Palliative and End-of-Life Care for Patients with Malignancy

Pharmacists' Behavioral Changes after Attending a Multi-Prefectural Palliative Care Education Program

Central to the pharmacist's role in palliative care is symptom management through direct participation in patient care and the provision of optimal pharmacotherapy to support patient outcomes. Consequently, palliative care requires extensive knowledge and action for patients with cancer. Therefore, this study aimed to evaluate how pharmacists' behavior changed after attending a palliative care educational program. We conducted a web-based questionnaire survey examining the behavior of pharmacists regarding palliative care before participating in the program, two months after participating in the program, and eight months after participating in the program to determine their behavior and changes over time. For all questions, scores were higher at two and eight months after attending the program than before attending the program (p < 0.05). In addition, no significant difference was observed between two and eight months after attending the program for any question (p = 0.504-1.000). The knowledge gained from the educational program was used to repeatedly intervene with patients with cancer in order to address the various symptoms they experienced and maintain their behavior. The proven effectiveness of this program serves as a stepping stone for nationwide rollout across Japan's 47 prefectures.

Aggressive End-of-Life Care and Caregiver Satisfaction for Patients With Advanced Cancer

Aggressive end-of-life care in patients with advanced cancer is associated with poor experiences and outcomes. The purpose of the study was to examine the impact of aggressive end-of-life care on caregiver satisfaction for caregivers of bereaved advanced cancer patients. Data of 101 caregivers were gathered using a longitudinal, descriptive correlational design study. Postdeath interviews were conducted 2 months after the patient's death. The most common end-of-life care indicators were patient not enrolled in hospice or enrolled within 3 days of death, >1 hospitalization, and intensive care unit admission. More than one-third of patients received at least one of the aggressive end-of-life care indicators in the last 30 days of life. From the multiple linear regression analyses, patient intensive care unit admission and having more than one hospitalization significantly affected caregiver satisfaction with care. Understanding caregiver satisfaction with care may improve the clinical practice of nurses who have crucial role in patients' end-of-life care.

Application of interdisciplinary collaborative hospice care for terminal geriatric cancer patients: a prospective randomized controlled study

BACKGROUND

Hospice care (HC) is specialized medical care for terminal patients who are nearing the end of life. Interdisciplinary collaborative hospice care (ICHC) is where experts from different disciplines and patients/caregivers form a treatment team to establish shared patient care goals. However, the ICHC efficacy has not been frequently studied in the terminal geriatric cancer patient (TGCP) population. This study aimed to gain insight into ICHC provided to TGCPs by an ICHC team and identify factors to ameliorate multidimensional HC.

METHODS

166 TGCPs were randomized by a computer-generated random number table using an allocation ratio of 1:1. The patients were divided into the ICHC group and life-sustaining treatment (LST) group. The scores of these questionnaires, such as EORTC, QLQ-C30, Hamilton anxiety scale, the median survival time (MST), symptoms improvement, the median average daily cost of drugs (MADDC), the median total cost of drugs (MTDC) in the last 2 days, and medical care satisfaction were observed in both groups.

RESULTS

After treatment, the improvement of emotional function and symptoms in the ICHC group were statistically higher than those in the LST group (P < 0.05). The MADDC and the MTDC in the last 2 days were statistically lower in the ICHC group than those in the LSTs group (P < 0.01). In addition, the overall satisfaction situation and the cooperation ability in the ICHC group were statistically higher than those in the LST group (P < 0.01).

CONCLUSION

The ICHC could provide TGCPs with coordinated, comfortable, high-quality, and humanistic care.

