Early palliative care for adults with advanced cancer

The benefits of early palliative care on psychological well-being, functional status, and health-related quality of life among cancer patients and their caregivers: a systematic review and meta-analysis

BACKGROUND

Patients with cancer and their caregivers experience significant psychological, physical, and emotional burdens throughout the disease trajectory which reduces their quality of life (QoL). Early palliative care (EPC) has been proposed as a strategy to alleviate physical, psychological and emotional burdens and improve health outcomes. While evidence generally supports the benefits of EPC, variations in reported outcomes highlight the need for a deeper understanding of its impact across different patient populations and healthcare settings.

OBJECTIVE

The primary aim of this study was to evaluate the pooled effects of EPC on psychological, functional status, and QoL outcomes in both cancer patients and their caregivers. The secondary aim was to evaluate the satisfaction of the patients and their family caregivers.

METHODS

A systematic review and meta-analysis were conducted following the preferred reporting item for systematic review and meta-analysis (PRISMA) guidelines. Four databases, PubMed, Scopus, EBSCOhost, and Cochrane, were searched up to January 2024. This study included randomized controlled trial (RCT) and pilot-RCT studies reporting psychological outcomes (anxiety, depression), functional status, QoL, and satisfaction in cancer patients and their caregivers. Subgroup analysis was performed to explore the short-term (< 24 weeks) versus long-term (≥ 24 weeks) effects of EPC. Mean differences (MD) and standard mean differences (SMD) were calculated using a fixed-effects model according to the Mantel-Haenszel model and a random-effects model according to the DerSimonian and Laird method.

RESULTS

A total of 24 studies met our inclusion criteria. For cancer patients, EPC significantly reduced anxiety (MD = -0.62, 95% CI: -1.02; -0.23, p = 0.002) and improved QoL (SMD 0.13, 95%CI: 0.06; 0.19, p = 0.0004). However, there was no significant reduction in depression (SMD -0.15, 95% CI: -0.36; 0.05, p = 0.14) and improvement in functional status (MD = 2.14, 95% CI: -0.78; 5.06, p = 0.15). Subgroup analysis revealed that long-term EPC significantly reduced anxiety and depression while improving QoL, but had no significant effects on functional status. For caregivers, EPC did not significantly impact either physical or mental QoL (Short form/SF-36 physical: MD = 0.81, 95% CI: -0.46; 2.09, p = 0.21; SF-36 Mental: MD = 0.53, 95% CI: -1.03; 2.08, p = 0.51). Moreover, satisfaction was more likely to be higher in patients and their caregivers who received EPC than in those who received usual care (MD 2.45, 95% CI: 0.90; 4.01, p = 0.002, MD 4.09, 95% CI: 0.60; 7.58, p = 0.02, respectively).

CONCLUSION

EPC reduces long term psychological burden and improve QoL and care satisfaction experience among patients with cancer. Therefore, EPC should be more broadly introduced into cancer care earlier to address patient's psychological burdens.

Defining "early palliative care" for adults diagnosed with a life-limiting illness: a scoping review

BACKGROUND

Palliative care is for people suffering from life-limiting illnesses that focuses on providing relief from symptoms and stress of illness. Previous studies have demonstrated that specialist palliative care consultation delivered earlier in the disease process can enhance patients' quality of life, reduce their symptom burden, reduce use of hospital-based acute care services and extend their survival. However, various definitions exist for the term early palliative care (EPC).

OBJECTIVE

To investigate how EPC has been defined in the literature for adults with life- limiting illnesses.

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews guidelines and follows the Joanna Briggs Institution methodology for scoping reviews. The literature search was conducted using MEDLINE (Ovid), CINAHL (EBSCO), Embase (Ovid), PsycINFO (Ovid), Web of Science Core Collection, Ovid Cochrane Library, and ProQuest (Health and Medicine and Sociology Collections). All articles retrieved were screened by three independent reviewers.

RESULTS

153 articles met the inclusion criteria between 2008 and 2024. Five categories of definitions for EPC were created to organize definitions: (1) time-based (e.g. time from advanced cancer diagnosis to EPC initiation); (2) prognosis-based (e.g. prognosis or the 'surprise question'); (3) location-based (e.g. access point within the healthcare system such as outpatient setting); (4) treatment-based (e.g. physician's judgement or prior to specific therapies); and (5) symptom-based (e.g. using symptom intensity questionnaires). Many studies included patients with cancer (n = 103), with the most common definition category being time-based (n = 53). Amongst studies focusing on multiple or non-cancer diagnoses (n = 50), the most common definition category was symptom-based (n = 16).

CONCLUSION

Our findings provide a useful reference point for those seeking to understand the scope and breadth of existing EPC definitions in cancer and non-cancer illnesses and contemplate their application within clinical practice.

Trends, Sociodemographic and Hospital-Level Factors Associated with Palliative Care Utilization Among Metastatic Prostate Cancer Patients

Background: Several factors are reported to be associated with palliative care utilization among patients with various cancers, but literature is lacking on metastatic prostate cancer (MPC) specific factors. Early integration of palliative care in management of MPC patients could increase their quality of life and overall outcomes. Methods: Retrospective longitudinal analyses were conducted using the National Inpatient Sample (NIS) data (2010 - 2019). Prevalence trends in palliative care utilization were assessed, and sociodemographic and hospital-level factors associated with palliative care utilization in MPC patients were examined. Results: The overall prevalence of palliative care utilization was 13.1% with an increasing trend from 8490 to 15,231 per 100,000 MPC admissions (p-trend <.001). MPC patients aged 65 years and above had similar odds of receiving palliative care compared to younger patients. Relative to non-Hispanic Whites, other racial groups had similar likelihood to utilize palliative care services. Patients in higher median household national income quartiles had greater odds of utilizing palliative care relative to those in the first income quartile. Patients on Medicaid, private insurance and other insurance types had greater odds of palliative care use in comparison to those on Medicare. Other factors identified were hospital region, location and teaching status, patient disposition, admission type, length of stay, and number of comorbidities. Conclusion: Our findings underscore the significance of enhanced government policies and institutional support in improving palliative care use among hospitalized MPC patients. Health systems must be proactive in addressing barriers to optimization of palliative care utilization in this population.

Forging an easier path through graduation: Improving the patient transition from paediatric to adult critical care

Adolescence and the journey to adulthood involves exciting opportunities as well as psychosocial stress for young people growing up. These normal experiences are potentially magnified for teenagers living with chronic illness or disability and their families. Advances in care have improved survival for children with a variety of serious chronic medical conditions such that many who may once have died in childhood now survive well into adulthood with ongoing morbidity. For those with highly complex needs, care is often provided at major paediatric hospitals with expertise, specially trained personnel, and resources to support young people and their families for the first decades of life. At the end of adolescence, however, it is generally appropriate and necessary for young adults and their caregivers to transition to the care of clinicians trained in the care of adults at general hospitals. While there are some well-managed models to support this journey of transition, these are often specific to certain conditions and usually do not involve intensive care. Many patients may encounter considerable challenges during this period. Difficulties may include the loss of established therapeutic relationships, a perception of austerity and reduced amenity in facilities oriented to caring for adult patients, and care by clinicians with less experience with more common paediatric conditions. In addition, there is a risk of potential conflict between clinicians and families regarding goals of care in the event of a critical illness when it occurs in a young adult with major disability and long-term health issues. These challenges present genuine opportunities to better understand the transition from paediatric to adult-based care and to improve processes that assist clinicians who support patients and families as they shift between healthcare settings.

Proactive symptom monitoring to initiate timely palliative care for patients with advanced cancer: a randomized controlled trial

PURPOSE

To deliver timely palliative care in response to supportive and palliative care needs as they arise, we developed a model called "Supportive and Palliative care Review Kit in Locations Everywhere" (SPARKLE), which comprises regular remote symptom monitoring using the Integrated Palliative care Outcome Scale (IPOS); early identification and prompt treatment of palliative care symptoms and concerns identified; and referral to specialist palliative care if follow-up is required.

METHODS

A prospective randomized controlled trial of SPARKLE versus usual care was conducted among patients with advanced cancers. The primary endpoint was Functional Assessment of Cancer Therapy-General (FACT-G) scores at 16 weeks post randomization.

RESULTS

A total of 239 patients were randomized-119 patients to usual care and 120 patients to SPARKLE intervention. There was no significant difference in total FACT-G score (baseline-adjusted difference 0.8, 95% CI - 3.5 to 5.1, p = 0.73). Physical well-being was better in the SPARKLE intervention group compared to the usual care group (baseline-adjusted difference 1.9, 95%CI 0.4 to 3.4, p = 0.01). There were no significant differences in the other domain scores. There were no differences in palliative care referrals, occurrence of emergency department visits, or hospital admissions.

CONCLUSION

Although there was no significant difference in overall quality of life, better physical symptom control could have been achieved through proactive identification and treatment of symptoms and concerns by the SPARKLE nurse. Further studies are warranted to evaluate how various components of palliative care service models impact clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04242251. Date of registration: 23 January 2020.

Early integration or last consultation: in-house palliative care involvement for hospitalized patients in tertiary medicine-a retrospective analysis

BACKGROUND

The importance of timely integration of palliative care has been confirmed over the past years for any patient suffering from a life-threatening or life-limiting disease. Palliative and supportive care increases quality of life of patients and caregivers in both oncological and non-cancer diseases and should therefore be offered on a needs-based approach and throughout the disease trajectory.

METHODS

We analyzEd all in-patient consultation requests of the leading university hospital in Switzerland in 2019. Sociodemographics, symptoms, and specific requests as well as provided support offers were retrieved from the electronic patient files. Demographic and clinical data was analyzed by descriptive statistics between groups. Overall survival from diagnosis and time from consultation to death was analyzed by means of Kaplan-Meier estimates and log-rank test.

