The role of a palliative care intervention in moderating the relationship between depression and survival among individuals with advanced cancer

Patient & Caregiver Experiences: Qualitative Study Comparison Before and After Implementation of Early Palliative Care for Advanced Colorectal Cancer

BACKGROUND

The Palliative Care Early and Systematic (PaCES) program implemented an early palliative care pathway for advanced colorectal cancer patients in January 2019, to increase specialist palliative care consultation and palliative homecare referrals more than three months before death. This study aimed to understand the experience of patients with advanced colorectal cancer and family caregivers who received early palliative care supports from a specialist palliative care nurse and compared those experiences with participants who experienced standard oncology care prior to implementation of early palliative care.

METHODS

This was a qualitative and patient-oriented study. We conducted semi-structured telephone interviews with two cohorts of patients with advanced colorectal cancer before and after implementation of an early palliative care pathway. We conducted a thematic analysis of the transcripts guided by a Person-Centred Care Framework.

RESULTS

Seven patients living with advanced colorectal cancer and five family caregivers who received early palliative care supports expressed that visits from their early palliative care nurse was helpful, improved their understanding of palliative care, and improved their care. Four main themes shaped their experience of early palliative care: care coordination, perception of palliative care & advance care planning, coping with advanced cancer, and patient and family engagement. These findings were compared with experiences of 15 patients and seven caregivers prior to pathway implementation.

CONCLUSION

An early palliative care pathway can improve advanced cancer care, and improve understanding and acceptance of early palliative care. This work was conducted in the context of colorectal cancer but may have relevance for the care of other advanced cancers.

Impact of interprofessional collaborative practice in palliative care on outcomes for advanced cancer inpatients in a resource-limited setting

BACKGROUND

Palliative care for patients with advanced cancer improves suffering symptoms, and quality of life (QoL). However, routine implementation of palliative care by specialty palliative care consultation is still an unmet need among in-patients with advanced cancer. Our study aim is to evaluate the effectiveness of a team-based approach on QoLs and readmission rate when compared to routine practice by among medical oncologists.

METHODS

This study was a prospective, Quasi-Experimental design. In-patients with advanced cancer were non-randomly assigned to receive palliative care service by team-based approach or medical oncologists only. The primary endpoint was QoL. The secondary endpoint was the readmission rate at 7 and 30 days of hospital discharge.

RESULTS

One hundred twenty-two in-patients were enrolled. In-patients who were assessed by a team-based approach had significantly improved change scores of subjective well-being (SWB) when compared to another group (∆ SWB: -1 [-19 - 11] vs 0 [-9 - 15], p-value = 0.043). Furthermore, patients who were assessed under a team-based approach had significantly decreased in terms of readmission rate at 7 days of hospital discharge (4.92% in the team-based approach group vs. 19.67% in the medical oncologist group, p-value = 0.013).

CONCLUSIONS

Interdisciplinary collaboration is the key to success in establishing goals of care, which are supporting the best possible QoL and relieving suffering symptoms for those in-patients with advanced cancer. Furthermore, the readmission rate at 7 days of hospital discharge was significantly reduced by a team-based approach. Therefore, comprehensive palliative care assessment by interprofessional collaborative practice is required.

TRIAL REGISTRATION

Thai Clinical Trials Registry (TCTR): number 20200312001. Date of first registration on 09/03/2020.

Enhanced supportive care for advanced cancer patients: study protocol for a randomized controlled trial

BACKGROUND

Early palliative care along with standard cancer treatments is recommended in current clinical guidelines to improve the quality of life and survival of cancer patients. This study protocol aims to evaluate the effect of "Enhanced Supportive Care", an early primary palliative care provided by nurses.

METHODS

A randomized controlled trial (RCT) will be conducted including advanced cancer patients scheduled for first-line palliative chemotherapy (N=360) and their caregivers in South Korea. Participants will be randomly assigned to the intervention or control group in a 1:1 ratio. Participants in the intervention group will receive the "Enhanced Supportive Care", which provides five sessions of symptom management and coping enhancement counseling by nurses. The control group will receive symptom monitoring five times. The primary endpoints are symptoms, coping, and quality of life (QoL) at 3 months. Secondary endpoints are symptoms, coping, and QoL at 6 months, depression and self-efficacy for coping with cancer at 3 and 6 months, symptom and depression change from baseline to 3 months, survival at 6 and 12 months among patients, and depression among caregivers at 3 and 6 months.

