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Lion KM, Jamieson A, Billin A, Jones S, Pinkham MB, Ownsworth T. 'It was never about me': A qualitative inquiry into the experiences of psychological support and perceived support needs of family caregivers of people with high-grade glioma. Palliat Med 2024:2692163241261211. [PMID: 38916277 DOI: 10.1177/02692163241261211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
BACKGROUND Family caregivers of people with high-grade glioma often report high rates of psychological distress, which has been attributed to the unique aspects of the disease and onerous care demands. Clinical practice guidelines advocate for caregiver support from diagnosis through to end-of-life and bereavement. Yet, research has identified that caregivers' support needs are often overlooked. AIM To explore caregivers' experiences of psychological support and perceptions of what constitutes optimal psychological support for caregivers in the context of high-grade glioma. DESIGN Qualitative study involving semi-structured interviews with data analysed using reflexive thematic analysis. SETTING/PARTICIPANTS Eighteen current (n = 11) and bereaved (n = 7) family caregivers (73% female, aged 33-69 years) of adults with high-grade glioma participated. Interviews explored caregivers' perceptions of psychological support. RESULTS Two major themes were generated. The first theme, 'It was never about me', reflected caregivers prioritise for people with high-grade glioma to be well supported despite experiencing their own unmet psychological support needs. The second theme, 'Continuous, coordinated and personalised support', highlighted the importance of timely and tailored interventions addressing caregivers' practical, educational and emotional support needs throughout the illness journey. CONCLUSIONS Caregivers commonly prioritise the support needs of people with high-grade gliomas; yet, have their own distinct needs that vary throughout the illness. Primary care providers have a potential role in facilitating timely access to palliative care, practical support and brain tumour-specific psychological support to meet caregivers' diverse needs across the care continuum in the context of high-grade glioma.
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Affiliation(s)
- Katarzyna M Lion
- School of Applied Psychology, Griffith University, Brisbane, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Anthony Jamieson
- School of Applied Psychology, Griffith University, Brisbane, QLD, Australia
| | - Abigail Billin
- School of Applied Psychology, Griffith University, Brisbane, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Stephanie Jones
- School of Applied Psychology, Griffith University, Brisbane, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Mark B Pinkham
- School of Medicine, University of Queensland, Saint Lucia, QLD, Australia
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Tamara Ownsworth
- School of Applied Psychology, Griffith University, Brisbane, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
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Soeda R, Ishikawa A, Oyamada S, Mitsuhashi M, Okano S, Yokosawa A, Okutsu T, Tsuji T. Trajectories of Activities of Daily Living in the Last Eight Weeks of Life Among Patients With Terminal Cancer in a Palliative Care Unit: A Retrospective Study. Palliat Med Rep 2024; 5:63-69. [PMID: 38406210 PMCID: PMC10890944 DOI: 10.1089/pmr.2023.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 02/27/2024] Open
Abstract
Background Although cancer patients' activities of daily living (ADL) are reported to decline before death, ADL trajectories have not been sufficiently clarified due to limitations in the assessment and analysis methods. Objectives To clarify the multiple trajectories of ADL in patients with terminal cancer using a comprehensive assessment measure. Design This was a retrospective observational study. Setting/Study Subjects Cancer patients aged ≥18 years discharged at death from a single-center palliative care unit. Measurements Functional Independence Measure (FIM) total scores for eight weeks retrospectively. Results In total, 306 patients were analyzed. Group-based trajectory modeling analysis estimated four groups as the best model for the FIM trajectory over eight weeks using the following trajectories: (1) a No Decline group, in which ADL did not decline until just before death; (2) a Rapid Decline group, in which ADL declined rapidly two weeks before death from a trajectory similar to the No Decline group; (3) a Moderate Disability and Slow Decline group, in which the patient slowly declined from requiring mild-to-severe assistance; and (4) a Severe Disability group, in which the patient continuously required severe assistance. Conclusions Multiple ADL trajectories were identified in the last eight weeks of life of patients with terminal cancer. These findings suggest that palliative care needs to be tailored to the characteristics of each patient.