RESULTS

We identified 507 in-patient consultation requests from 24 oncological and non-oncological departments in 2019. The final analysis cohort comprised 290 patients, of which 133 women (45.9%). Median overall survival of the population from diagnosis was 21.1 months (CI 15.57-26.72). Median survival from palliative care consultation was 29 days (CI 20.89-37.11), independent of primary diagnosis (p = 0.298) or sex (p = 0.079). A total of 38.9% (N = 140) of consultations were requested concurrently to a tumor-targeted treatment. Palliative care consultations provided more support services than requested (p < 0.001).

CONCLUSION

Our findings underline the persisting late involvement of palliative care services in the disease trajectory, despite being a concurrently consultable and readily available support service to address patient and caregiver needs.

Prognostic models for survival predictions in advanced cancer patients: a systematic review and meta-analysis

BACKGROUND

Prognostication of survival among patients with advanced cancer is essential for palliative care (PC) planning. The implementation of a clinical point-of-care prognostic model may inform clinicians and facilitate decision-making. While early PC referral yields better clinical outcomes, actual referral time differs by clinical contexts and accessible. To summarize the various prognostic models that may cater to these needs, we conducted a systematic review and meta-analysis.

METHODS

A systematic literature search was conducted in Ovid Medline, Embase, CINAHL Ultimate, and Scopus to identify eligible studies focusing on incurable solid tumors, validation of prognostic models, and measurement of predictive performances. Model characteristics and performances were summarized in tables. Prediction model study Risk Of Bias Assessment Tool (PROBAST) was adopted for risk of bias assessment. Meta-analysis of individual models, where appropriate, was performed by pooling C-index.

RESULTS

35 studies covering 35 types of prognostic models were included. Palliative Prognostic Index (PPI), Palliative Prognostic Score (PaP), and Objective Prognostic Score (OPS) were most frequently identified models. The pooled C-statistic of PPI for 30-day survival prediction was 0.68 (95% CI: 0.62-0.73, n = 6). The pooled C-statistic of PaP for 30-day survival prediction was 0.76 (95% CI: 0.70-0.80, n = 11), while that for 21-day survival prediction was 0.80 (0.71-0.86, n = 4). The pooled C-statistic of OPS for 30-days survival prediction was 0.69 (95% CI: 0.65-0.72, n = 3). All included studies had high risk of bias.

CONCLUSION

PaP appears to perform better but further validation and implementation studies were needed for confirmation.

Factors associated with avoidable 30-day readmissions in patients with cancer: a single institution study

PURPOSE

Unplanned readmissions have profound medical and financial implications for patients and hospitals. Cancer patients are particularly susceptible to readmission and often face complex care needs. This quality improvement project aimed to identify factors associated with avoidable hospitalizations among oncology patients.

METHODS

Hospital discharges of adult cancer patients at Stony Brook University Hospital (June 2021-July 2022) were reviewed to identify unplanned 30-day readmissions. Readmissions were categorized as avoidable or unavoidable. Factors analyzed included patient demographics, cancer characteristics, social factors, outpatient follow-up, and palliative care involvement.

RESULTS

Of the 468 hospitalized cancer patients, 96 (21%) were readmitted within 30 days of discharge. Most readmitted patients had stage IV disease (51%). Fifty-seven percent of patients were symptomatic on index admission compared to 100% on readmission. Pain was the most frequently reported symptom, increasing from 36 patients (38%) on index admission to 54 (56%) on readmission (p < 0.001). Notably, 16 patients (17%) were discharged on comfort-focused care and 11 (12%) died inpatient on readmission. Palliative care was consulted 2.3 times more frequently during readmission compared to index admission. Readmissions were determined to be avoidable for 27 patients (28%). A complaint of failure to thrive on readmission (p < 0.04), no identifiable post-discharge caretaker (p < 0.009), being symptomatic at index admission (p < 0.04), and not attending an outpatient visit prior to readmission (p < 0.05) were associated with avoidable readmissions.

CONCLUSION

Timely outpatient support and early palliative care involvement to manage symptoms and optimize care transitions are readily addressable measures that may reduce avoidable readmissions among advanced-stage cancer patients.

The use of selected palliative medicine scales by family doctors in Poland, preliminary online study and its potential impact on knowledge dissemination

BACKGROUND

This study addresses the limited knowledge among Polish family doctors of scales for evaluating palliative care patients and their ability to assess symptoms using those scales. The aim was to identify the potential advantages and disadvantages for implementing this type of tools.

METHODS

A Computer-Assisted Web Interview (CAWI) was conducted among primary health care doctors. The survey assessed knowledge and usage of selected medical scales (KPS, ECOG, NRS, Barthel, Katz, ESAS, and a non-existent scale for bias check) in the daily practice of family physicians in relation to palliative care patients.

RESULTS

The study analysed responses from 706 doctors, revealing significant gaps in their knowledge and practical application of the scales. It presented lack of familiarity and inappropriate application of 4 out of 6 scales. Over 66% of surveyed doctors couldn't identify the appropriate tool for assessing the quality of life of patients with heart failure, and over 76% could not identify the appropriate tool for assessing shortness of breath and constipation. Based on the NRS pain scale this study indicates that knowledge of a scale translates directly to its practical application.

CONCLUSIONS

Appropriate educational activities should be provided to support GPs in broadening their knowledge and in using selected scales. Further studies need to be performed not only in the area of tools validation but simultaneously on how to disseminate the usage of those tools.

Advanced practice nurse-led early palliative care: a novel model for improved access to care

BACKGROUND

Although the benefits of early palliative care have been established in advanced cancers, there remains a lack of access to and poor uptake of these services. Barriers include healthcare provider attitudes, lack of standardized referral approach, misaligned policy limited resources, and lack of palliative care expertise.

PURPOSE

In consideration of these barriers, a description of the development and implementation of an early palliative care initiative at CancerCare Manitoba in Canada is presented. Explanations of innovative planning, processes, teams, and interventions are offered to facilitate insight for those intending to offer early palliative care.

DISCUSSION

Barriers and facilitators to integrating a nurse-led early palliative care initiative are discussed. Considerations to mitigate common barriers encountered and leveraging existing resources are offered.

CONCLUSIONS

This information may be beneficial to those working to facilitate access to palliative care in oncology for patients with advanced cancers. This model has been successful at our institution with pre and post implementation data presented in an upcoming publication.

Patients' psychosocial attributes and aggressiveness of cancer treatments near the end of life

BACKGROUND

While the use of chemotherapy near the end of life (EOL) has been identified as a relevant criterion for assessing quality of cancer care and has been estimated as non-beneficial, a trend of aggressiveness in cancer care during the last period of life remains. Both patients' sociodemographic characteristics and physicians' practice setting are associated with this use. The role of patients' psychosocial characteristics has however been understudied. The objectives were to study oncologists' intention to recommend chemotherapy or therapeutic abstention in an EOL patient's case and to examine the factors associated with this decision.

METHODS

A clinical vignette-based questionnaire survey was conducted. While the case presented to the participating oncologists of a patient with EGFR-mutated lung cancer, progressing after osimertinib, ECOG 3, with leptomeningeal disease (N = 146), was strictly equivalent in terms of medical aspects and age, 4 patients' non-medical characteristics were manipulated: gender, marital status, parenthood, and psychosocial characteristics ("nice" patients, patients "making strong demands," or control patients).

RESULTS

77.4% of the oncologists surveyed stated that they would recommend chemotherapy in this situation. Only scenarios with nice patients or patients making strong demands were associated with less recommendation of chemotherapy (70.8% for the nice/making strong demands scenarios together vs 87.7%, for the control scenario P = .017). Medical oncologists with previous experience of similar cases were also less keen to recommend chemotherapy (73% vs 100%, P = .007). Of the 76.7% of respondents declaring that they would think of other therapeutic options, 49.1% mentioned "other treatments" without mentioning palliative care.

CONCLUSION

Developing physicians' awareness of the psychosocial aspects at stake in their medical decisions in these sensitive situations may improve EOL care.

Algorithm-Based Palliative Care in Patients With Cancer: A Cluster Randomized Clinical Trial

Importance

Among patients with advanced solid malignant tumors, early specialty palliative care (PC) is guideline recommended, but strategies to increase PC access and effectiveness in community oncology are lacking.

Objective

To test whether algorithm-based defaults with opting out and accountable justification embedded in the electronic health record (EHR) increase completed PC visits.

Design, Setting, and Participants

This 2-arm cluster randomized clinical trial was conducted from November 1, 2022, to December 31, 2023. Eligible patients from 15 urban or rural clinics within a large community oncology network in Tennessee had advanced lung or noncolorectal gastrointestinal cancer and were identified by an automated EHR algorithm adapted from national guidelines. Data were analyzed between November 1, 2023, and March 4, 2024.

Intervention

At sites randomized to control, clinicians received weekly reports detailing PC referral rates compared with peer clinicians (peer comparison) and referred patients to PC at their discretion. At sites randomized to intervention, clinicians also received default PC orders using the EHR. Clinicians who opted out of PC consultation were asked to provide justification (accountable justification). If clinicians did not opt out, a study coordinator contacted patients to introduce and schedule PC visits using a standardized, predefined script.

Main Outcomes and Measures

The primary outcome was a completed PC consultation within 12 weeks of enrollment. Exploratory outcomes included quality of life, feeling heard and understood, and intensive end-of-life care. Outcomes were analyzed using clustered generalized linear and logistic regression models.

