Concordant palliative care delivery in advanced head and neck cancer

OBJECTIVES

To describe the palliative care consultation practices in an academic head and neck surgery practice.

METHODS

This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period.

RESULTS

Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH.

CONCLUSION

Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.

Learnings From Longitudinal Patient-Reported and Clinical Outcomes in Palliative Head and Neck Cancer Care

OBJECTIVE

Patients with palliative head and neck cancer experience many symptoms in a short period of time. Longitudinal data on patient-reported outcomes in this phase are lacking. The aim of this study is to use structurally obtained patient-reported outcome data combined with clinical patient data and obtain insight in patient-reported outcomes, survival, circumstances of death, and interventions and treatment during the palliative phase in order to improve the quality of end-of-life care and patient-centered counseling.

STUDY DESIGN

Longitudinal observational cohort study.

SETTING

Tertiary cancer center.

METHOD

Quality of life was prospectively collected using the European Organization for Research and Treatment of Cancer QLQ-C15-PAL. Tumor- and patient-specific data were retrospectively collected. Descriptive statistics, linear mixed models, and regression analyses were performed.

RESULTS

A significant deterioration was found in global health status, physical functioning, fatigue, dyspnea, appetite loss, and constipation over time. However, emotional functioning improved. Median survival was 5.1 months, and only a low percentage of in-hospital death was observed (7.8%). Higher global health status at intake was associated with prolonged survival.

CONCLUSION

Structural measurement of patient-reported outcome together with clinical outcomes provides unique insight, which enables improvement of patient-centered counseling and care.

The unmet needs of patients with advanced incurable head and neck cancer and their carers: A systematic review and meta-ethnography of qualitative data

INTRODUCTION

Patients with advanced-stage head and neck cancers (HNC) endure a significant symptom burden and suffer greatly towards the end of their lives. Qualitative evidence can provide insight into how existing services meet their needs. We aimed to synthesise qualitative data from patients with advanced HNC and their carers to inform improvements to services and care.

METHODS

A systematic search was conducted in MEDLINE and EMBASE for studies containing qualitative data from patients with advanced HNC and their carers. An interpretive account was generated using the meta-ethnography methodology.

RESULTS

We identified 8 studies including 38 patients and 25 carers. Twenty-six themes were synthesised into five concepts: psychological impact and adjustment, physical limitations and deliverance of symptomatic care, communication and information needs from healthcare professionals, social support and dependence, and needs of the primary caregiver. We identified that patients had complex psychological needs, centred on uncertainty and fear of suffering. Patients desired full information and found poor communication highly distressing. There was a dearth of literature on the subjective impact of physical limitations. Patients became reliant on social networks, and those with lower quality relationships coped poorly. However, caregivers struggled to meet patients' complex needs, resulting in distress and isolation.

CONCLUSIONS

Patients with advanced HNCs have complex needs that are not met in current systems. Further qualitative work focusing on the physical and psychological impact of advanced HNC would be of value.

Needs of Informal Caregivers of Patients With Head and Neck Cancer: A Systematic Review

PROBLEM IDENTIFICATION

Informal caregivers for patients with head and neck cancer perform complex caregiving tasks on a daily basis, but caregivers' needs are rarely acknowledged or addressed in current healthcare practice.

LITERATURE SEARCH

A thorough review of CINAHL®, MEDLINE®/PubMed®, and PsycINFO® was conducted by the authors.

DATA EVALUATION

266 manuscripts were identified, with no time limit. The search was conducted in November 2019. In total, 19 articles were included in the review.

SYNTHESIS

Throughout the disease trajectory, caregivers' psychological and emotional support needs are consistently high, whereas information needs diminish over time.

IMPLICATIONS FOR PRACTICE

Informal caregivers are imperative in supplementing the continuing care demands of people living with head and neck cancer; however, they are at risk for experiencing caregiving burden. Skill training and psychological support interventions are needed for educating and supporting caregivers.

The palliative care needs and experiences of people with advanced head and neck cancer: A scoping review

BACKGROUND

The palliative care needs of people with advanced head and neck cancer pose unique complexities due to the impact the illness has on eating, speaking, appearance and breathing. Examining these needs would help provide guidance about developing relevant models of care and identify gaps in research knowledge.

AIM

To identify and map out the palliative care needs and experiences for people with advanced head and neck cancer.

DESIGN

A scoping literature review following the methods described by the Joanna Briggs Institute.

DATA SOURCES

An electronic search of the literature was undertaken in MEDLINE (Ovid), EMBASE and CINAHL covering the years January 1996 to January 2019.