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Affiliation(s)
- Ryo Soeda
- Department of Rehabilitation, Tsurumaki-Onsen Hospital, Hadano, Kanagawa, Japan
- Department of Rehabilitation Medicine, Keio University Graduate School, Shinjuku, Tokyo, Japan
| | - Aiko Ishikawa
- Department of Rehabilitation Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Shunsuke Oyamada
- Department of Biostatistics, Japanese Organisation for Research and Treatment of Cancer, Arakawa, Tokyo, Japan
| | | | - Suzune Okano
- Department of Rehabilitation, Tsurumaki-Onsen Hospital, Hadano, Kanagawa, Japan
| | - Aiko Yokosawa
- Department of Rehabilitation, Tsurumaki-Onsen Hospital, Hadano, Kanagawa, Japan
| | | | - Tetsuya Tsuji
- Department of Rehabilitation Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
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Bozzao A, Weber D, Crompton S, Braz G, Csaba D, Dhermain F, Finocchiaro G, Flannery T, Kramm C, Law I, Marucci G, Oliver K, Ostgathe C, Paterra R, Pesce G, Smits M, Soffietti R, Terkola R, Watts C, Costa A, Poortmans P. European Cancer Organisation Essential Requirements for Quality Cancer Care: Adult glioma. J Cancer Policy 2023; 38:100438. [PMID: 37634617 DOI: 10.1016/j.jcpo.2023.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCCs) are explanations of the organisation and actions necessary to provide high-quality care to patients with a specific cancer type. They are compiled by a working group of European experts representing disciplines involved in cancer care, and provide oncology teams, patients, policymakers and managers with an overview of the essential requirements in any healthcare system. The focus here is on adult glioma. Gliomas make up approximately 80% of all primary malignant brain tumours. They are highly diverse and patients can face a unique cognitive, physical and psychosocial burden, so personalised treatments and support are essential. However, management of gliomas is currently very heterogeneous across Europe and there are only few formally-designated comprehensive cancer centres with brain tumour programmes. To address this, the ERQCC glioma expert group proposes frameworks and recommendations for high quality care, from diagnosis to treatment and survivorship. Wherever possible, glioma patients should be treated from diagnosis onwards in high volume neurosurgical or neuro-oncology centres. Multidisciplinary team working and collaboration is essential if patients' length and quality of life are to be optimised.
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Affiliation(s)
- Alessandro Bozzao
- NESMOS (Neurosciences, Mental Health and Sensory Organs) Department, Rome, Italy; School of Medicine and Psychology, "Sapienza" University - Rome, Rome, Italy; European Society of Oncologic Imaging (ESOI), Rome, Italy
| | - Damien Weber
- Paul Scherrer Institute, Center for Proton Therapy, Villigen, Switzerland; European Society for Radiotherapy and Oncology (ESTRO), Villigen, Switzerland
| | | | - Graça Braz
- European Oncology Nursing Society (EONS), Oporto, Portugal; Portuguese Oncology Institute, Outpatient Clinic Department, Oporto, Portugal
| | - Dégi Csaba
- International Psycho-Oncology Society (IPOS), Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Frederic Dhermain
- European Organisation for Research and Treatment of Cancer (EORTC) Brain Tumour Group, Villejuif, France; Head of the Brain Tumor Board, Gustave Roussy University Hospital, Radiation Oncology, Villejuif, France
| | - Gaetano Finocchiaro
- Organisation of European Cancer Institutes (OECI), Milano, Italy; IRCCS Ospedale San Raffaele, Department of Neurology, Milano, Italy
| | - Thomas Flannery
- European Cancer Leagues (ECL), Belfast, Ireland; Royal Victoria Hospital Belfast, Department of Neurosurgery, Belfast, Ireland
| | - Christof Kramm
- The European Society for Paediatric Oncology (SIOPE), Goettingen, Germany; University Medical Center Goettingen, Division of Pediatric Hematology and Oncology, Goettingen, Germany