Results

The trial enrolled 562 patients (mean [SD] age, 68.5 [10.1] years; 288 male [51.2%]), of whom 433 (77.0%) had lung cancer. There were 130 of 296 patients (43.9%) randomized to the intervention group and 22 of 266 (8.3%) randomized to the control group who completed PC visits (adjusted odds ratio, 8.9 [95% CI, 5.5-14.6]; P < .001). Among 179 patients who died at the 24-week follow-up, 6 of 92 (6.5%) in the intervention group compared with 14 of 87 (16.1%) in the control group received systemic therapy within 14 days of death (adjusted odds ratio, 0.3 [95% CI, 0.1-0.7]; P = .05). There were no differences in quality of life, feeling heard and understood, or late hospice referral.

Conclusions and Relevance

In this randomized clinical trial of algorithm-based EHR defaults, the intervention increased PC consultations and decreased end-of-life systemic therapy. The intervention provides a scalable implementation strategy to increase specialty PC referrals in the community oncology setting.

Trial Registration

ClinicalTrials.gov Identifier: NCT05590962.

Timely short-term specialised palliative home care for older people with frailty and their family: a mixed-methods pilot randomised controlled trial and process evaluation

OBJECTIVE

The primary study aims were to evaluate the implementation, mechanisms and context of a timely short-term specialised palliative care intervention for older people with frailty (Frailty+ intervention) as well as to assess the feasibility of a randomised controlled trial to evaluate Frailty+. Our secondary aim was to describe any preliminary effects of Frailty+.

DESIGN

Pilot randomised controlled trial with process evaluation.

SETTING/PARTICIPANTS

We aimed to recruit 50 adults (≥70 years) with Clinical Frailty Scale score 5-7, and complex care needs and their main family carer, if available, from two Belgian hospitals on discharge.

INTERVENTIONS

Patients were randomised to the Frailty+ intervention alongside standard care or standard care alone.

OUTCOME MEASURES

Implementation and trial feasibility were assessed through interviews, focus groups and quantitative data. The primary outcome to be used in a potential full-scale trial if the study is feasible and implementable was mean change in five palliative care symptoms over 8 weeks.

RESULTS

We enrolled 37 patients (19 intervention, 18 control) and 26 family carers (15 intervention, 11 control). Patients and family carers valued the home visits from palliative care nurses, and nurses saw value in Frailty+. But most patients received only one visit over 8 weeks, and nurses did not organise foreseen multidisciplinary meetings, referring to absence of urgent needs. Many aspects of the trial methods were feasible, but recruitment was challenging. The baseline mean score on the five palliative care symptoms was 6.0 and 5.6 in intervention and control group, respectively; and 4.5 and 4.1 at 8 weeks (adjusted ratio 1.0, ie, no effects on symptoms).

CONCLUSIONS

While Frailty+ was generally welcomed by older people with frailty, families and palliative care nurses, our process evaluation uncovered multiple barriers, mostly rooted in the current organisation of specialised palliative care that is tailored to advanced stages of illness. Ensuring timely access requires efforts beyond timely referral alone, and implies profound organisational and cultural change.

TRIAL REGISTRATION NUMBER

ISRCTN39282347.

Pain Assessment and Management in Oncological Practice: A Survey from the Italian Network of Supportive Care in Oncology

Background/Objectives: Cancer pain is prevalent across all stages of the disease, significantly impacting patients' lives. Despite the availability of guidelines, its assessment and management remain suboptimal in many clinical settings. This study aimed to explore how healthcare professionals in Italy assess and manage cancer pain, identifying gaps and educational needs to improve adherence to best practices. Methods: A multidisciplinary Scientific Board designed an online survey comprising 28 items addressing demographics, pain assessment tools, perception of pain, pharmacological management, adverse effects, and barriers to care. The survey targeted oncologists, nurses, radiotherapists, and surgeons within the Italian Network of Supportive Care in Oncology. Data were collected from March to May 2024 and analyzed descriptively. Results: Eighty-five professionals participated, predominantly oncologists (63.5%). Most respondents utilized pain scales, with the Numerical Rating Scale (60.3%) being the most frequent. However, specific tools like the Edmonton Symptom Assessment System (ESAS) were underutilized, possibly due to limited training and time constraints. Factors influencing analgesic choice included patient comorbidities (30.3%) and polypharmacy (28.0%). The main barriers to effective pain management included inadequate training (85.5%) and poor communication between patients and caregivers (40.6%) and within care teams (31.9%). Preventive measures for opioid-induced adverse events were widely employed, with laxatives (52.7%) and antiemetics (40.5%) being the most common. Conclusions: Findings underscore the need for structured training programs, improved communication, and integration of validated assessment tools. A multidisciplinary, proactive approach to cancer pain assessment and management is essential to optimize care and reduce its burden across all disease stages.

First-time use of electronic patient-reported outcome measures in a cluster randomized trial: a qualitative study

BACKGROUND

Although there is clear evidence supporting the beneficial effects of regularly assessing patient-reported outcomes (PROs), the comprehensive integration of patient-reported outcome measures (PROMs) into routine cancer care remains limited. This study aimed to explore the facilitators and barriers encountered by principal investigators (PIs) (oncologists) and study nurses during the implementation of the Eir ePROM within a cluster randomized trial (c-RCT) in cancer outpatient clinics. Additionally, we sought to examine the influence of Eir on the working routines of the participants.

METHODS

Individual semi-structured interviews and a focus group were conducted with nine oncologists and study nurses involved in the implementation of the ePROM tool Eir. Interviews elucidated their experiences of barriers and facilitators when implementing Eir through a cluster randomized trial. Data were analysed according to Framework Analysis, using both an inductive and deductive approach. The Consolidated Framework for Implementation Research (CFIR) was used in the deductive stages of analysis.

RESULTS

Three overarching themes were identified from the data: (1) Willingness to invest; accepting that new eras come with a cost, (2) Management anchoring; changes start at the top, and (3) Creation of a cohesive framework; fostering collective comprehension. We found a notable disparity between oncologists and nurses in their willingness to invest time and effort in implementing the tool. While participants recognized the need to transform patient consultation methods to benefit from digital symptom management, opinions varied on whether the potential benefits justified the associated cost. Furthermore, the degree of management anchoring at various levels significantly impacted the implementation process. At the local level, it was seen as either a facilitator or a barrier, influencing the outcome of the implementation. Additionally, establishing a cohesive framework was crucial, as this fostered a collective understanding among those involved in the implementation.

CONCLUSIONS

Our study underscores the importance of considering the diverse perspectives of health care professionals and fostering interprofessional collaboration for the successful implementation of ePROMs in healthcare settings. Future research should explore strategies to bridge professional disparities and promote a shared understanding of the value provided by ePROMs.

Enhancing oncology patient care: nurses' knowledge, attitudes, and perceived benefits of early palliative integration - a cross-sectional study

BACKGROUND

Palliative care aims to improve quality of life for patients with end-stage illnesses by addressing physical, psychological, social and spiritual needs. Early referral to palliative care improves patient outcomes, quality of life and overall survival in a variety type of cancers. This study aimed to assess knowledge, attitudes and perceived benefits of early integration of palliative care among oncology nursing.

METHODS

A descriptive cross-sectional study was conducted in public, private, and educational hospitals located in Palestine. Data were collected using paper based self-administered questionnaires from nurses working in hematology, general oncology, and bone marrow transplantation departments.

RESULTS

Among of 128 nurses, the study revealed a moderate level of knowledge (3.64 ± 0.96), Positive attitude (3.59 ± 1.02) and moderately recognized the perceived benefits of early palliative care (3.57 ± 1.02). A statistically significant difference in nurses' knowledge, attitudes and perceived benefits of early palliative care based on clinical experience. Pearson's correlation showed a significant positive relationship between the total knowledge and attitudes score (r = 0.211, p < 0.001), as well as with perceived benefits total score (r = 0.567, p < 0.001). Moreover, there was a significant positive relationship between the total attitude score and perceived benefits score (r = 0.303, p < 0.001).

CONCLUSIONS

These findings suggest that enhancing knowledge and highlighting the benefits of early palliative care integration could foster more favorable attitudes among oncology nurses. investing in education and training to have all nurses prepared to provide high-quality palliative care results in better patient outcomes and less suffering. Patients with advanced cancer should be referred to the palliative care teams at an early stage of treatment in conjunction with their treatment in order to improve patient outcomes and quality of life.

Does the role of family meetings important at the end-of-life? A retrospective national study in Taiwan

BACKGROUND

Numerous studies have pointed out the benefits of family meetings, but it is unclear who uses family meetings and what the effects are on use of the end-of-life care.

AIM

The purposes of this study were to explore which characteristics are associated with the use of the family meeting and what effects the family meeting has on end-of-life care.

DESIGN

A retrospective observational study using 2012-2017 data from Taiwan's National Health Insurance claims database, cancer registry, and death registry.

SETTING/PARTICIPANTS

People who died between 2013 and 2017 in Taiwan as the study population. The deceased people whose information on gender, marital status, or insured classification that was unknown were excluded from this study.

RESULTS

A total of 792,947 people were included. All demographic characteristics were associated with the use of family meetings, and all demographic characteristics (except for gender and residence area) and hospital characteristics were associated with the initiation time of family meetings. We also found use of family meetings increased the use of hospice care (OR:4.949) and decreased the use of CPR (OR:0.208) at the end of life, initiation time was also associated with the hospice and CPR, but the effects were varied.

CONCLUSION

This study demonstrated that family meetings affected the care at end-of-life. Although the utilization of family meeting was increased by year, but also variation still existed among demographic and health characteristics, how to promote it is the next concern in the future.