RESULTS

People with advanced head and neck cancer often had palliative care needs but there was variability in the timing and access to relevant services. A high prevalence of interventions, for example hospital admissions were needed even during the last month of life. This was not necessarily negated with early engagement of palliative care. Dissonance between patients and family carers about information needs and decision-making was an additional complexity. Studies tended to be descriptive in nature, and often involved a single centre.

CONCLUSION

This scoping review demonstrates the complexity of care for people with advanced head and neck cancer and the issues related to the current healthcare systems. Focus on appropriate referral criteria, increased integration and coordination of care and robust evaluation of specific care components seems key. Linkage between research and service design delivery across teams, disciplines and care settings seems pertinent.

Supportive Care Needs of Patients with Head and Neck Cancer Referred to Palliative Medicine

OBJECTIVE

Patients with head and neck cancer (HNC) face a unique set of unmet needs. A subset of these patients experience symptom control challenges related to their disease burden and treatments. A multidisciplinary approach involving palliative medicine is underutilized but crucial to identify and address these concerns. There is limited information on palliative integration with head and neck oncology.

STUDY DESIGN

Case series with planned data collection.

SETTING

Academic quaternary care center.

SUBJECTS AND METHODS

We provide descriptive analyses of patients with HNC, including psychodiagnostic assessment and validated quality-of-life screening, from patients' first encounter at outpatient palliative medicine.

RESULTS

HNC (N = 80) contributed the greatest number of palliative referrals (25%) between 2010 and 2012. This cohort was 74% male and 79% Caucasian with a mean age of 53 years (95% CI, 51.1-54.9) and with stage IV disease of the oral cavity (28%) or oropharynx (31%). Sixty-three percent of patients had no evidence of disease. Seventy-five percent had a psychological history based on DSM-IV criteria (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), and 70% had a history of substance use disorder. The most distressing quality-of-life concerns were pain, housing and financial problems, and xerostomia.

CONCLUSIONS

Patients with HNC who were referred to palliative medicine are burdened by multiple physical, psychological, substance use, and social challenges. We recommend comprehensive cancer-specific screening, such as the James Supportive Care Screening, to triage patients to appropriate supportive care services. Palliative care is one of many services that these patients may need, and it should be utilized at any point of the disease trajectory rather than reserved for end-of-life care.

Volunteers in Palliative Care Make A Difference

Family care giving is important for the quality of life of terminally ill patients and their family members. Although family caregivers are generally eager to provide palliative care, at some point it may become too demanding, and then volunteers can make a difference. This four-study paper presents the experiences of families of terminally ill patients with volunteer support. In four sequential studies, information was gathered from focus groups (n=22), a survey (n=237), individual interviews (n=6), and an Internet panel (n=1,712). The focus groups revealed that volunteers can make the last phase of life less stressful for family caregivers by offering practical and emotional support, and this was confirmed by the survey; however, one improvement is needed: every volunteer support should be concluded with a closing contact. The individual interviews showed that in the end-of-life stage the crucial decision is whether the patient can remain at home, not whether the caregiver needs volunteer support; and in such extreme situations, it is understood that volunteer support must involve more than one volunteer. The Internet panel revealed that in the Netherlands the general public is aware that volunteers can provide palliative care support, but many people don't know how to contact these volunteers. We must find ways to extend volunteer support in palliative care in the Netherlands and elsewhere. We must also study further the experiences of caregivers of terminally ill patients with volunteers and others who provide palliative care.

Measuring the quality of end-of-life care: Development, testing, and cultural validation of the Danish version of Views of Informal Carers' Evaluation of Services-Short Form

BACKGROUND

The perspectives of patients and relatives are important in the improvement of the quality of health care. However, the quality of end-of-life care has not been systematically evaluated in Scandinavia.

AIM

To develop or adapt and subsequently validate a questionnaire assessing the quality of end-of-life care in Denmark. The questionnaire was intended for bereaved relatives in order to assess the quality of care in the last 3 months of the patient's life and the circumstances surrounding death.

DESIGN AND DATA SOURCES

Based on the literature and interviews with 15 bereaved relatives and 17 healthcare professionals, relevant topics to include in a questionnaire were identified. The topics were prioritized by 100 bereaved relatives and subsequently compared to existing questionnaires. The chosen questionnaire was tested by cognitive interviews with 36 bereaved relatives.

RESULTS

Most of the important topics were covered by the Views of Informal Carers' Evaluation of Services-Short Form, but not all Danish settings (e.g. home care by a palliative team) were covered. These settings were added to the Views of Informal Carers' Evaluation of Services-Short Form, and a few adaptations were made before a Danish version of the Views of Informal Carers' Evaluation of Services-Short Form was tested by cognitive interviews. This cultural validation showed that the slightly adapted Danish version was perceived as relevant, understandable, and acceptable. Furthermore, the cognitive interviews gave insight in the comprehension and interpretation of Views of Informal Carers' Evaluation of Services-Short Form items.