| | - Ian Law
- European Association of Nuclear Medicine (EANM), Copenhagen, Denmark; Rigshospitalet, Dept of Clinical Physiology, Nuclear Medicine & PET, Copenhagen, Denmark
| | - Gianluca Marucci
- European Society of Pathology (ESP), Milan, Italy; European Confederation of Neuropathological Societies (Euro-CNS), Milan, Italy; Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | | | - Rosina Paterra
- Fondazione IRCCS Istituto Neurologico Besta, Milano, Italy
| | - Gianfranco Pesce
- European School of Oncology (ESO), Bellinzona, Switzerland; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Marion Smits
- European Society of Radiology (ESR), Rotterdam, the Netherlands; Erasmus MC, Department of Radiology and Nuclear Medicine, University Hospital Rotterdam, Rotterdam, the Netherlands
| | - Riccardo Soffietti
- European Academy of Neurology (EAN), Turin, Italy; University and City of Health and Science Hospital, Department of Neuro-Oncology, Turin, Italy
| | - Robert Terkola
- European Society of Oncology Pharmacy (ESOP), the Netherlands; University of Groningen, University Medical Centre Groningen, the Netherlands; University of Florida College of Pharmacy, Department of Pharmacotherapy and Translational Research, Gainesville, USA
| | - Colin Watts
- European Association of Neurosurgical Societies, Birmingham, UK; Neurosurgical Oncology Section, Institute of Cancer and Genomic Sciences, Birmingham, UK
| | | | - Philip Poortmans
- European Society for Radiotherapy and Oncology (ESTRO), Antwerp, Belgium; Iridium Netwerk and University of Antwerp, Antwerp, Belgium
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Ullrich A, Goldbach S, Hollburg W, Wagener B, Rommel A, Müller M, Kirsch D, Kopplin-Foertsch K, Schulz H, Bokemeyer C, Oechsle K. Specialist palliative care until the very end of life - reports of family caregivers and the multiprofessional team. BMC Palliat Care 2023; 22:153. [PMID: 37814271 PMCID: PMC10563273 DOI: 10.1186/s12904-023-01266-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/20/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Specialist palliative care (SPC) includes care for incurably ill patients and their family caregivers at home or on a palliative care ward until the very end of life. However, in the last days of life, patients can rarely express their needs and little is known about SPC outcomes as reported by multiprofessional SPC teams and family caregivers. METHODS Using the Palliative Care Outcome Scale (POS; Score 0-40), proxy assessments of SPC outcomes in the patient's last 3 days of life were performed by SPC teams and primary family caregivers of three home care and three inpatient services. Additional questions were asked about problems solved 'particularly well' or 'inadequately' (last 7 days), which were content analyzed and quantified. RESULTS Proxy assessments by SPC teams were available in 142 patients (of whom 51% had died at home). Family caregiver assessments exist for a subgroup of 60 of these patients. SPC teams (POS total score: mean 13.8, SD 6.3) reported SPC outcomes slightly better than family caregivers (mean 16.7, SD 6.8). The POS items consistently rated as least affected (= 0) by both, SPC teams and family caregivers, were 'not wasted time' (team 99%/family caregivers 87%), 'information' (84%/47%) and 'support' (53%/31%). Items rated as most affected (= 4) were 'patient anxiety' (31%/51%), 'life not worthwhile' (26%/35%) and 'no self-worth' (19%/30%). Both groups indicated more problems solved 'particularly well' than 'inadequately'; the latter concerned mainly clinically well-known challenges during end-of-life care and family caregiver care. CONCLUSIONS This study shows the range and type of symptoms and other concerns reported in the patient's last days. Starting points for further improvements in family caregiver care and psychosocial and spiritual issues were identified.