Is shared decision making an aspect of palliative care integration? An observation of collaboration between oncologists and palliative care professionals

BACKGROUND

Early palliative care interventions in oncology, as recommended by international oncology societies, promote patient understanding and support decision-making. At the same time, shared decision-making models are being developed to enhance patient participation as part of a new model of patient-physician relationship. For patients with palliative needs, this participation is essential and helps to avoid futile and aggressive treatments at the end of life. The aim of this study is to observe decision making during meetings between oncology and palliative care professionals, focusing particularly on the components of shared decision-making models, but also on the role played by palliative care professionals.

METHODS

We conducted a non-participant observation of multidisciplinary meetings and outpatient clinic activities in two Comprehensive Cancer Centres in France. Field notes were then coded using thematic content analysis. Deductive analysis was conducted using the observation grid developed from Elwyn's three-talk model.

RESULTS

Only a few elements of the different models of shared decision-making are apparent in the multidisciplinary meetings. Palliative care professionals emphasise the importance of involving patients and providing them with information about the advantages and disadvantages of different treatment options. However, patient involvement in decision-making remains difficult in daily practice. Decisions to discontinue oncological treatment are often driven by clinical and biological signs of terminal evolution rather than shared decision-making.

CONCLUSIONS

There are still cultural and organisational barriers to actual implementation of early integrated onco-palliative care. Promotion of shared decision making can be a strong lever of change which is frequently mobilised by palliative care teams.

Oncology and Palliative Care Integration Model: A Cost Analysis Study in a Brazilian Hospital Setting

Background: In 2019, the São Paulo State Cancer Institute (ICESP) implemented a novel model integrating Oncology with Palliative Care specialists. We evaluated the impact of this model on healthcare resource utilization and costs. Methods: We analyzed data from all patients who passed away in February (1 month prior to implementation) and November (8 months after model implementation group) at ICESP, Brazil. Healthcare utilization data, including emergency department visits, hospital and intensive care unit admissions, chemotherapy, and radiotherapy use, were retrieved from Electronic Medical Records. Unit cost values were obtained from the administrative database. Results: A total of 198 patients who died in February and 196 in November were included in the analysis. Groups exhibited similarities in sex, age, ECOG, cancer type, previous outpatient palliative care consultations, and place of death (ward: 56.6% pre-intervention, 50% post-intervention). The mean cost per patient was US$13,226.29 pre-intervention and US$11,445.82 post-intervention (P = .007). Statistically significant differences were noted in days hospitalized in the surgical ward (227 vs 115), emergency department visits (233 vs 45), chemotherapy sessions (140 vs 26), and radiotherapy sessions (146 vs 10). Excluding outpatient treatments, the total costs for chemotherapy and radiotherapy in the last 30 days of life were US$16,924.45 pre-intervention and US$7851.65 post-intervention. Reductions were more pronounced in patients with ECOG 3-4 (P = .039). Conclusion: Our data suggests that the integration model was associated with a reduction in potentially inappropriate treatments during the last month of life, leading to decreased healthcare utilization and costs.

Constricting Gaps: Protocol development, implementation challenges and lessons learned for the reality map of unmet needs for Palliative Care Interventions in advanced cancer patients study in Romania and Switzerland

Background

Patients with advanced cancer experience many symptoms and needs requiring a Palliative Care Intervention (PCI). Identifying gaps between needs for PCIs and experienced delivery may improve health care, furthermore the association of gaps with quality indicators (QI). The multicentre Romanian (RO)-Swiss (CH) reality map study implemented a novel protocol based on needs concepts and culturally adapted quality indicators (QI).

Methods

An interactive mapping guide measuring unmet needs for PCIs monthly over six months, patient characteristics (cognition, EAPC basic data set, Cofactors) and QI (Inappropriate Anticancer Treatment, High Symptom Burden [IPOS, EQ5D], Repeated ER Admissions, Aggressive End-of-Life Care, and Quality of Death-and-Dying) were developed, applying swiss standards for quality assurance. A composite endpoint (QI, cofactors) was planned. Finally, local solutions responding to gaps were piloted.

Results

From 308 patients (RO: 262, CH: 46, age 62j [mean], 74 % ECOG PS 1&2, 81 % current anticancer treatment) baseline and first follow-up data revealed main gaps (symptom management, spiritual needs, family support), country differences (e.g. illness understanding, spiritual needs) and a significant association of the number of gaps with depression. Later data become less, and data quality on QI variable, revealing gaps in research conduct competences, resources, and applicability of over-sophisticated quality assurance tools. Nevertheless, the unmet needs data promoted local initiatives, 81 patients participated in feasibility studies. Finally, the joint experience stimulated academic developments and national integration of palliative care into oncology.

Conclusions

Pairing motivation and enthusiasm with more modest aims, feasibility testing of all outcomes and investment in research competences may disperse gaps.

Early palliative care in metastatic uveal melanoma (early together): protocol of a prospective randomized Phase III trial

Metastatic uveal melanoma (UM) patients often initially present with limited symptoms despite a poor prognosis, complicating communication with patients and caregivers. Early Together (NCT04728113) is a randomized Phase III trial that integrates early palliative care through systematic joint visits involving the palliative care team and the medical oncologist, compared with standard oncological care, in 162 metastatic UM patients beginning systemic treatment. This collaboration aims to enhance patient functioning, improve quality of life and facilitate coping mechanisms. Patients' quality of life and needs for information, care and support are assessed over 12 months using validated questionnaires in both groups. Investigators receive training throughout the study to improve communication skills in addressing uncertainty and poor prognosis. This article describes the trial protocol.

Psychological assessment and the role of the psychologist in early palliative care

Background

Early palliative care (EPC) is a recommended model for improving the quality of life for patients with advanced cancer and their caregivers. However, limited research has focused on the role of psychological evaluation within EPC. The Veneto Institute of Oncology (IOV), a Comprehensive Cancer Centre, employs an interdisciplinary team to assess patients with advanced-stage disease. This study aims to assess the psychological needs of these patients, investigate any correlations between psychological symptoms (PSs) and factors such as awareness of diagnosis and prognosis, symptoms detected using the Edmonton Symptom Assessment System (ESAS), as well as the patient's gender, age, social issues, and survival and to clarify the psychologist's role within the interdisciplinary team.

Methods

Data were retrieved from a prospectively maintained database. From 1st January 2018 to 31st December 2021, 819 consecutive patients were evaluated during EPC consultations, with 753 participants enrolled in the study. The ESAS was administered to each patient before the consultation.

Results

More than half of the patients (385, 57.1%) reported at least one PS, with an ESAS score of ≥4. Specifically, 34.9% reported depression, 28.7% reported anxiety, and 43.2% indicated feeling "not well." Referring oncologists tended to overestimate the presence of PSs compared to patient self-reports (51.8% versus 41.3%). According to the psychologists' assessment, 29.2% of participants were found to have depression, and 10.8% of participants had anxiety. Additionally, 31 patients (10.8%) with psychological disorders were diagnosed with an adaptation disorder related to a physical condition. The psychology service engaged 47% of patients, while 18.5% declined psychological support. Patients exhibiting other ESAS symptoms with scores of ≥4 had an increased odds ratio for reporting PSs of ≥4. However, multivariable analysis revealed no significant relationship between PSs and awareness of diagnosis and prognosis.

Conclusion

The systematic use of self-assessment in EPC is essential for understanding patient's experience, determining whether PSs stem from physical disorders, and prioritizing interventions. Awareness of prognosis does not correlate with increased anxiety and depression in patients. Therefore, EPC is an ideal opportunity to discuss prognosis and facilitate patients' end-of-life choices early in their care journey.

Symptom burden and quality of life among patient and family caregiver dyads in advanced cancer

PURPOSE

Symptom management among patients diagnosed with advanced cancer is a high priority in clinical care that often involves the support of a family caregiver. However, limited studies have examined parallel patient and caregiver symptom burden and associations with their own and each other's quality of life (QOL). This study seeks to identify patient and caregiver symptom clusters and investigate associations between identified clusters and demographic, clinical, and psychosocial factors (cognitive appraisals and QOL).

METHODS

This study was a secondary analysis of self-reported baseline survey data collected from a randomized clinical trial of 484 adult advanced cancer patients and their caregivers. Latent class analysis and factor analysis were used to identify symptom clusters. Bivariate statistics tested associations between symptom clusters and demographic, clinical, and psychosocial variables.

RESULTS

The most prevalent symptom for patients was energy loss/fatigue and for caregivers, mental distress. Low, moderate, and high symptom burden subgroups were identified at the patient, caregiver, and dyad level. Age, gender, race, income, chronic conditions, cancer type, and treatment type were associated with symptom burden subgroups. Higher symptom burden was associated with more negative appraisals of the cancer and caregiving experience, and poorer QOL (physical, social, emotional, functional, and overall QOL). Dyads whose caregivers had more chronic conditions were more likely to be in the high symptom burden subgroup.

CONCLUSION

Patient and caregiver symptom burden influence their own and each other's QOL. These findings reinforce the need to approach symptom management from a dyadic perspective.

Living fully, choosing wisely: Exploring patient-centred approaches to palliative care and MAiD - Part I

With increasing numbers of individuals presenting with advanced cancer, strong recommendations for the integration of palliative care in oncology, and the availability and acceptance of medical assistance in dying, oncology nurses must be informed and prepared to provide patient-centred care in advanced cancer. This is part one of a two-part case report presenting an exploration of early palliative care and medical assistance in dying in the setting of advanced cancer. It focuses on the patient and family experience throughout the illness trajectory, from diagnosis to death, and incorporates some of the common challenges seen in supporting someone with advanced cancer. While highlighting the perspective of the patient and family, it demonstrates how palliative care and medical assistance in dying can work together to achieve a patient's goals. The paper provides valuable insight for oncology nurses to consider in their practice.