Palliative Care Consultation Services on Terminally Ill Cancer Patients and Non-Cancer Patients: Trend Analysis from a 9-Year-Long Observational Study in Taiwan

Early integration of palliative care for terminally ill cancer and non-cancer patients improves quality of life. However, there are sparse data on results of palliative care consultation services (PCCS) between cancer and non-cancer patients. In this 9-year observational study, data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill cancer and non-cancer patients who received PCCS during 2011 to 2019 were enrolled. Trend analysis was performed to evaluate differences in outcomes of PCCS, including duration of PCCS, the awareness of disease of patients and families before and after PCCS, status of PCCS termination, and DNR declaration before and after PCCS among cancer and non-cancer patients throughout study period. In total, 5223 cancer patients and 536 non-cancer patients received PCCS from 2011 to 2019. The number of people who received PCCS increased stably over the decade, both for cancer and non-cancer patients. The average duration of PCCS for cancer and non-cancer patients was 21.4 days and 18.4 days, respectively. Compared with non-cancer patients, cancer patients had longer duration of PCCS, less DNR declaration (82% vs. 98%, respectively), and more transfers to the palliative care unit (17% vs. 11%, respectively), or for palliative home care (12% vs.8%, respectively). Determinants of late referral to PCCS includes age (OR 0.992, 95% CI 0.987–0.996), DNR declaration after PCCS (OR 1.967, 95% CI 1.574–2.458), patients’ awareness after PCCS (OR 0.754, 95% CI 0.635–0.895), and status of PCCS termination. This 9-year observational study showed that the trend of PCCS among cancer and non-cancer patients had changed over the duration of the study, and early integration of PCCS to all patients is essential for both cancer and non-cancer patients.

Palliative Oncological Patients with Insomnia: Concerns of the Patients and Their Relatives' Perception

Insomnia is one of the most frequent symptoms and usually generates significant stress in 60% of patients with advanced cancer. Worries from the patients' and relatives' perspective are crucial to improve the patients' quality of life but have received limited attention. The aims were to identify the concerns of patients with insomnia in the terminal illness stage in a palliative care unit and the relatives' perception, and to compare both. Here, 63 patients and 53 relatives answered a questionnaire about worries in the personal, spiritual, family-related and economic area, as well as a quality-of-life uniscale. The results showed that the relatives' most frequent concern was "Having lived life to the fullest" (100%), and the most intense was "The possible suffering during the process" (9.2/10). The patients' most expressed concern was: "Having unfinished business" (100%), and the most intense was "Suffering during the process" (9.3/10). Quality of life showed an average value of 6.95 out of 10. Relatives only coincided significantly in: "Not knowing what happens after death" (r = 0.600; p = 0.000). These results bring visibility to concerns during the final stage of oncological palliative patients with insomnia from the patients' and relatives' perspective. Knowing both is useful for professionals to foster the well-being for a short, yet very important, period for patients, relatives and the caregiving team.

End-of-life care for Aboriginal and Torres Strait Islander people with cancer: an exploratory study of service utilisation and unmet supportive care needs

BACKGROUND

Indigenous Australians diagnosed with cancer have substantially higher cancer mortality rates compared with non-Indigenous Australians, yet there is a paucity of information about their end-of-life service utilisation and supportive care needs.

PURPOSE

To describe the service utilisation and supportive care needs of Aboriginal and Torres Strait Islander people with cancer at end-of-life.

METHOD

Hospital admission data were linked to self-reported data from a study of Indigenous cancer patients from Queensland, Australia during the last year of their life. Needs were assessed by the Supportive Care Needs Assessment Tool for Indigenous Cancer Patients which measures 26 need items across 4 domains (physical/psychological; hospital care; information/communication; practical/cultural). A descriptive analysis of health service utilisation and unmet needs was conducted.

RESULTS

In total, 58 Indigenous cancer patients were included in this analysis. All patients had at least one hospital admission within the last year of their life. Most hospital admissions occurred through emergency (38%) and outpatient (31%) departments and were for acute care (85%). Palliative care represented 14% of admissions and 78% died in hospital. Approximately half (48%) did not report any unmet needs. The most frequently reported moderate-to-high unmet need items were worry about the treatment results (17%), money worries (16%) and anxiety (16%).

CONCLUSIONS

Utilisation of palliative care services that manage a full range of physical and psychosocial needs was low. Addressing worries about treatment results, finances and generalised anxiety are priorities in this population.