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Affiliation(s)
- Anneke Ullrich
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Eppendorf, Hamburg, Germany.
| | - Sven Goldbach
- Specialist outpatient palliative care team 'PalliativPartner Hamburg GbR', Hamburg, Germany
| | - Wiebke Hollburg
- Specialist outpatient palliative care team 'PalliativPartner Hamburg GbR', Hamburg, Germany
| | - Bettina Wagener
- Specialist outpatient palliative care team 'PalliativPartner Hamburg GbR', Hamburg, Germany
| | - Annette Rommel
- Specialist outpatient palliative care team 'Das Palliativteam', Hamburg, Germany
| | - Marten Müller
- Palliative care ward, Asklepios Hospital Rissen, Hamburg, Germany
| | - Denise Kirsch
- Specialist outpatient palliative care team 'PCT Hamburg-West', Hamburg, Germany
| | | | - Holger Schulz
- Department of Medical Psychology, University Medical Center Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Eppendorf, Hamburg, Germany
| | - Karin Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Eppendorf, Hamburg, Germany
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Liu G, Lam VK. Podcast on Lorlatinib as a First-Line Treatment Option for Patients with ALK-Positive Metastatic NSCLC with Brain Metastasis. Adv Ther 2023; 40:4117-4126. [PMID: 37573276 PMCID: PMC10499938 DOI: 10.1007/s12325-023-02606-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/03/2023] [Indexed: 08/14/2023]
Abstract
Brain metastases are especially common in anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC), with a cumulative incidence of over 50% and associated with a poor prognosis, high symptom burden, and decreased quality of life. Lorlatinib is a brain-penetrant, third-generation ALK tyrosine kinase inhibitor (TKI), which has a high potency against resistance mutations seen with earlier generation ALK TKIs. In 2018, lorlatinib was granted accelerated approval in second- and third-line treatment for use in patients with ALK-positive metastatic NSCLC on the basis of phase 1/2 study results. This initial approval was expanded for first-line treatment of patients with ALK-positive metastatic NSCLC on the basis of the interim analysis of the phase 3 CROWN study showing longer progression-free survival, time to intracranial progression, duration of response, and objective response rate compared with crizotinib. This manuscript is a transcript of our podcast, in which we discuss the clinical significance of controlling the onset of brain metastases, considerations in selecting a first-line therapy option, efficacy and safety observed in patients with and without brain metastases, and rationales for using lorlatinib upfront versus reserving for a later line in therapy.
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Affiliation(s)
- Geoffrey Liu
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Vincent K Lam
- Johns Hopkins Medicine, 201 N. Broadway, Baltimore, MD, 21287, USA.
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6
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Dadhania S, Pakzad-Shahabi L, Mistry S, Williams M. Triaxial accelerometer-measured physical activity and functional behaviours among people with High Grade Glioma: The BrainWear Study. PLoS One 2023; 18:e0285399. [PMID: 37224155 DOI: 10.1371/journal.pone.0285399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 04/17/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND High-grade gliomas (HGG) account for 60-75% of all adult gliomas. The complexity of treatment, recovery and survivorship creates a need for novel monitoring approaches. Accurate assessment of physical function plays a vital role in clinical evaluation. Digital wearable tools could help us address unmet needs by offering unique advantages such as scale, cost and continuous real-world objective data. We present data from 42 patients enrolled into the BrainWear study. METHODS An AX3 accelerometer was worn by patients from diagnosis or at recurrence. Age-, sex-matched UK Biobank control groups were chosen for comparison. RESULTS 80% of data were categorised as high-quality demonstrating acceptability. Remote, passive monitoring identifies moderate activity reduces both during a course of radiotherapy (69 to 16 minutes/day) and at the time of progressive disease assessed by MRI (72 to 52 minutes/day). Mean acceleration (mg) and time spent walking daily (h/day) correlated positively with the global health quality of life and physical functioning scores and inversely with the fatigue score. Healthy controls walked on average 2.91h/day compared to 1.32h/day for the HGG group on weekdays and 0.91h/day on the weekend. The HGG cohort slept for longer on weekends (11.6h/day) than weekdays (11.2h/day) compared to healthy controls (8.9h/day). CONCLUSION Wrist-worn accelerometers are acceptable and longitudinal studies feasible. HGG patients receiving a course of radiotherapy reduce their moderate activity by 4-fold and are at least half as active as healthy controls at baseline. Remote monitoring can provide a more informed and objective understanding of patient activity levels to help optimise health related quality of life (HRQoL) among a patient cohort with an extremely limited lifespan.