DISCUSSION

This RCT will evaluate the effects of "Enhanced Supportive Care" on symptoms, depression, coping, self-efficacy for coping with cancer, QoL and survival of patients, as well as depression of caregivers. It will provide evidence of a strategy to implement early primary palliative care provided by nurses, which may consequently improve cancer care for newly diagnosed patients with advanced stage cancer.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04407013. Registered on May 29, 2020, https://www.

CLINICALTRIALS

gov/ct2/show/study/NCT04407013 . The protocol version is ESC 1.0.

Palliative Care and Documented Suicide: Association Among Veterans With High Mortality Risk

CONTEXT

Palliative care consultations (PCCs) are associated with reduced physical and psychological symptoms that are related to suicide risk. Little is known, however, about the association between PCCs and death from suicide among patients at high risk of short-term mortality.

OBJECTIVE

To examine the association between the number of PCCs and documentation of suicide in a cohort of Veterans at high risk of short-term mortality, before and after accounting for Veterans' sociodemographic characteristics and clinical conditions.

METHODS

An observational cohort study was conducted using linked Veterans Affairs clinical and administrative databases for 580,620 decedents with high risk of one-year mortality. Logistic regression models were used to examine the association between number of PCCs and documentation of suicide.

RESULTS

Higher percentages of Veterans who died by suicide were diagnosed with chronic pulmonary disease as well as mental health/substance use conditions compared with Veterans who died from other causes. In adjusted models, one PCC in the 90 days prior to death was significantly associated with a 71% decrease in the odds of suicide (OR = 0.29, 95% CI = 0.23-0.37, P < 0.001) and two or more PCCs were associated with a 78% decrease (OR = 0.22, 95% CI = 0.15-0.33, P < 0.001). Associated "number needed to be exposed" estimates suggest that 421 Veterans in this population would need to receive at least one PCC to prevent one suicide.

CONCLUSION

While acknowledging the importance of specialized mental health care in reducing suicide among high-risk patients, interventions delivered in the context of PCCs may also play a role.

Association of Early Palliative Care Use With Survival and Place of Death Among Patients With Advanced Lung Cancer Receiving Care in the Veterans Health Administration

Importance

Palliative care is a patient-centered approach associated with improvements in quality of life; however, results regarding its association with a survival benefit have been mixed, which may be a factor in its underuse.

Objective

To assess whether early palliative care is associated with a survival benefit among patients with advanced lung cancer.

Design, Setting, and Participants

This retrospective population-based cohort study was conducted among patients with lung cancer who were diagnosed with cancer between January 1, 2007, and December 31, 2013, with follow-up until January 23, 2017. Participants comprised 23 154 patients with advanced lung cancer (stage IIIB and stage IV) who received care in the Veterans Affairs health care system. Data were analyzed from February 15, 2019, to April 28, 2019.

Exposure

Palliative care defined as a specialist-delivered palliative care encounter received after lung cancer diagnosis.

Main Outcomes and Measures

The primary outcome was survival. The association between palliative care and place of death was also examined. Propensity score and time-varying covariate methods were used to calculate Cox proportional hazards and to perform regression modeling.

Results

Of the 23 154 patients enrolled in the study, 57% received palliative care. The mean (SD) age of participants was 68 (9.5) years, and 98% of participants were men. An examination of the timing of palliative care receipt relative to cancer diagnosis found that palliative care received 0 to 30 days after diagnosis was associated with decreases in survival (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.97-2.30), palliative care received 31 to 365 days after diagnosis was associated with increases in survival (aHR, 0.47; 95% CI, 0.45-0.49), and palliative care received more than 365 days after diagnosis was associated with no difference in survival (aHR, 1.00; 95% CI, 0.94-1.07) compared with nonreceipt of palliative care. Receipt of palliative care was also associated with a reduced risk of death in an acute care setting (adjusted odds ratio, 0.57; 95% CI, 0.52-0.64) compared with nonreceipt of palliative care.

Conclusions and Relevance

The results suggest that palliative care was associated with a survival benefit among patients with advanced lung cancer. Palliative care should be considered a complementary approach to disease-modifying therapy in patients with advanced lung cancer.