European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit

The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.

Nurse-Led Screening-Triggered Early Specialized Palliative Care Program for Patients With Advanced Lung Cancer: A Multicenter Randomized Controlled Trial

BACKGROUND

We aimed to examine the effectiveness of a nurse-led, screening-triggered early specialized palliative care intervention program for patients with advanced lung cancer.

METHODS

Patients with advanced lung cancer who underwent initial chemotherapy were randomized to intervention and usual care groups between January 2017 and September 2019. The intervention comprised comprehensive needs assessments, counseling, and service coordination by advanced-level nurses. Patients in the usual care group received the usual oncological care. The primary end point was a change in the trial outcome index (TOI) scores from baseline to 12 weeks. The secondary end-points were TOI scores at week 20, depression, anxiety, and survival.

RESULTS

In total, 102 patients were assigned to each group. Compared with the usual care group, no significant improvement in TOI scores was observed at 12 weeks in the intervention group (mean group difference: 2.13; 90% confidence interval: -0.70, 4.95; p = 0.107, one-sided), whereas significant improvement was observed at 20 weeks (3.58; 90% confidence interval: 0.15, 7.00; p = 0.043). There were no significant differences in the change from baseline depression and anxiety between the groups from baseline at week 12 and 20 weeks (depression: p = 0.60 and 0.10, anxiety: p = 0.78 and 0.067). Survival did not significantly differ between the groups (median survival time: 12.1 vs. 11.1 months; p = 0.302).

CONCLUSIONS

Nurse-led, screening-triggered, early specialized palliative care did not show significant superiority over usual care during the 12-week study period. However, it may have yielded delayed clinical benefits, such as improved quality of life and this feasible model can be acceptable in clinical practice.

TRIAL REGISTRATION

The University Hospital Medical Information Network Clinical Trials Registry: UMIN000025491.

Together but still alone - A qualitative study exploring how family members of persons with incurable oesophageal or gastric cancer manage everyday life

BACKGROUND

Cancer affects not only the person with the disease but those around them. Being a family member is described as strenuous and, often, associated with stress, anxiety and feelings of loneliness. There is a heightened risk of distress for family of those with fast-progressing, severe oesophageal or gastric cancer. Early palliative care involving family is vital yet often overlooked. In order to include family members in early palliative care their management in everyday life needs to be explored.

METHOD

Qualitative inductive interview study using content analysis guided by Graneheim and Lundman.

RESULT

The analysis resulted in the overarching theme "Managing the disease together but still alone". Three categories were identified: Adapting to the disease, Taking control of the situation, Processing emotions. Each category described family members management in various aspects of everyday life together with the ill person and alone.

CONCLUSION

The results may contribute to an awareness of family members' management of large parts of everyday life and, further, their feelings of loneliness, and indicates that family members should be included early in oesophageal or gastric cancer palliative care. Further studies are needed to develop the content of such family-inclusive early palliative care.

High Symptom Burden in Patients With Advanced Chronic or Prolonged Infectious Diseases: Not Only Pain

INTRODUCTION

The growing evidence of increased life expectancy in the future reveals the high relevance of frailty in patients with chronic-degenerative diseases; identification and management of symptoms may improve significantly their quality of life. The objective of our study was to assess the symptom burden in patients with advanced chronic or prolonged infectious diseases.

MATERIALS AND METHODS

A cross-sectional study was performed enrolling 88 patients, referred to palliative care consultation for chronic pain, and evaluated using the Edmonton Symptom Assessment System to define Total Symptom Distress Score (TSDS) and high symptom burden (HSB) when more than six symptoms along with Numerical Rating Scale ≥4 were present.

RESULTS

All participants reported moderate to severe pain; in addition, 86 (97.7%) experienced a lack of well-being, 81 (92%) tiredness, 67 (76.1%) lack of appetite, 66 (75%) drowsiness, 66 (75%) depression, 56 (63.6%) anxiety, 49 (55.6%) nausea, and 39 (44.3%) shortness of breath. Forty-four patients (50%) had high TSDS, greater than 40.5, and presented lower Karnofsky Performance Scale (KPS) (median 40 vs. 70, p=0.0005), higher comorbidities (median 7 vs. 4, p=0.00001), and higher drug burden (median 9 vs. 6, p=0.0003) than those with low TSDS. Furthermore, considering symptom intensity, 40 patients (45.4%) had HSB and presented lower KPS (median 50 vs. 70, p=0.0005), higher comorbidities (median 7 vs. 4, p=0.00001), and higher drug burden (mean 9 vs. 6, p=0.01) compared to patients without HSB.

CONCLUSION

Our population had an HSB, in addition to pain, revealing high frailty. A correct assessment of symptoms is, therefore, required to manage patients with chronic infectious diseases. In this setting, attention should be given to identifying patients at high risk of HSB through a correct diagnosis and effective management, which should be based on a multi-professional approach.

Utilization of medical interventions in hospitalized Mexican adults with cancer at the end of life in a referral hospital: The importance of early palliative care

OBJECTIVES

To investigate the impact of early vs. late palliative care (PC) on the frequency of admissions to acute hospital settings and the utilization of end-of-life (EoL) interventions in cancer decedents.

METHODS

In this single-center, cross-sectional study, we examined the frequency of intensive care unit (ICU) and emergency department (ED) admissions among adult cancer decedents between 2018 and 2022 in a referral hospital in México. Additionally, we assessed EoL medical interventions, categorizing patients into 3 groups: those who received early PC (EPC), late PC (LPC), and those who did not receive PC (NPC).

RESULTS

We analyzed data from 1762 patients, averaging 56 ± 16.3 years old, with a predominant representation of women (56.8%). PC was administered to 45.2% of patients, but EPC was limited to only 12.3%. The median time from the initiation of PC to death was 5 days (interquartile range: 2.0-31.5). Hematological malignancies were the most prevalent, affecting 21.5% of patients. EPC recipients demonstrated notable reductions in ICU and ED admissions, as well as diminished utilization of chemotherapy, radiotherapy (RT), antibiotics, blood transfusions, and surgery when compared to both LPC and NPC groups. EPC also exhibited fewer medical interventions in the last 14 days of life, except for RT.

SIGNIFICANCE OF RESULTS

The findings of this study indicate that a significant proportion of EoL cancer patients receive PC; however, few receive EPC, emphasizing the need to improve accessibility to these services. Moreover, the results underscore the importance of thoughtful deliberation regarding the application of EoL medical interventions in cancer patients.

The life threat in hematopoietic allogeneic stem cell transplantation - an interview and focus group study on health care professionals' perspectives

Understanding healthcare professionals' (HCPs) experiences with patients undergoing hematopoietic allogeneic stem cell transplantation (allo-HSCT) is crucial, given its dual nature of offering a hope for cure which on the other hand is accompanied by a high risk for morbidity and mortality. Yet, how HCPs experience their patients' existential threats remains unexplored. Qualitative thematic content analysis was employed to comprehend these experiences. This involved conducting three focus groups and 11 individual in-depth interviews with nurses and hematologists. We found that HCPs struggled to balance curative goals and the therapy's risks, while attempting to maintain their patients' hopes. The unpredictability of patient trajectories and their suffering burdened HCPs. Despite occasional disagreements within the team, (inter-)professional exchanges remained a crucial ressource, especially in addressing the patients' potential life threat. Team meetings and palliative care specialist supervisions were emphasized as vital for managing these challenges. HCPs sought support in communicating with patients about death-related issues and managing the transition from a curative to a palliative goal of care. Our research underscores the need for targeted support for HCPs and lays a groundwork for addressing their challenges. Trial registration number DRKS00027290 (German Clinical Trials Register). Date of trial registration January 10th, 2022.

Effect of applying digital health in palliative care for patients with advanced cancer: a meta-analysis and systematic review

PURPOSE

To assess the effectiveness of applying digital health palliative care to improve symptoms, mood, and quality of life in patients with advanced cancer.

METHODS

We searched PubMed, Embase, Web of Science, Cochrane Library (CENTRAL), and CINAHL databases on November 16, 2023, to identify randomized controlled trials of the impact of palliative care applying digital health on patients with advanced cancer. The Cochrane Risk of Bias Tool version 1.0 was used to evaluate the quality of randomized controlled trials.

RESULTS

A total of 20 randomized controlled trials were included, of which 18 were meta-analyzed. Compared with usual care, palliative care applying digital health was effective in improving symptoms (SMD = -0.21, 95% CI: -0.37 to -0.06, P = 0.007) and reducing the intensity of pain (SMD = -0.49, 95% CI: -0.85 to -0.13, P = 0.008) in patients with advanced cancer, but no effective improvement in depressive symptoms, anxiety symptoms, or quality of life was found.

CONCLUSIONS

Our systematic review provides evidence that palliative care applying digital health has great potential to improve symptoms in patients with advanced cancer, but more research is needed to explore its impact on mood and quality of life.

Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer: A Multisite Randomized Clinical Trial

Importance

Numerous studies show that early palliative care improves quality of life and other key outcomes in patients with advanced cancer and their caregivers, although most lack access to this evidence-based model of care.

Objective

To evaluate whether delivering early palliative care via secure video vs in-person visits has an equivalent effect on quality of life in patients with advanced non-small cell lung cancer (NSCLC).

Design, Setting, and Participants

Randomized, multisite, comparative effectiveness trial from June 14, 2018, to May 4, 2023, at 22 US cancer centers among 1250 patients within 12 weeks of diagnosis of advanced NSCLC and 548 caregivers.