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Affiliation(s)
- Seema Dadhania
- Computational Oncology Group, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
- Radiotherapy Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Lillie Pakzad-Shahabi
- Computational Oncology Group, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
- Radiotherapy Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Faculty of Medicine, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Sanjay Mistry
- NIHR Clinical Research Department, Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Matt Williams
- Computational Oncology Group, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
- Radiotherapy Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Faculty of Medicine, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Olvera CE, Levin ME, Fleisher JE. Community-based neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:49-66. [PMID: 36599515 DOI: 10.1016/b978-0-12-824535-4.00001-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Community-based palliative care is defined as palliative care delivered outside of the hospital and outpatient clinics. These settings include the home, nursing homes, day programs, volunteer organizations, and support groups. There is strong evidence outside of the neuropalliative context that community-based palliative care can reduce hospital costs and admissions at the end of life. Research that focuses on specialized community-based palliative care for neurologic disease have similar findings, although with significant variability across conditions and geographic locations. Several of these studies have investigated home-based care for neurologic conditions including dementia, Parkinson's disease, multiple sclerosis, brain tumors, and motor neuron disease. Other work has focused on incorporating palliative care models into the treatment of patients with neurologic diseases within nursing home settings. Similar to nonneurologic community-based palliative care, little has been published on patient and caregiver quality-of-life outcomes in such models of care, although the emerging data are generally positive. Future studies should explore how best to provide comprehensive, cost-effective, scalable, and replicable models of community-based neuropalliative care, patient and caregiver outcomes in such models, and how care can be adapted between and within specific patient populations and healthcare systems.
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Affiliation(s)
- Caroline E Olvera
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States; Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, United States
| | - Melissa E Levin
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States; Chicago Medical School-Rosalind Franklin University, North Chicago, IL, United States
| | - Jori E Fleisher
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States.
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Willert AC, Meyerling J, Ploner CJ, Kowski AB. The First Neuropalliative Care Unit in Germany-Characteristics of Patients. Brain Sci 2022; 12:1498. [PMID: 36358424 PMCID: PMC9688298 DOI: 10.3390/brainsci12111498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 10/08/2023] Open
Abstract
UNLABELLED A unique structure of care for neurological inpatients with significant palliative care (PC) needs was established in the Department of Neurology at the Charité-Universitätsmedizin Berlin in 2021: a specialized neuropalliative care (NPC) unit. After one year, we provide an overview of the concept and the patients' characteristics. METHODS We retrospectively analyzed the characteristics of patients treated in our NPC unit between February 2021-February 2022. Data were extracted from medical records and PC assessment including diagnosis, mode of admission and discharge, length of stay, and palliative symptoms. Data are presented as averages with a 95% confidence interval [lower limit; upper limit] or percentage (absolute number). RESULTS We included 143 patients (52% (75) female, 67.9 years [65.6; 70.2]). Patients were admitted from general wards (48%; 68), their homes (22%; 32), intensive care units (16%; 23) or emergency departments (14%; 20). The main diagnoses were tumors of the nervous system (39%; 56), neurodegenerative diseases (30%; 43), neurologic complications (13%; 19) and cerebrovascular diseases (12%; 17). Complaints most frequently rated as severely to overwhelmingly burdensome were motor- or fatigue-associated problems, problems communicating, dysphagia and pain. The average length of stay was 13.7 days [12.2; 15.2]. Forty-five percent (64) of patients were discharged without further PC, 17% (24) were referred to a hospice and 13% (18) were discharged with outpatient PC. Five percent (7) were referred to neurorehabilitation and 21% (30) of patients died. CONCLUSIONS Our NPC unit is a new model of care for neurological patients with substantial PC needs especially within the structures of a highly specialized and individualized medicine.