Optimal Supportive Care for Patients With Metastatic Breast Cancer According to Their Disease Progression Phase

The clinical progression patterns of metastatic breast cancer (MBC) are heterogeneous; patients experience acute and stable phases at different time points. The acute phase consists of rapid progressive symptomatic changes, whereas in the stable phase, patients have relatively low symptom burden. Therefore, personalized interdisciplinary care is essential. The optimal palliative or supportive care in MBC is to provide comprehensive care that is individually prioritized to the patient's disease status. The purpose of this review is to provide a practical guide for oncologists to understand the priorities for supportive care for patients with MBC in the two phases. We note that for better decision making in patient care, performance status should be broadened to consider not only physical status but also psychosocial needs and cognitive condition. We summarize the clinical importance of physical symptom control, psychosocial support, physical activity, nutrition support, and advance care planning. For optimal care, we present palliative or supportive care checklists according to the disease progression phase, combining the limited evidence with expert input. In the acute phase, close monitoring of the patient's status and symptom management take priority. In the stable phase, the focus can shift to maintenance or improvement of physical strength and emotional condition. Finally, we discuss future directions and unmet needs in providing the best supportive care for patients with MBC.

Research of Psycho-emotional State of Patients, Who Receive Palliative Care in Ambulant Conditions

Anxieties, depression, fear, depressive disorders are symptoms, which may be the part of physiological feeling with incurable disease, especially when the diagnosis is informed. Sometimes, the assumption of difficult news, related to worsening of health and even risk to life can lead to fatal consequences. For family physicians and other professionals, who are involved in palliative care, it is important to be able to diagnose the worsening of patients’ psycho-emotional state in time, in order to provide professional psychological support. In this article, the results of research of level of difficulty of depressive disorders in palliative patients depending on different demographic and social data are presented, which can be modified with changing attitudes towards these patients (when ensuring correct communication and managing of the palliative patient by the family physician). The research has shown that socio-demographic indicators significantly affect the forming of state of depression in palliative patients, and require appropriate communication between the family physician and the patient, and the organization of additional measures for managing these patients. Special attention should be given to some results of research when providing palliative care, in particular: depression of different level of difficulty, based on the PHQ-9 scale was found in 81 % of palliative patients; it was set that 90 % of people, aged of 75–90 years had depression of different level of difficulty; it was determined that all patients with high income had depression, among them 16.7 % of light and 58.3 % of moderate level of difficulty, that can be considered as a neurotic reaction of incurable disease. Depression was found in all unmarried patients, among them 35 % of light and 35 % of moderate level of difficulty, and 30 % of patients with high level as well, that significantly predominate over the number of married people (4.1 %) and widows 14 %), that may indicate character traits, which complicate the adaptation of behavioral reactions on stress factors , including to the disease. Depression was found in all unmarried patients, among them 35 % of light and 35 % of moderate level of difficulty, and 30 % of patients with high level as well, that significantly predominate over the number of married people (4.1 %) and widows 14 %), that may indicate character traits, which complicate the adaptation of behavioral reactions on stress factors, including to the disease. Such patients need additional psychological support for reducing their suffering, in particular for preventing of mental genesis pains. According to the indicators of various socio-demographic parameters, the portrait of the most vulnerable palliative patients was determined: they are women of age group 75–89 years, living in the city, by civil state – single (additional depressive factor can be assumed – long-term loneliness), by social status – pensioners with Higher Education and high income, based on a scale of PHQ-9 >20 points, that corresponds to the diagnosis: depressive syndome of heavy level.

A technology-enhanced model of care for transitional palliative care versus attention control for adult family caregivers in rural or medically underserved areas: study protocol for a randomized controlled trial