CONCLUSION

With a few adaptations, the British Views of Informal Carers' Evaluation of Services-Short Form was relevant in a Danish setting.

End-of-life care for head and neck cancer patients: a population-based study

PURPOSE

Head and neck cancers (HNCs) usually present a poor prognosis and cause high morbidity rates. Recent surveys have demonstrated that HNC incidence rates are still on the increase in many countries. Our study objective was to assess the end-of-life care for patients with HNCs in Taiwan.

METHODS

Data was retrieved from Taiwan's National Health Insurance Research Database, where we identified patients who had been diagnosed with HNCs from January 1997 to December 2010. Each patient's annual trend of opioid use and hospice care needs, along with the distribution of place of death in the study cohort, were all analyzed.

RESULTS

A total of 98,211 HNC patients diagnosed between 1997 and 2010 were eligible for this study. The majority of HNC patients died in hospital. Patients who were male, lived in capital area, had a higher income, had received palliative hospice care, and had been prescribed opioids tended to choose to die at home or in hospice wards. Both opioid prescription and hospice care have increased during the past 10 years; however, the rate of palliative hospice care remained below 50%.

CONCLUSIONS

Our results demonstrate that greater efforts are needed to implement palliative care for HNC patients in Taiwan.

Analysis of deaths between 2007 and 2012 of patients with cancer of the head and neck on a surgical ward at a regional centre and in an independent hospice

Providing the best care for patients dying from cancer of the head and neck is crucial, and their complex, unpredictable needs, particularly at the end of life, mean that they are likely to die in institutional care. To evaluate the care given at the end of life we retrospectively reviewed the case notes of patients who died between 2007 and 2012 in a regional head and neck unit and a specialist palliative care unit (hospice). Deaths were categorised as sudden (rapid or unanticipated) or expected (gradual or anticipated). A total of 105 patients died, of whom 29 were excluded from analysis because records were missing. Of the remaining 76, 63 died in the head and neck unit and 13 in the hospice. Patients who died the hospice were younger (mean (SD) age 63.7 (11.0) years) than those who died in hospital (mean (SD) age 70.6 (11.9) years). Most had stage III or IV disease (head and neck unit 45/57, 79%, hospice 9/13, 69%). Death was sudden in 33 (43%) and expected in 43 (57%). Haemorrhage was the commonest cause of sudden death (n=13) and carcinomatosis (n=17) the commonest cause of expected death. Specialists in palliative care had been involved in the care of 13 patients who died suddenly (39%) and 34 whose deaths were expected (79%). The family was present at the time of death (or was aware of it) in 30 who died suddenly (91%) and in 40 (93%) whose deaths were expected. In patients with cancer of the head and neck death can be sudden because of unpredictable complications, and everyone should be aware of this.

Measuring Experience With End-of-Life Care: A Systematic Literature Review

CONTEXT

Increasing interest in end-of-life care has resulted in many tools to measure the quality of care. An important outcome measure of end-of-life care is the family members' or caregivers' experiences of care.

OBJECTIVES

To evaluate the instruments currently in use to inform next steps for research and policy in this area.

METHODS

We conducted a systematic review of PubMed, PsycINFO, and PsycTESTS(®) for all English-language articles published after 1990 using instruments to measure adult patient, family, or informal caregiver experiences with end-of-life care. Survey items were abstracted and categorized into content areas identified through an iterative method using three independent reviewers. We also abstracted information from the most frequently used surveys about the identification of proxy respondents for after-death surveys, the timing and method of survey administration, and the health care setting being assessed.

RESULTS

We identified 88 articles containing 51 unique surveys with available content. We characterized 14 content areas variably present across the 51 surveys. Information and care planning, provider care, symptom management, and overall experience were the most frequent areas addressed. There was also considerable variation across the surveys in the identification of proxy respondents, the timing of survey administration, and in the health care settings and services being evaluated.

CONCLUSION

This review identified several comprehensive surveys aimed at measuring the experiences of end-of-life care, covering a variety of content areas and practical issues for survey administration. Future work should focus on standardizing surveys and administration methods so that experiences of care can be reliably measured and compared across care settings.