Intervention

Participants were randomized to meet with a specialty-trained palliative care clinician every 4 weeks either via video visit or in person in the outpatient clinic from the time of enrollment and throughout the course of disease. The video visit group had an initial in-person visit to establish rapport, followed by subsequent virtual visits.

Main Outcomes and Measures

Equivalence of the effect of video visit vs in-person early palliative care on quality of life at week 24 per the Functional Assessment of Cancer Therapy-Lung questionnaire (equivalence margin of ±4 points; score range: 0-136, with higher scores indicating better quality of life). Participants completed study questionnaires at enrollment and at weeks 12, 24, 36, and 48.

Results

By 24 weeks, participants (mean age, 65.5 years; 54.0% women; 82.7% White) had a mean of 4.7 (video) and 4.9 (in-person) early palliative care encounters. Patient-reported quality-of-life scores were equivalent between groups (video mean, 99.7 vs in-person mean, 97.7; difference, 2.0 [90% CI, 0.1-3.9]; P = .04 for equivalence). Rate of caregiver participation in visits was lower for video vs in-person early palliative care (36.6% vs 49.7%; P < .001). Study groups did not differ in caregiver quality of life, patient coping, or patient and caregiver satisfaction with care, mood symptoms, or prognostic perceptions.

Conclusions and Relevance

The delivery of early palliative care virtually vs in person demonstrated equivalent effects on quality of life in patients with advanced NSCLC, underscoring the considerable potential for improving access to this evidence-based care model through telehealth delivery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03375489.

Age- and gender-based social inequalities in palliative care for cancer patients: a systematic literature review

Objectives

Cancer is a major public health problem worldwide, given its magnitude and growing burden, in addition to the repercussions on health and quality of life. Palliative care can play an important role improving quality of life and it is cost-effective, but some population groups may not benefit from it or benefit less based on age and gender inequalities. The aim of this systematic review was to analyze the available evidence on age- and gender-based social inequalities in access to and use of palliative care in cancer patients.

Methods

A systematic review was conducted following the PRISMA guidelines. An exhaustive literature research was performed in Pubmed, CINHAL and Embase until November 2022 and were not restricted by language or date of publication. Eligible studies were observational studies analyzing the access and use of palliative care in cancer patients.

Results

Fifty-three studies were included in the review. Forty-five analyzed age and 44 analyzed gender inequalities in relation to use of and access to palliative care. Our results show that older people receive poorer quality of care, worst symptom control and less preferences for palliative care. In relation to gender, women have a greater preference for the use of palliative care and generally have more access to basic and specialized palliative care services and palliative care facilities.

Conclusion

This review reveals difficulties for older persons and men for access to key elements of palliative care and highlights the need to tackle access barriers for the most vulnerable population groups. Innovative collaborative services based around patient, family and wider community are needed to ensure optimal care.

Supportive Services at End of Life can Help Reduce Acute Care Services: Observations From the Medicare Care Choices Model

OBJECTIVES

This study identifies the mechanisms through which supportive and palliative care services at the end-of-life helped prevent unnecessary use of acute care services.

BACKGROUND

From 2016 to 2021, the Medicare Care Choices Model (MCCM) tested whether offering Medicare beneficiaries the option to receive supportive and palliative care services through hospice providers, concurrently with treatments for their terminal conditions, improved patients' quality of life and care and reduced Medicare expenditures. Previous MCCM evaluation results showed that the model achieved its goals, but did not examine in depth the causal mechanisms leading to these results.

METHODS

Mixed-methods evaluation based on descriptive analysis of MCCM encounter data and qualitative analysis of interviews with staff from high-performing MCCM hospices.

RESULTS

MCCM hospices provided 217 156 encounters to 7263 enrollees over 6 years. Enrollees received on average 30 encounters with hospice staff while enrolled in the model, representing about 10 encounters per month enrolled. Most encounters were delivered by clinically trained staff in the patient's home. Hospice staff identified five services critical for keeping patients from seeking acute care services: early and frequent needs assessments, direct observation of patients in their homes, immediate responses to patients' medical complaints, round-the-clock telephone access to nursing staff, and communication and coordination of care with primary care physicians and specialists.

CONCLUSIONS

Palliative care approaches that are high-touch, employ clinically trained staff who visit patients in their homes, routinely evaluate how to manage patient symptoms, and are available when needs arise can improve outcomes and decrease costs at the end of life.

Quality of life for patients with advanced gastrointestinal cancer randomised to early specialised home-based palliative care: the ALLAN trial

BACKGROUND

The primary aim of specialised palliative care (SPC) is to improve the quality of life (QoL) for patients with a high symptom burden from a life-threatening disease. This randomised study aimed to assess the QoL impact of early integration of SPC alongside tumour-specific palliative treatment in patients with gastrointestinal (GI) cancers.

METHODS

We randomly assigned ambulatory patients with advanced GI cancer to early integration of SPC and palliative tumour-specific treatment or tumour-specific treatment alone. The primary endpoint was QoL assessed at baseline and every sixth week using the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire.

RESULTS

A total of 118 patients were randomised. The difference in total FACT-G score between patients assigned to early integration with SPC and controls was 5.2 points (95% CI: -0.1 to 10.5, p = 0.216), 6.7 points (95% CI: 0.2 to 13.3, p = 0.172), and 13 points (95% CI: 5.7 to 20.2, p = 0.004) at weeks 6, 12, and 24, respectively.

CONCLUSIONS

This prospective randomised trial strengthens the argument for early integration of SPC with tumour-specific treatment in patients with advanced GI cancers. We found an improved QoL for patients with advanced GI cancer 24 weeks after randomisation to early integration of home-based SPC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (ref: NCT02246725).

Barriers and Facilitators of Early Palliative Care in the Trajectory of People Living with Chronic Condition: A Mini Review Using Socio-ecological Framework to Inform Public Health Strategy

The increasing incidence of chronic conditions on a global scale requires a comprehensive approach to palliative care, which is recognized as an essential element of the continuum of care for people with life-threatening conditions. It has been argued that the integration of early palliative care for people with chronic conditions is beneficial. Nevertheless, barriers to integrating early palliative care have been extensively not reviewed. This review aimed to explore the barriers and facilitators of integrating early palliative care for people living with chronic conditions, employing a socio-ecological framework to provide a critical understanding of the influencing factors at multiple levels. The method was a mini review. This review emphasizes the complex and diverse factors that either hinder or facilitate progress in four areas: individual (such as gaps in knowledge and emotional reactions), interpersonal (such as support from family caregiver), healthcare professionals and policy (such as barriers in education, guidelines, and collaboration among professionals), and community (such as societal knowledge and attitudes). Each level presents unique challenges and opportunities for enhancing early palliative care integration, from addressing misconceptions and fears at the individual level, to fostering supportive policies and community awareness. In conclusion, the effective management of early palliative care requires a comprehensive strategy that spans various dimensions, including educational initiatives, policy adjustments, and active involvements of the community. Healthcare systems are supposed to enhance the integration of early palliative care into the trajectory of chronic conditions and enhance the quality of life of affected persons and their families by recognizing and addressing the socio-ecological elements involved.

Developing research priorities for palliative care in Colombia: a priority setting partnership approach

BACKGROUND

A recent Lancet commission called for more research on palliative care in low- and middle-income (LMIC) countries such as Colombia. A research priority setting approach has been recommended by The Global Forum for Health Research to address the huge gap in research output between LMIC and high-income countries, with influential health service bodies recommending the active involvement of non-research expert stakeholders in establishing research priorities to address service user needs.

METHOD

Priority setting partnership (PSP) following the four stages of the James Lind Alliance methodology; establishing the partnership, identifying evidence uncertainties, refining questions and uncertainties, and prioritization. Data from MS forms were analysed using descriptive statistics.

RESULTS

A total of 33 stakeholders attended an online PSP workshop and completed the Mentimeter exercise in Microsoft Teams. A total of 48 attended the subsequent in person prioritisation exercise in urban Bogota (n = 22) and rural Popayan (n = 25). The stakeholders were a diverse group of health professionals (physicians, medical students, nurses, dentists, physiotherapists, nutritionist, occupational and speech therapists), financial and administrative staff and patients with life-limiting illness and caregivers. Top research priorities included patient and caregiver needs, service provider education and training, and better integration of palliative care with cancer and non-cancer services. The key challenges included a lack of interest in palliative care research, along with funding, time and resource constraints. Key solutions included collaboration across disciplines and settings, highlighting benefits of palliative research to help secure adequate resources, and multicentre, mixed method research, with patient involvement from the research development stage.

CONCLUSION

The findings of this PSP should be disseminated among palliative care associations worldwide to inform international multicentre studies, and among governmental and nongovernmental organisations that promote research in Colombia. A focus on patient and family caregiver palliative care needs in Colombia should be prioritised.

Early Integrated Palliative Care in Patients With Advanced Cancer: A Randomized Clinical Trial

Importance

Limited data suggest that early palliative care (EPC) improves quality of life (QOL) and survival in patients with advanced cancer.

Objective

To evaluate whether comprehensive EPC improves QOL; relieves mental, social, and existential burdens; increases survival rates; and helps patients develop coping skills.

Design, Setting, and Participants

This nonblinded randomized clinical trial (RCT) recruited patients from 12 hospitals in South Korea from September 2017 to October 2018. Patients aged 20 years or older with advanced cancer who were not terminally ill but for whom standard chemotherapy has not been effective were eligible. Participants were randomized 1:1 to the control (receiving usual supportive oncological care) or intervention (receiving EPC with usual oncological care) group. Intention-to-treat data analysis was conducted between September and December 2022.

Interventions

The intervention group received EPC through a structured program of self-study education materials, telephone coaching, and regular assessments by an integrated palliative care team.