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Abstract
Despite the use of aggressive multimodality therapies, the prognosis of brain tumor patients remains poor. Tumors of glial origin typically have the worst prognosis, with a predicted median survival of 12-15months for glioblastoma multiforme (WHO grade IV) and 2-5years for anaplastic glioma (WHO grade III). Palliative care problems and needs in patients with primary and secondary brain tumors are significantly different, both due to different trajectory of disease and to variable prognosis which in metastatic brain tumors is related to the natural history of primary tumors. This chapter describes the complex interactions influencing communication and the treatment decision process in primary brain tumor patients. The whole trajectory of disease and particularly the end-of-life (EOL) phase of brain tumor (BT) patients are quite different in respect to the expected trajectory observed in the general cancer population. The need to improve the communication of prognosis in BT patients has been clearly reported in neuro-oncological literature, but several issues may hinder a good communication in these patients. Adequate prognostic awareness (PA) is important for several reasons: to respect patient autonomy, to obtain her/his preferences about treatments and goal of care, and to share EOL treatment decisions. The high incidence of cognitive deficits in BT patients is one of the most challenging issues influencing the quality of communication and the participation of patients in the process of treatment decisions. Impaired neurocognitive functions may impact capacities of understanding, appreciation, reasoning, and expression of choice, reducing Medical Decisions Capacity (MDC). The lack of capacity to express preferences about EOL treatment decisions represents an important ethical issue, with a great impact on both the patient's family and healthcare professionals involved in the decision processes. Also, patients' coping styles may have an important influence in critical aspects of care such as communication of diagnosis and prognosis, discussion with patients and their caregivers about goal of treatments, early introduction of PC, and advanced planning of patients' preferences concerning EOL treatment and issues. Several barriers hinder good communication in BT patients. This chapter analyzes emerging literature data and possible strategies to improve communication about prognosis and goals of care and to promote patients' involvement in the treatment decision process particularly in the palliative care setting.
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Affiliation(s)
- Andrea Pace
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
| | - Antonio Tanzilli
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Dario Benincasa
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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Dasch B, Lenz P. [The Place of Death of Neurological Patients with Selected Disease Entities: Data from an Observational Study on Places of Death from Germany]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 90:447-455. [PMID: 34844276 DOI: 10.1055/a-1669-9177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND So far, there are only few data on places where neurological patients die in Germany. METHODS In the context of the most comprehensive study on the place of death in Germany to date, the present investigation examined the place of death of neurological patients with selected disease entities (ALS (ALS), malignant neoplasm of the brain (BNG), brain metastasis(es) (HM), hypoxic brain damage after resuscitation (HHS), non-traumatic SAB (SAB), dementia (≥65 years) (DEM)). All death certificates issued in the city of Münster of 2017 were evaluated. Patients were identified on the basis of the medical information on the cause of death. RESULTS A total of 3,844 people died, including neurological patients with the following disease entities: ALS (6), BNG (29), HM (102), HHS (54), SAB (20), DEM (485). The distribution of places of death was as follows: (AS, BNG, HM, HHS, SAB, DEM;%): home 50.0/10.3/13.7/1.9/0.0/12.0; hospital 33.3/48.3/38.2/90.7/100/23.1; intensive care unit 0.0/6.9/5.9/61.1/65.0/2.7; palliative care unit 33.3/0.0/6.9/0.0/0.0/1.4; hospice 16.7/27.6/43.1/0.0/0.0/1.2; nursing home 0.0/13.8/4.9/7.4/0.0/63.7; other places 0.0/0.0/0.0/0.0/0.0/0.0. CONCLUSION The most common place of death of neurological patients with selected disease entities is as follows: ALS>home, malignant brain tumour>hospital, brain metastasis(es)>hospice, hypoxic brain injury after resuscitation>hospital, non-traumatic SAB>hospital, dementia patients (≥65 years)>nursing home.