Awareness of Palliative Care, Hospice Care, and Advance Directives in a Racially and Ethnically Diverse Sample of California Adults

BACKGROUND

Numerous studies have documented multilevel racial inequalities in health care utilization, medical treatment, and quality of care in minority populations in the United States. Palliative care for people with serious illness and hospice services for people approaching the end of life are no exception. It is also well established that Hispanics and non-Hispanic Blacks are more likely than non-Hispanic Whites to have less knowledge about advance care planning and directives, hospice, and palliative care. Both qualitative and quantitative research has identified lack of awareness of palliative and hospice services as one of the major factors contributing to the underuse of these services by minority populations. However, an insufficient number of racial/ethnic comparative studies have been conducted to examine associations among various independent factors in relation to awareness of end-of-life, palliative care and advance care planning and directives.

AIMS

The main objective of this analysis was to examine correlates of awareness of palliative, hospice care and advance directives in a racially and ethnically diverse large sample of California adults.

METHODS

This cross-sectional study includes 2,328 adults: Hispanics (31%); non-Hispanic Blacks (30%); and non-Hispanic Whites (39%) from the Survey of California Adults on Serious Illness and End-of-Life 2019. Using multivariate analysis, we adjusted for demographic and socio-economic variables while estimating the potential independent impact of health status, lack of primary care providers, and recent experiences of participants with a family member with serious illnesses.

RESULTS

Hispanic and non-Hispanic Black participants are far less likely to report that they have heard about palliative and hospice care and advance directives than their non-Hispanic White counterparts. In this study, 75%, 74%, and 49% of Hispanics, non-Hispanic Blacks, and non-Hispanic White participants, respectively, claimed that they have never heard about palliative care. Multivariate analysis of data show gender, age, education, and income all significantly were associated with awareness. Furthermore, being engaged with decision making for a loved one with serious illnesses and having a primary care provider were associated with awareness of palliative care and advance directives.

DISCUSSION

Our findings reveal that lack of awareness of hospice and palliative care and advance directives among California adults is largely influenced by race and ethnicity. In addition, demographic and socio-economic variables, health status, access to primary care providers, and having informal care giving experience were all independently associated with awareness of advance directives and palliative and hospice care. These effects are complex, which may be attributed to various historical, social, and cultural mechanisms at the individual, community, and organizational levels. A large number of factors should be addressed in order to increase knowledge and awareness of end-of-life and palliative care as well as completion of advance directives and planning. The results of this study may guide the design of multi-level community and theoretically-based awareness and training models that enhance awareness of palliative care, hospice care, and advance directives among minority populations.

Palliative care and infection management at end of life in nursing homes: A descriptive survey

BACKGROUND

Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics.

AIM

The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation.

DESIGN

This is a cross-sectional survey of nationally representative US nursing homes.

SETTING/PARTICIPANTS

Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation.

RESULTS

Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics.

CONCLUSION

The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.

Systematic Review of the Prevalence, Predictors, and Treatment of Insomnia in Palliative Care

Introduction:

The primary function of palliative care is to improve quality of life. The recognition and treatment of symptoms causing suffering is central to the achievement of this goal. Insomnia reduces quality of life of patients under palliative care. Knowledge about prevalence, associated factors, and treatment of insomnia in palliative care is scarce.

Methodology:

Literature review about the prevalence, predictors, and treatment options of insomnia in palliative care patients. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in identified articles and selected reviews. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

Results:

A total of 65 studies were included in the review. Most studies had acceptable /good quality. The prevalence of insomnia in the included studies ranged from 2.1% to 100%, with a median overall prevalence of 49.5%. Sociodemographic factors such as age; clinical characteristics such as functional status, disease stage, pain, and use of specific drugs, including opioids; psychological factors such as anxiety/depression; and spiritual factors such as feelings of well-being were identified as predictors. The treatment options identified were biological (pharmacological and nonpharmacological), psychological (visualization, relaxation), and spiritual (prayer).

Conclusions:

The systematic review showed that the prevalence of insomnia is high, with at least one in 3 patients affected in most studies. Insomnia’s risk factors and treatment in palliative care are both associated to physical, psychological, social, and spiritual factors, reflecting its true holistic nature.