Background

Transitioning care from hospital to home is associated with risks of adverse events and poor continuity of care. These transitions are even more challenging when new approaches to care, such as palliative care, are introduced before discharge. Family caregivers (FCGs) are expected to navigate these transitions while also managing care. In addition to extensive caregiving responsibilities, FCGs often have their own health needs that can inhibit their ability to provide care. Those living in rural areas have even fewer resources to meet their self-care and caregiving needs. The purpose of this study is to test the efficacy and cost-effectiveness of an intervention to improve FCGs’ health and well-being. The intervention uses video visits to teach, guide, and counsel FCGs in rural areas during hospital-to-home transitions. The intervention is based on evidence of transitional and palliative care principles, which are individualized to improve continuity of care, provide caregiver support, enhance knowledge and skills, and attend to caregivers’ health needs. It aims to test whether usual care practices are similar to this technology-enhanced intervention in (1) caregiving skills (e.g., caregiving preparedness, communication with clinicians, and satisfaction with care), (2) FCG health outcomes (e.g., quality of life, burden, coping skills, depression), and (3) cost. We describe the rationale for targeting rural caregivers, the methods for the study and intervention, and the analysis plan to test the intervention’s effect.

Methods

The study uses a randomized controlled trial design, with FCGs assigned to the control condition or the caregiver intervention by computer-generated lists. The intervention period continues for 8 weeks after care recipients are discharged from the hospital. Data are collected at baseline, 2 weeks, 8 weeks, and 6 months. Time and monetary costs from a societal perspective are captured monthly.

Discussion

This study addresses 2 independent yet interrelated health care foci—transitional care and palliative care—by testing an intervention to extend palliative care practice and improve transition management for caregivers of seriously ill patients in rural areas. The comprehensive cost assessment will quantify the commitment and financial burden of FCGs.

Trial registration

ClinicalTrials.gov NCT03339271. Registered on 13 November 2017.

Protocol version: 11.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s13063-020-04806-0.

Effect of an Early Palliative Care Telehealth Intervention vs Usual Care on Patients With Heart Failure: The ENABLE CHF-PC Randomized Clinical Trial

IMPORTANCE

National guidelines recommend early palliative care for patients with advanced heart failure, which disproportionately affects rural and minority populations.

OBJECTIVE

To determine the effect of an early palliative care telehealth intervention over 16 weeks on the quality of life, mood, global health, pain, and resource use of patients with advanced heart failure.

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, intervention vs usual care randomized clinical trial was conducted from October 1, 2015, to May 31, 2019, among 415 patients 50 years or older with New York Heart Association class III or IV heart failure or American College of Cardiology stage C or D heart failure at a large Southeastern US academic tertiary medical center and a Veterans Affairs medical center serving high proportions of rural dwellers and African American individuals.

INTERVENTIONS

The ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers) intervention comprises an in-person palliative care consultation and 6 weekly nurse-coach telephonic sessions (20-40 minutes) and monthly follow-up for 48 weeks.

MAIN OUTCOMES AND MEASURES

Primary outcomes were quality of life (as measured by the Kansas City Cardiomyopathy Questionnaire [KCCQ]: score range, 0-100; higher scores indicate better perceived health status and clinical summary scores ≥50 are considered "fairly good" quality of life; and the Functional Assessment of Chronic Illness Therapy-Palliative-14 [FACIT-Pal-14]: score range, 0-56; higher scores indicate better quality of life) and mood (as measured by the Hospital Anxiety and Depression Scale [HADS]) over 16 weeks. Secondary outcomes were global health (Patient Reported Outcome Measurement System Global Health), pain (Patient Reported Outcome Measurement System Pain Intensity and Interference), and resource use (hospital days and emergency department visits).

RESULTS

Of 415 participants (221 men; baseline mean [SD] age, 63.8 [8.5] years) randomized to ENABLE CHF-PC (n = 208) or usual care (n = 207), 226 (54.5%) were African American, 108 (26.0%) lived in a rural area, and 190 (45.8%) had a high-school education or less, and a mean (SD) baseline KCCQ score of 52.6 (21.0). At week 16, the mean (SE) KCCQ score improved 3.9 (1.3) points in the intervention group vs 2.3 (1.2) in the usual care group (difference, 1.6; SE, 1.7; d = 0.07 [95% CI, -0.09 to 0.24]) and the mean (SE) FACIT-Pal-14 score improved 1.4 (0.6) points in the intervention group vs 0.2 (0.5) points in the usual care group (difference, 1.2; SE, 0.8; d = 0.12 [95% CI, -0.03 to 0.28]). There were no relevant between-group differences in mood (HADS-anxiety, d = -0.02 [95% CI, -0.20 to 0.16]; HADS-depression, d = -0.09 [95% CI, -0.24 to 0.06]).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial with a majority African American sample and baseline good quality of life did not demonstrate improved quality of life or mood with a 16-week early palliative care telehealth intervention. However, pain intensity and interference (secondary outcomes) demonstrated a clinically important improvement.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