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Affiliation(s)
- Burkhard Dasch
- Zentrale Einrichtung Palliativmedizin, Universitätsklinikum Münster, Münster, Deutschland
| | - Philipp Lenz
- Zentrale Einrichtung Palliativmedizin, Universitätsklinikum Münster, Münster, Deutschland
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Barbaro M, Blinderman CD, Iwamoto FM, Kreisl TN, Welch MR, Odia Y, Donovan LE, Joanta-Gomez AE, Evans KA, Lassman AB. Causes of Death and End-of-Life Care in Patients With Intracranial High-Grade Gliomas: A Retrospective Observational Study. Neurology 2021; 98:e260-e266. [PMID: 34795049 PMCID: PMC8792811 DOI: 10.1212/wnl.0000000000013057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/05/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To understand patterns of care and circumstances surrounding end of life in patients with intracranial gliomas. METHODS We retrospectively analyzed end-of-life circumstances in patients with intracranial high-grade gliomas at Columbia University Irving Medical Center who died from January 2014 through February 2019, including cause of death, location of death, and implementation of comfort measures and resuscitative efforts. RESULTS There were 152 patients (95 men, 57 women; median age at death 61.5 years, range 24-87 years) who died from 1/2014-2/2019 with adequate data surrounding end-of-life circumstances. Clinical tumor progression (n=117, 77.0%) was the most common cause of death with all patients transitioned to comfort measures. Other causes included, but were not limited to, infection (19, 12.5%); intratumoral hemorrhage (5, 3.3%); seizures (8, 5.3%); cerebral edema (4, 2.6%); pulmonary embolism (4, 2.6%); autonomic failure (2, 1.3%); and hemorrhagic shock (2, 1.3%). Multiple mortal events were identified in 10 (8.5%). Seventy-three patients (48.0%) died at home with hospice. Other locations were inpatient hospice (40, 26.3%); acute care hospital (34, 22.4%) including 27 (17.8%) with and 7 (4.6%) without comfort measures; skilled nursing facility (4, 3.3%) including 3 (2.0%) with and 1 (0.7%) without comfort measures; or religious facility (1, 0.7%) with comfort measures. Acute cardiac and/or pulmonary resuscitation was performed in 20 patients (13.2%). DISCUSSION Clinical tumor progression was the most common (77.0%) cause of death followed by infection (12.5%). Hospice or comfort measures were ultimately implemented in 94.7% of patients, though resuscitation was performed in 13.2%. Improved understanding of circumstances surrounding death, frequency of use of hospice services, and frequency of resuscitative efforts in patients with gliomas may allow physicians to more accurately discuss end-of-life expectations with patients and caregivers, facilitating informed care planning.