[The role of the family doctor in the palliative care of chronic and terminally ill patients]

The objective of this work was to identify the role of family physicians in the care of patients and their families in the approach to the end of life. Nowadays, with the increase in the demand for care of patients with terminal illnesses, there is also evidence on the lack of physicians with the profile and skills to fulfil this coverage deficit. A review of the literature was carried out in five databases from January 2015 to May 2018, and concluded that family doctors, based on their professional skills, ability to engage with the patients, their families, and their performance in the coordination of medical resources, are in an ideal position to attend and solve complex problems of patients at the end of life. In the present review, the specific roles of family physicians in clinical and psychosocial areas, and also the difficulties in facing the challenges in the care of patients and families undergoing the end of life process are described.

Palliative Care Use Among Patients With Solid Cancer Tumors: A National Cancer Data Base Study

BACKGROUND

Palliative care has been increasingly recognized as an important part of cancer care but remains underutilized in patients with solid cancers. There is a current gap in knowledge regarding why palliative care is underutilized nationwide.

OBJECTIVE

To identify the factors associated with palliative care use among deceased patients with solid cancer tumors.

METHODS

Using the 2016 National Cancer Data Base, we identified deceased patients (2004-2013) with breast, colon, lung, melanoma, and prostate cancer. Data were described as percentages. Associations between palliative care use and patient, facility, and geographic characteristics were evaluated through multivariate logistic regression.

RESULTS

A total of 1 840 111 patients were analyzed; 9.6% received palliative care. Palliative care use was higher in the following patient groups: survival >24 months (17% vs 2%), male (54% vs 46%), higher Charlson-Deyo comorbidity score (16% vs 8%), treatment at designated cancer programs (74% vs 71%), lung cancer (76% vs 28%), higher grade cancer (53% vs 24%), and stage IV cancer (59% vs 13%). Patients who lived in communities with a greater percentage of high school degrees had higher odds of receiving palliative care; Central and Pacific regions of the United States had lower odds of palliative care use than the East Coast. Patients with colon, melanoma, or prostate cancer had lower odds of palliative care than patients with breast cancer, whereas those with lung cancer had higher odds.

CONCLUSIONS

Palliative care use in solid cancer tumors is variable, with a preference for patients with lung cancer, younger age, known insurance status, and higher educational level.

The Determinants of Palliative Care Use in Patients With Colorectal Cancer: A National Study

BACKGROUND

Palliative care is associated with improved survival and quality of life, but its use among patients with colorectal cancer varies nationwide and the determinants of those variations are not clear.

OBJECTIVE

To determine the factors associated with palliative care use among patients who died of colorectal cancer.

METHODS

Deceased patients treated for colorectal cancer (2004-2013) were identified within the National Cancer Database. Multivariable logistic regression was used to evaluate patient and institutional characteristics associated with palliative care use. Patients were classified based on their length of survival (<6 months, 6-24 months, and 24+ months) to provide timing context.

RESULTS

A total of 287 923 patients were analyzed. Overall, 4.3% of the patients received palliative care. Patients who received palliative care were more likely to be younger, recently diagnosed, treated at academic hospitals, and have stage IV disease. Patients living in Mountain and Pacific regions had higher odds of palliative care receipt than those in the East Coast. Patients without insurance had higher odds of palliative care if they survived <24 months. Insurance coverage through Medicaid was associated with increased palliative care use among patients who survived 6 to 24 months. Patients who survived <6 months and lived >9 miles from the institution received more palliative care.

CONCLUSION

Palliative care use among patients with colorectal cancer is associated with a younger age, a more recent year of diagnosis, insurance status, academic hospitals, and living in Mountain and Pacific regions.

Palliative Care and Interventional Pulmonology

Since pulmonary pathologies, such as lung cancer and chronic obstructive pulmonary disease (COPD), are some of the leading causes of morbidity and mortality around the world, pulmonologists are likely to encounter patients with unmet palliative care needs. This article focuses on the symptoms and complications encountered by patients with terminal pulmonary conditions, briefly describes the non-interventional palliative strategies, and then discusses more advanced therapies available in the realm of interventional pulmonology. Most of the literature discussed here is derived from patients with lung cancer and COPD.