Cultural Adaptation and Open Pilot of Meaning-Centered Psychotherapy for Puerto Rican Patients with Advanced Cancer

In Puerto Rico, cancer incidence increases significantly, and is accompanied with a greater risk of experiencing high levels of depressive symptoms, emotional distress, and reduced quality of life when compared to other minority ethnic groups. Studies suggest that interventions to attend distress in Latino patient population would benefit from including components that seek to improve patients' spiritual well-being. The purpose of this study is to identify the level of comprehension and acceptance of Meaning-Centered Psychotherapy (MCP) concepts. A mixed method design was conducted with in-depth interviews and open pilot data. A total of nine participants with advanced or metastatic cancer were sampled from an Oncology Clinic in the south of Puerto Rico. Six semi-structured interviews and six ethnographic notes with audiotape sessions were selected and transcribed. All material was analyzed, resulting in a sample of six semi-structured interview and six ethnographic note peer sessions. Patients showed low comprehension of the MCP concepts of meaning, the finite, and legacy. Patients showed low acceptance of death and its related concepts. They also reported high acceptance of integrating family members to their therapy. In order to tailor the intervention and improve comprehension, the content should include examples, shorter questions, and brief definitions. Additionally, there is a need to address death and its related concepts in end of life.

Follow the trail: Using insights from the growth of palliative care to propose a roadmap for cancer rehabilitation

Despite research explicating the benefits of cancer rehabilitation interventions to optimize physical, social, emotional, and vocational functioning, many reports document low rates of referral to and uptake of rehabilitation in oncology. Cancer rehabilitation clinicians, researchers, and policy makers could learn from the multidisciplinary specialty of palliative care, which has benefited from a growth strategy and has garnered national recognition as an important and necessary aspect of oncology care. The purpose of this article is to explore the actions that have increased the uptake and integration of palliative care to yield insights and multimodal strategies for the development and growth of cancer rehabilitation. After examining the history of palliative care and its growth, the authors highlight 5 key strategies that may benefit the field of cancer rehabilitation: 1) stimulating the science in specific gap areas; 2) creating clinical practice guidelines; 3) building clinical capacity; 4) ascertaining and responding to public opinion; and 5) advocating for public policy change. Coordinated and simultaneous advances on these 5 strategies may catalyze the growth, utilization, and effectiveness of patient screening, timely referrals, and delivery of appropriate cancer rehabilitation care that reduces disability and improves quality of life for cancer survivors who need these services.

Validation of the Brief Edinburgh Depression Scale (BEDS) in a Mexican population with advanced cancer in a palliative care service

OBJECTIVE

Depression in palliative advanced cancer patients is common, but often goes unrecognized. One of the first steps toward improving detection is the development of tools that are valid in the specific language and setting in which they are to be used. The Brief Edinburgh Depression Scale (BEDS) is a sensitive case-finding tool for depression in advanced cancer patients that was developed in the United Kingdom. There are no validated instruments to identify depression in Mexican palliative patients. Our aim was to validate the Spanish-language version of the BEDS in Mexican population with advanced cancer.

METHOD

We conducted a cross-sectional study with outpatients from the palliative care unit at the Instituto Nacional de Cancerología in Mexico City. The Mexican BEDS was validated against a semistructured psychiatric clinical interview according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, classification criteria for major depressive disorder. The interviewer was blind to the BEDS score at the time of the assessment.

RESULT

Seventy subjects completed the scale and interview. Women represented 71.4% of the sample and median age of subjects was 56.5 years (range, 20-85 years). The prevalence of major depressive disorder according to the psychiatric interview was 20%. The most valid cutoff for defining a case of depression was a score ≥5 of 18 on the Mexican BEDS, which gave a sensitivity of 85.7% and specificity of 62.5%. The scale's Cronbach's alpha was 0.71.

SIGNIFICANCE OF RESULTS

Major depressive disorder is frequent in Mexican palliative patients. The Spanish-language Mexican version of the BEDS is the first valid case-finding tool in advanced cancer patients in this setting.