Main Outcomes and Measures

The primary outcome was the change in overall QOL score (assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care) from baseline to 24 weeks after enrollment, with evaluations also conducted at 12 and 18 weeks. Secondary outcomes were social and existential burdens (assessed with the McGill Quality of Life Questionnaire) as well as crisis-overcoming capacity and 2-year survival.

Results

A total of 144 patients (83 males [57.6%]; mean [SD] age, 60.7 (7.2) years) were enrolled, of whom 73 were randomized to the intervention group and 71 to the control group. The intervention group demonstrated significantly greater changes in scores in overall health status or QOL from baseline, especially at 18 weeks (11.00 [95% CI, 0.78-21.22] points; P = .04; effect size = 0.42). However, at 12 and 24 weeks, there were no significant differences observed. Compared with the control group, the intervention group also showed significant improvement in self-management or coping skills over 24 weeks (20.51 [95% CI, 12.41-28.61] points; P < .001; effect size = 0.93). While the overall survival rate was higher in the intervention vs control group, the difference was not significant. In the intervention group, however, those who received 10 or more EPC interventions (eg, telephone coaching sessions and care team meetings) showed a significantly increased probability of 2-year survival (53.6%; P < .001).

Conclusions and Relevance

This RCT demonstrated that EPC enhanced QOL at 18 weeks; however, no significant improvements were observed at 12 and 24 weeks. An increased number of interventions sessions was associated with increased 2-year survival rates in the intervention group.

Trial Registration

ClinicalTrials.gov Identifier: NCT03181854.

Sexual health-a topic for cancer patients receiving oncological treatment with palliative intent

OBJECTIVES

Sexuality is an important dimension of health-related quality of life (HRQOL) in cancer patients. Studies evidence that most patients report impairments of their sexual health related to their disease or its treatment. The Quality of Life Group of the European Organization for the Research and Treatment of Cancer (EORTC) developed a patient reported outcome measure assessing multidimensional aspects of sexual health. The validation study for this instrument revealed heterogenous results for patients in palliative oncological treatment. The aim of this secondary analyses is to examine differences in patient related sexual health outcomes between palliative patients with good performance status (GPS) and those with poor performance status (PPS).

METHODS

In this observational cohort study, self-reported sexual health issue scores were compared between the two groups of patients in palliative oncological treatment with GPS vs PPS status.

RESULTS

Patients with GPS experienced significantly more sexual satisfaction than patients with PPS (p = 0.015). They reported significantly more treatment effects on their sexual activity (p = 0.005) and suffer more from decreased libido (p = 0.008). Patients with PPS reported significantly more fatigue (p = 0.03) and regarded preservation of sexual activity of higher importance than did patients with GPS (p = 0.049).

CONCLUSIONS

Our study demonstrates the importance of sexuality for patients in palliative oncological treatment, especially for those with limited performance status. Considering the patients´ perspective, sexual health reaches beyond physical functioning. Patients in a palliative phase of disease report high levels of psychosexual problems while sexual performance deteriorates. Sexuality is an important aspect of HRQOL for these patients, needs to be addressed by health care providers and sensitively integrated into palliative care plans.

Navigating end-of-life decision-making in nursing: a systematic review of ethical challenges and palliative care practices

OBJECTIVES

This systematic review aimed to synthesize evidence on the ethical dilemma's nurses encounter in end-of-life care and effective palliative care practices. The objectives were to understand key ethical issues, evaluate communication and decision-making strategies, and identify approaches to support nurses and patients.

METHODS

A comprehensive search of major databases was conducted according to the PRISMA guidelines. Studies directly relating to nursing ethics, challenges in end-of-life decision-making, and palliative care practices were included. The risk of bias was assessed using ROBVIS-II. Data on ethical issues, palliative interventions, and outcomes was extracted and analyzed thematically.

RESULTS

22 studies met the inclusion criteria. Key themes that emerged were: (1) Effective communication and involving patients in decision-making are essential but complex. (2) Nurses face dilemmas around balancing autonomy, beneficence and relational issues. (3) Integrating palliative care principles enhances symptom management and aligns care with patient values. (4) Education and organizational support are needed to equip nurses with skills and coping strategies.

CONCLUSION

Navigating end-of-life care requires addressing interconnected ethical, communication and support needs. While studies provided insights, further research is required on cultural competence training, standardized education programs and longitudinal evaluations.

Quality indicators for integrating oncology and home palliative care in Japan: modified Delphi study

CONTEXT

Home palliative care service increases the chance of dying at home, particularly for patients with advanced cancer, but late referrals to home palliative care services still exist. Indicators for evaluating programs that can facilitate the integration of oncology and home palliative care have not been defined.

OBJECTIVES

This study developed quality indicators for the integration of oncology and home palliative care in Japan.

METHODS

We conducted a systematic literature review (Databases included CENTRAL, MEDLINE, EMBASE, and Emcare) and a modified Delphi study to develop the quality indicators. Panelists rated a potential list of indicators using a 9-point scale over three rounds according to two criteria: appropriateness and feasibility. The criterion for the adoption of candidate indicators was set at a total mean score of 7 or more. Final quality indicators with no disagreement were included.

RESULTS

Of the 973 publications in our initial search, 12 studies were included. The preliminary list of quality indicators by systematic literature review comprised 50 items. In total, 37 panelists participated in the modified Delphi study. Ultimately, 18 indicators were identified from the following domains: structure in cancer hospitals, structure in home palliative care services, the process of home palliative care service delivery, less aggressive end-of-life care, patient's psychological comfort, caregiver's psychological comfort, and patient's satisfaction with home palliative care service.

CONCLUSION

Comprehensive quality indicators for the integration of oncology and home palliative care were identified. These indicators may facilitate interdisciplinary collaboration between professional healthcare providers in both cancer hospitals and home palliative care services.

Outpatient Training During Hospice and Palliative Medicine Fellowship: A National Survey

CONTEXT

Outpatient palliative care (PC) has strong evidence demonstrating impact across serious illnesses, resulting in growing demand for skilled outpatient PC clinicians. However, there is limited literature examining the existing state and quality of outpatient PC education during postgraduate training.

OBJECTIVES

Characterize the current state of outpatient training in United States (US) Hospice and Palliative Medicine (HPM) physician fellowships and elicit perceptions regarding quality of outpatient PC education.

METHODS

A cross-sectional survey of US adult HPM fellowship program directors (PDs) or their designee conducted between March and July, 2023.

RESULTS

Of 161 programs, 85 participated (53% response rate) with representation across all US regions. HPM fellows spend a median of 4.8 weeks in outpatient PC compared to 24 weeks inpatient PC and 10.5 weeks in hospice settings. Over half (51%) of fellows saw outpatients from primarily one disease type with limited exposure to patients with other serious illnesses. Across programs, fellows' clinic structure, interdisciplinary team composition, and didactic experiences varied. On a 5-point rating scale, PDs reported significantly lower quality outpatient versus inpatient training (mean rating: 3.58 vs. 4.62, P<0.001) and perceived fellows as less prepared for independent outpatient practice upon graduation (mean: 4.06 vs. 4.73, P<0.001).

CONCLUSION

Our survey of US HPM fellowships identified multiple gaps between outpatient and inpatient PC education and training during fellowship and raises concern about the adequacy of outpatient PC training. To prepare the HPM workforce to meet the diverse needs of seriously ill populations and ensure adequate access, outpatient PC training requires reform.

Homologous recombination proficient subtypes of high-grade serous ovarian cancer: treatment options for a poor prognosis group

Approximately 50% of tubo-ovarian high-grade serous carcinomas (HGSCs) have functional homologous recombination-mediated (HR) DNA repair, so-called HR-proficient tumors, which are often associated with primary platinum resistance (relapse within six months after completion of first-line therapy), minimal benefit from poly(ADP-ribose) polymerase (PARP) inhibitors, and shorter survival. HR-proficient tumors comprise multiple molecular subtypes including cases with CCNE1 amplification, AKT2 amplification or CDK12 alteration, and are often characterized as "cold" tumors with fewer infiltrating lymphocytes and decreased expression of PD-1/PD-L1. Several new treatment approaches aim to manipulate these negative prognostic features and render HR-proficient tumors more susceptible to treatment. Alterations in multiple different molecules and pathways in the DNA damage response are driving new drug development to target HR-proficient cancer cells, such as inhibitors of the CDK or P13K/AKT pathways, as well as ATR inhibitors. Treatment combinations with chemotherapy or PARP inhibitors and agents targeting DNA replication stress have shown promising preclinical and clinical results. New approaches in immunotherapy are also being explored, including vaccines or antibody drug conjugates. Many approaches are still in the early stages of development and further clinical trials will determine their clinical relevance. There is a need to include HR-proficient tumors in ovarian cancer trials and to analyze them in a more targeted manner to provide further evidence for their specific therapy, as this will be crucial in improving the overall prognosis of HGSC and ovarian cancer in general.

Standardizing Integrated Oncology and Palliative Care Across Service Levels: Challenges in Demonstrating Effects in a Prospective Controlled Intervention Trial

INTRODUCTION

Patients with cancer often want to spend their final days at home. In Norway, most patients with cancer die in institutions. We hypothesized that full integration of oncology and palliative care services would result in more time spent at home during end-of-life.

METHODS

A prospective non-randomized intervention trial was conducted in two rural regions of Mid-Norway. The hospitals' oncology and palliative care outpatient clinics and surrounding communities participated. An intervention including information, education, and a standardized care pathway was developed and implemented. Adult non-curative patients with cancer were eligible. Proportion of last 90 days of life spent at home was the primary outcome.

