The research palliative care unit

[Treatment of non-painful symptoms in terminally ill children]

The care of children at the end of life is gradually improving. Nevertheless, more than half suffer from intractable symptoms before dying. Although pain has been the subject of clinical research, evidence-based data are almost completely lacking for other symptoms, highlighting the need for clinical research in palliative care. We review the available evidence on fatigue, anorexia, dyspnea, respiratory secretions, cough, constipation, mouth dryness, urinary obstruction, terminal convulsions and gasping. When evidence is lacking, we offer our empiric approach. Short duration benzodiazepines have become an important component of treatment that should remain simple, while providing the dying child the comfort needed to experience the highest quality relationships with those around him.

Place of death and its predictors for local patients registered at a comprehensive cancer center

PURPOSE

To help with planning of a palliative care program, we reviewed the place of death of patients who were registered at our comprehensive cancer center and explored factors that predicted death in the hospital versus death at home.

PATIENTS AND METHODS

A retrospective study was undertaken of local patients who were registered at the University of Texas M.D. Anderson Cancer Center and died during the 1997/1998 fiscal year. Data from the institutional tumor registry and from the State of Texas Bureau of Vital Statistics file were collected and analyzed. The main outcome measures were place of death, patient characteristics associated with place of death, and time from registration at the institution to death.

RESULTS

Of 1,793 local patients, 251 (14%) died at M.D. Anderson Cancer Center; the remaining 86% died elsewhere. A total of 617 (34%) died at home, and 929 (52%) died in an acute hospital setting (including M.D. Anderson). A total of 1,040 (58%) died within 2 years of registration. The risk of hospital death versus home death increased for patients with cancer at a hematologic site (odds ratio [OR], 4.4; 95% confidence interval [CI], 2.8 to 6.8) and black ethnicity (OR, 1.9; 95% CI, 1.4 to 2.6) and decreased for patients who paid with Medicare (OR, 0.71; 95% CI, 0.57 to 0.90).

CONCLUSION

Most patients died in an acute care hospital setting and within 2 years of registration. Our data show some predictors of hospital death for cancer patients and suggest that better hospital palliative care services and integrated palliative care systems that bridge community and acute hospitals are needed.

Time spent in hospital in the last six months of life in patients who died of cancer in Ontario

PURPOSE

To describe hospital bed utilization in the final 6 months of life in patients dying of cancer in Ontario, Canada.

PATIENTS AND METHODS

Hospital separation records were linked to a population-based cancer registry to identify factors associated with hospitalization in the 203,713 patients who died of cancer in Ontario between 1986 and 1998.

RESULTS

Between 1986 and 1998, 5.3% of all acute care beds in Ontario were devoted to the care of cancer patients in the last 6 months of life. The mean time spent in hospital in the last 6 months of life decreased from 34.3 days in 1986 to 22.7 days in 1998. Hospitalization rates increased exponentially during the last month of life. Patients younger than 50 years of age, women, and residents of poorer communities spent significantly longer in hospital than others. Hospitalization rates differed very little among the common solid tumors, but patients with CNS malignancies, the lymphomas, and the leukemias spent significantly longer in hospital than the other groups. There was significant interregional variations in hospitalization that were not explained by differences in case mix. There was a statistically significant inverse correlation between the rate of use of palliative radiotherapy and the hospital bed use in the county in which the patient resided.

CONCLUSION

The total time spent in hospital in the last 6 months of life has decreased over the last decade, but acute care hospitals continue to play a large role in the care of patients who are dying of cancer.

Clinical research in palliative care: choice of trial design

Prospective controlled clinical trials provide the highest level of evidence in palliative care. Both parallel and crossover studies have unique advantages and disadvantages. Excellent knowledge of the patient population, interventions and endpoints are useful in choosing the most appropriate trial. Open pilot studies can assist the investigator in understanding the intervention and measurement tools better before embarking in costly and lengthy controlled trials. More controlled clinical trails are need to generate the evidence that will advance patient management in palliative care.

Clinical research in palliative care: patient populations, symptoms, interventions and endpoints

Clinical trials in palliative care involve multiple issues relating to patient populations, interventions and endpoints. Careful data collection and analysis of variables are vital for good clinical research in this complex area.