Place and time of death in patients treated with palliative intent for oral cancer

Information about place and time of death can help patients, carers, general medical practitioners, and multi-professional teams to put palliation for oral cancer into context, particularly the aspirations of patients about where they die. Aintree Regional Maxillofacial Unit treated 487 consecutive patients for primary oral squamous cell carcinoma between 2006 and 2010. Mortality was ascertained from the Office for National Statistics. A total of 65 (13%) patients were treated with palliative intent, and median (IQR) survival was 4.3 months (2.1-8.0). The most common reasons for palliation were inoperability (33%) and extensive disease associated with serious comorbidity (18%). A total of 22 died in hospital, 14 in a hospice, 14 in their own home, 14 in a nursing, residential, or old people's home, and one elsewhere. Most patients given palliative care do not die in hospital and survival is short. Their needs and those of their carers can be better met through integrated care that is linked to the primary sector.

Experience of palliative care for patients with head and neck cancer through the eyes of next of kin: impact of an Expert Center

BACKGROUND

Literature is scarce on the palliative care experiences of patients with head and neck cancer. We report our experience in this patient population after the establishment of our Expert Center.

METHODS

We administered a questionnaire to 40 surviving relatives of patients with head and neck cancer after the establishment of our Expert Center and compared the results to a similar group of patients with head and neck cancer before the establishment of our Expert Center.

RESULTS

Since the establishment of our Expert Center, we found: an improved evaluation of the psychosocial support offered; better contact between head and neck surgeons, the patients, and families; and improvement in the quantity of information in the palliative phase. Some relatives, however, reported that patients received treatment against their wishes and life was not made as comfortable as possible.

CONCLUSION

Important aspects of palliative care, such as psychosocial support and contact between patient and surgeon, have been improved since the establishment of our Expert Center.

Symptoms of patients with incurable head and neck cancer: prevalence and impact on daily functioning

BACKGROUND

There is lack of research on symptoms in patients with head and neck cancer in the palliative phase. The aim of this study was to explore symptom prevalence and the impact of these symptoms on daily functioning in patients with incurable head and neck cancer. Also, discrepancies between patients and family caregivers are described.

METHODS

Questionnaires were used to collect data about symptom prevalence (n = 124) and symptom impact (n = 24).

RESULTS

We discovered that the symptoms with a high prevalence were fatigue, pain, weakness, trouble with short walks outside, and dysphagia. The symptoms with the greatest impact on daily functioning were dyspnea, voice changes, trouble with short walks outside, anger, and weakness.

CONCLUSIONS

Patients with incurable head and neck cancer experience a great number of different symptoms. Focus on these symptoms by health care professionals could further optimize symptom management. In future research, we recommend further validation of the used questionnaires.

End-of-life care among head and neck cancer patients

OBJECTIVE

This study is designed to (1) determine the perceived quality of care received by patients with head and neck cancer at the end of their lives, in order to (2) better anticipate and improve upon the experiences of future patients.

STUDY DESIGN

Cross-sectional survey.

SETTING

Single-institution, academic tertiary care medical center.

SUBJECTS AND METHODS

A validated survey instrument, the Family Assessment of Treatment at the End of life (FATE), was administered to families of patients who died of head and neck cancer (n = 58). The primary outcome was the overall FATE score. Independent variables included clinical characteristics, treatments received, and the care provided at the time of death.

RESULTS

Overall FATE scores and the domains assessing management of symptoms and care at the time of death did not vary by disease status (logoregional vs distant metastasis) at the end of life (P = .989). The location of death in the home or in hospice (vs hospital) significantly improves scores in all 3 categories (P = .023). Involvement of a palliative care team improved the care at the time of death (P < .001), and palliative treatments (radiation and/or chemotherapy) improved scores in managing symptoms and care at the time of death (P = .011, P = .017).

CONCLUSION

The FATE survey is a useful measure of the end-of-life experience of head and neck cancer patients. Palliative treatments of head and neck cancer, death outside of the hospital, and palliative care team involvement all improve the end-of-life experience in this population.

The influence of nursing in head and neck cancer management

PURPOSE OF REVIEW

Nurses can play an essential role in the treatment of head and neck cancer and the care of patients and their families. The role and influence of nursing is dependent on available evidence to fulfill that role and on the sociopolitical and organizational factors that shape the context for nursing and interdisciplinary practice.

RECENT FINDINGS

Nurses influence treatment for head and neck cancer through symptom management and tobacco cessation to improve quality of life and patient-reported outcomes. Nurses and interdisciplinary teams in the United States and Europe report successful, novel nurse-led care models that optimize influence on management.

SUMMARY

Current research suggests that nurses can influence head and neck cancer treatment through emphasis on symptom management, tobacco and alcohol cessation, and on patient and family education and care coordination. Nonetheless, evidence for practice remains scant. Only continued research, employing qualitative and quantitative approaches, conducted by nurse and interdisciplinary investigator teams will advance head and neck cancer management and optimize influence of nursing within it. Novel models for nursing care that are well fit into the organizations and society in which care is delivered may further improve care and patient outcomes. Evaluation of such models is further required to document improvements.