RESULTS

We included 129 patients in the intervention group (I) and 76 patients in the comparison group (C), of whom 82% of patients in I and 78% of patients in C died during follow-up. The mean proportion of last 90 days of life spent at home was 0.62 in I and 0.72 in C (p = 0.044), with 23% and 36% (p = 0.073), respectively, dying at home. A higher proportion died at home in both groups compared to pre-study level (12%). During the observation period the comparison region developed and implemented an alternative intervention to the study intervention, with the former more focused on end-of-life care.

CONCLUSION

A higher proportion of patients with cancer died at home in both groups compared to pre-study level. Patients with cancer in I did not spend more time at home during end-of-life compared to those in C. The study intervention focused on the whole disease trajectory, while the alternative intervention was more directed towards end-of-life care. "Simpler" and more focused interventions on end-of-life care may be relevant for future studies on integration of palliative care into oncology.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02170168.

Palliative care integration and end-of-life care intensity for patients with NSCLC

BACKGROUND

Non-small cell lung cancer (NSCLC) without oncogenic driver mutations is considered to have a poor prognosis, although recent therapeutic progress. This study aims to assess the real-life integration of palliative care (PC) and the intensity of end-of-life (EOL) care for this population.

METHODS

This was an observational cohort study of decedent patients from metastatic NSCLC without oncogenic driver mutations over the period 01/2018 to 12/2022, treated in first line with immunotherapy +/- chemotherapy. We analysed PC integration and aggressiveness criteria of EOL care in the last month before death: systemic anti-cancer treatment administration, emergency room visits, intensive care unit admission, hospitalization, hospitalization duration > 14 days, and hospital death.

RESULTS

Among 149 patients, 75 (50 %) met the PC team at least once, and the median time from the first encounter to death was 2.3 months. In the last month before death, at least one criterion of aggressive EOL care was present for 97 patients (70 %). For patients with PC use < 30 days and for patients with PC use < 90 days before death, there were significant changes: increase in the frequency of systemic anti-cancer treatment (respectively 51.1 % vs 20 %; p < 0.001 and 58.7 % vs 6.2 %; p < 0.001); decrease in hospitalization lasting > 14 days (respectively 30 % vs 7 %; p = 0.001 and 36 % vs 6.2 %; p = 0.018) and in death hospitalisation (respectively 66 % and 18 %; p < 0.001 and 58.7 % and 10.3 %; p < 0.001). After adjusting for the factors tested, patients with no PC or late PC use in the last month before death or in the last three month before death, the odds ratio (OR) remained significantly greater than 1 (respectively OR = 3.97 [1.70; 9.98]; p = 0.001 and OR = 23.1 [5.21-177.0], p < 0.0001).

CONCLUSION

PC is still insufficiently integrated for patients with NSCL cancer. Cancer centres should monitor key indicators such as PC use and aggressiveness criteria of EOL care.

Impact of a comprehensive rehabilitation palliative care program on the quality of life of patients with terminal cancer and their informal caregivers: a quasi-experimental study

BACKGROUND

Palliative care schemes, which include pain management, symptom control, psychosocial support and rehabilitation, aim to boost patients' quality of life, ease the burden and anxiety of informal caregivers, and ultimately provide a comprehensive approach to enhance well-being during this challenging and sensitive period. This study aims to evaluate the impact of a comprehensive rehabilitation palliative care program on the quality of life of patients with terminal cancer and their informal caregivers.

METHODS

This quasi-experimental study, conducted from August 2023 to January 2024 at outpatient clinics affiliated with the Oncology Center at Mansoura University, Egypt, focused on cancer patients and their caregivers in the palliative care department. Employing pre- and post-test phases, data were gathered using a questionnaire, EORTC QLQ C30, Hospital Anxiety and Depression Scale, Short Form Health Survey, Caregiver Burden Inventory, and Beck Anxiety Inventory. The investigation evaluated a 16-week rehabilitation program comprising exercise, psychoeducation, individual counselling, and spiritual support. Exercises, led by a physiotherapist, targeted fatigue and stress through tailored aerobic and resistance training. Psychoeducation sessions aimed to bolster coping abilities, covering fatigue management and nutrition. Trained counsellors addressed spiritual and existential concerns. Personal advisory sessions were available for individual support. Caregivers received education on rehabilitation and palliative care protocols, ensuring comprehensive patient care.

RESULTS

The mean age for cancer patients was 65.79 ± 13.85. In contrast, the mean age for primary carers was 42.05 ± 11.15. The QOL for cancer patients during the pre-test phase was 77.8 ± 7.16 and rose to 87.34 ± 14.56 during the post-test phase. Additionally, the total anxiety level of patients before the rehabilitation palliative care program was conducted was 15.45 ± 3.05 compared to 6.12 ± 3.21 after the post test phase. Furthermore, the total depression levels of the patients during the pre-test phase were 20.89 ± 9.21. However, after implementing the rehabilitation palliative care program, it decreased to 15.5 ± 6.86. In regards to the total quality of life of informal caregivers, it was measured at 67.28 ± 32.09 before conducting the program. Nevertheless, it increased to 25.95 ± 40.29 after conducting it. Additionally, the total Caregiver Burden Inventory before implementing the program was 37.45 ± 25.7, and it decreased to 29.36 ± 16.4 after conducting it. Additionally, the total score on the Beck Anxiety Inventory decreased from 45.7 ± 4.3 during the initial testing phase to 17.35 ± 23.67.

CONCLUSION

The program for rehabilitation palliative care successfully achieved its goals by enhancing the overall quality of life for cancer patients and their caregivers. Additionally, it reduced the anxiety and depression levels among the patients, as well as the anxiety and caregiver burden among the caregivers. Continue research into the effectiveness of rehabilitation palliative care programs to identify best practices, improve existing programs, and expand access to these services.

Development and psychometric evaluation of the death risk perception scale for advanced cancer patients

BACKGROUND

An accurate perception of death risk is a prerequisite for advanced cancer patients to make informed end-of-life care decisions. However, there is to date no suitable scale to measure death risk perception. This study was to develop and psychometrically test the death risk perception scale (DRPS) for advanced cancer patients.

METHODS

Process of instrument development and psychometric evaluation were used. First, qualitative research, a literature review, brainstorming, a Delphi study, and cognitive interviews were conducted to construct a pretest scale of death risk perception. Second, a scale-based survey was administered to 479 advanced cancer patients. Item, exploratory factor, and confirmatory factor analyses were employed to optimize the scale. The Cronbach's alpha was calculated as a reliability analysis. The validity analysis included construct, convergent, discriminant, and content validity values.

RESULTS

A three-dimension, 12-item scale was developed, including deliberative, affective, and experiential risk perception. The confirmatory factor analysis supported the three-factor model with satisfactory convergent and discriminant validity levels. The Cronbach's alpha coefficient for internal consistency was 0.807 and scale-level content validity index was 0.98.

CONCLUSIONS

The 12-item DRPS is a reliable and valid instrument for assessing the level of death risk perception in advanced cancer patients. More studies are needed to examine its structure and robustness prior to use.

Qualitative evaluation of motives for acceptance or refusal of early palliative care in patients included in early-phase clinical trials in a French comprehensive cancer center: the PALPHA study

PURPOSE

The integration of palliative care (PC) into oncological management is recommended well before the end of life. It improves quality of life and symptom control and reduces the aggressiveness of end-of-life care. However, its appropriate timing is still debated. Entry into an early-phase clinical trial (ECT) represents hopes for the patient when standard treatments have failed. It is an opportune moment to integrate PC to preserve the patient's general health status. The objective of this study was to evaluate the motives for acceptance or refusal of early PC management in patients included in an ECT.

METHODS

Patients eligible to enter an ECT were identified and concomitant PC was proposed. All patients received exploratory interviews conducted by a researcher. Their contents were analyzed in a double-blind thematic analysis with a self-determination model.

RESULTS

Motives for acceptance (PC acceptors: n = 27) were both intrinsic (e.g., pain relief, psychological support, anticipation of the future) and extrinsic (e.g., trust in the medical profession, for a relative, to support the advance of research). Motives for refusal (PC refusers: n = 3) were solely intrinsic (e.g., PC associated with death, negative representation of psychological support, no need for additional care, claim of independence).

CONCLUSIONS

The motives of acceptors and refusers are not internalized in the same way and call for different autonomy needs. Acceptors and refusers are influenced by opposite representations of PC and a different perception of mixed management.

Palliative care for patients with hematologic malignancies in Germany: a nationwide survey on everyday practice and influencing factors from the perspective of treating physicians

Integrating palliative care into the treatment of patients with advanced hematological malignancies (HM) remains challenging. To explore treating physicians' perspectives on current palliative care practice and to evaluate factors influencing integration, we conducted a nationwide online survey. Based on literature and expert review, the survey addressed the importance of palliative care, communication about life-threatening conditions, challenges in establishing goals of care, and factors influencing the integration of palliative care. 207 physicians treating patients with HM in Germany participated. We used standard descriptive statistics to analyze quantitative data and a content structuring approach. Most physicians considered palliative care in HM to be very important (60.6%) and discussed life-threatening conditions with more than half of their patients (52%), especially when goals of care were changed (87.0%) or when patients raised the topic (84.0%). Disease-related factors, different professional perspectives on prognosis, and patient hopes were the main barriers to changing goals of care, but collaboration with colleagues and multidisciplinary teams provided important support. Time constraints were identified as the main barrier to integrating palliative care. The majority worked well with palliative care teams. Referral processes and conditions were perceived as minor barriers. The study highlights the need to address barriers to integrating palliative care into the management of patients with advanced HM. Future research should aim at optimizing palliative care for patients with HM.