathways such as Gold Standards Framework and Liverpool Care Pathway for the Dying.     

Validation of the Mexican–Spanish version of the EORTC QLQ‐C15‐PAL questionnaire for the evaluation of health‐related quality of life in patients on palliative care

Background: Health‐related quality of life (HRQL) is an important outcome in oncology, particularly in the palliative care setting. The European Organization for Research and Treatment of Cancer (EORTC) QLQ‐C15‐PAL questionnaire is a brief version of QLQ‐C30. Our aim is to validate the Mexican–Spanish version of the QLQ‐C15‐PAL questionnaire to measure HRQL in patients with terminal cancer. Methods: Consecutive patients with biopsy proven cancer were included in the study. All were treated in a cancer center in Mexico and were referred for palliative care because of far‐advanced, recurrent or metastatic cancer. QLQ‐C15‐PAL questionnaire was applied in the first visit to the Unit and palliative care was offered to all patients depending on their specific necessities. Results: Eighty‐three patients were enrolled in this study (mean age, 61.2 years). Compliance rates were high; all patients completed to the questionnaire in <20 min and the instrument was well‐received. Five missing values in five different items were found. QLQ‐C15 scales distinguished between other clinically distinct groups of patients. Multi‐trait scaling analysis demonstrated good convergent and discriminant validity. Cronbach's α coefficients were >0.7 in three of four multi‐item scales (0.67 in the fourth). Test–retest scores were consistent in some scales, while improve or worsen in others. Better Global health, Dyspnea, Insomnia, Fatigue and Appetite scales were associated with longer survival. Conclusion: The Mexican–Spanish version of the EORTC QLQ‐C15‐PAL questionnaire is reliable and valid for HRQL measurement in patients with terminal cancer, and is appropriate for use in clinical trials of Mexican patients. Copyright © 2010 John Wiley & Sons, Ltd.     

Intensity of integrated cancer palliative care plans and end‐of‐life acute medical hospitalisation among cancer patient in Northern Italy

A high hospital utilisation at the end of life (EOL) is an indicator of suboptimal quality of health care. We evaluated the impact of the intensity of different Integrated Cancer Palliative Care (ICPC) plans on EOL acute medical hospitalisation among cancer decedents. Decedents of cancer aged 18–84 years, who were residents in two Italian regions, were investigated through integrated administrative data. Outcomes considered were prolonged hospital stay for medical reasons, 2+ hospitalisations during the last month of life and hospital death. The ICPC plans instituted 90 to 31 days before death represented the main exposure of interest. Other variables considered were gender, age class at death, marital status, recent hospitalisation and primary cancer site. Among 6,698 patients included in ICPC plans, 44.3% presented at least one critical outcome indicator; among these, 76.5% died in hospital, 60.3% had a prolonged (12+ days) medical hospitalisation, 19.1% had 2+ hospitalisations at the EOL. These outcomes showed a strong dose–response effect with the intensity of the ICPC plans, which is already evident at levels of moderate intensity. A well‐ICPC approach can be very effective—beginning at low levels of intensity of care—in reducing the percentage of patients spending many days or dying in hospital.     

The effect of horticultural therapy on the quality of life of palliative care patients

Palliative care patients experience a variety of needs and perceive their quality of life as being only fair. This study adopted a single-group repeated-measure design to investigate the effect of horticultural therapy on the quality of life of palliative care patients using the Quality of Life Concern in End of Life Questionnaire. Significant differences in the domains of “existential distress” and “health care concern” were observed immediately postintervention and at 4 weeks postintervention, respectively. No other significant differences were seen in the other domains or in the total mean score of the outcome measure.     

Systematic versus on-demand early palliative care: results from a multicentre,randomised clinical trial

BackgroundEarly palliative care (EPC) in oncology has been shown to have a positive impact on clinical outcome, quality-of-care outcomes, and costs. However, the optimal way for activating EPC has yet to be defined.MethodsThis prospective, multicentre, randomised study was conducted on 207 outpatients with metastatic or locally advanced inoperable pancreatic cancer. Patients were randomised to receive ‘standard cancer care plus on-demand EPC’ (n = 100) or ‘standard cancer care plus systematic EPC’ (n = 107). Primary outcome was change in quality of life (QoL) evaluated through the Functional Assessment of Cancer Therapy – Hepatobiliary questionnaire between baseline (T0) and after 12 weeks (T1), in particular the integration of physical, functional, and Hepatic Cancer Subscale (HCS) combined in the Trial Outcome Index (TOI). Patient mood, survival, relatives' satisfaction with care, and indicators of aggressiveness of care were also evaluated.FindingsThe mean changes in TOI score and HCS score between T0 and T1 were −4.47 and −0.63, with a difference between groups of 3.83 (95% confidence interval [CI] 0.10–7.57) (p = 0.041), and −2.23 and 0.28 (difference between groups of 2.51, 95% CI 0.40–4.61, p = 0.013), in favour of interventional group. QoL scores at T1 of TOI scale and HCS were 84.4 versus 78.1 (p = 0.022) and 52.0 versus 48.2 (p = 0.008), respectively, for interventional and standard arm. Until February 2016, 143 (76.9%) of the 186 evaluable patients had died. There was no difference in overall survival between treatment arms.InterpretationsSystematic EPC in advanced pancreatic cancer patients significantly improved QoL with respect to on-demand EPC.