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Affiliation(s)
- Marissa Barbaro
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Perlmutter Cancer Center at NYU Langone Hematology Oncology Associates-Mineola, NYU Long Island School of Medicine, NYU Langone Health, Mineola, NY, USA
| | - Craig D Blinderman
- Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Division of Hematology/Oncology, Palliative Care Service Section, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Fabio M Iwamoto
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Teri N Kreisl
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Novartis AG, East Hanover, NJ, USA
| | - Mary R Welch
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Yazmin Odia
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Laura E Donovan
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,James J. Peters Department of Veterans Affairs Medical Center
| | - Adela E Joanta-Gomez
- Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Katharine A Evans
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA.,Montefiore Health System, New York, NY, USA
| | - Andrew B Lassman
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA .,Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY, USA
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12
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Palliative Care in Primary and Metastatic Brain Tumors. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.863385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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13
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Willert AC, Ploner CJ, Kowski AB. Causes for Emergency Hospitalization of Neurological Patients With Palliative Care Needs. Front Neurol 2021; 12:674114. [PMID: 34408720 PMCID: PMC8365085 DOI: 10.3389/fneur.2021.674114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/01/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Acute and unexpected hospitalization can cause serious distress, particularly in patients with palliative care needs. Nevertheless, the majority of neurological inpatients receiving palliative care are admitted via an emergency department. Objective: Identification of potentially avoidable causes leading to acute hospitalization of patients with neurological disorders or neurological symptoms requiring palliative care. Methods: Retrospective analysis of medical records of all patients who were admitted via the emergency department and received palliative care in a neurological ward later on (n = 130). Results: The main reasons for acute admission were epileptic seizures (22%), gait disorders (22%), disturbance of consciousness (20%), pain (17%), nutritional problems (17%), or paresis (14%). Possible therapy limitations, (non)existence of a patient decree, or healthcare proxy was documented in only 31%. Primary diagnoses were neoplastic (49%), neurodegenerative (30%), or cerebrovascular (18%) diseases. Fifty-nine percent were directly admitted to a neurological ward; 25% needed intensive care. On average, it took 24 h until the palliative care team was involved. In contrast to initially documented problems, key challenges identified by palliative care assessment were psychosocial problems. For 40% of all cases, a specialized palliative care could be organized. Conclusion: Admissions were mainly triggered by acute events. Documentation of the palliative situation and treatment limitations may help to prevent unnecessary hospitalization. Although patients present with a complex symptom burden, emergency department assessment is not able to fully address multidimensionality, especially concerning psychosocial problems. Prospective investigations should develop short screening tools to identify palliative care needs of neurological patients already in the emergency department.
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Affiliation(s)
| | - Christoph J Ploner
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander B Kowski
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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14
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Biomimetic and cell-based nanocarriers - New strategies for brain tumor targeting. J Control Release 2021; 337:482-493. [PMID: 34352316 DOI: 10.1016/j.jconrel.2021.07.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 12/16/2022]
Abstract
In the last two decades no significant advances were achieved in the treatment of the most frequent and malignant types of brain tumors. The main difficulties in achieving progress are related to the incapacity to deliver drugs in therapeutic amounts into the central nervous system and the associated severe side effects. Indeed, to obtain effective treatments, the drugs should be able to cross the intended biological barriers and not being inactivated before reaching the specific therapeutic target. To overcome these challenges the development of synthetic nanocarriers has been widely explored for brain tumor treatment but unfortunately with no clinical translation until date. The use of cell-derived nanocarriers or biomimetic nanocarriers has been studied in the last few years, considering their innate bio-interfacing properties. The ability to carry therapeutic agents and a higher selectivity towards brain tumors would bring new hope for the development of safe and effective treatments. In this review, we explore the biological barriers that need to be crossed for effective delivery in brain tumors, and the types and properties of cell-based nanocarriers (extracellular vesicles and cell-membrane coated nanocarriers) currently under investigation.
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15
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Crooms RC, Lin HM, Neifert S, Deiner SG, Brallier JW, Goldstein NE, Gal JS, Gelfman LP. Palliative Care Consultation for Hospitalized Patients with Primary and Secondary Brain Tumors at a Single Academic Center. J Palliat Med 2021; 24:1550-1554. [PMID: 34166114 DOI: 10.1089/jpm.2021.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Studies addressing palliative care delivery in neuro-oncology are limited. Objectives: To compare inpatients with brain tumors who received palliative care (through referral or trigger) with those receiving usual care. Design: Retrospective cohort study. Setting/Subjects: Inpatients with primary or secondary brain tumors who did or did not receive palliative care at a U.S. medical center. Measurements: Sociodemographic, clinical, and utilization characteristics were compared. Results: Of 1669 brain tumor patients, 386 (23.1%) received palliative care [nontrigger: 246 (14.7%); trigger: 140 (8.4%)] and 1283 (76.9%) received usual care. Nontrigger patients were oldest (mean age 65.0 years; trigger: 61.1 years; usual care: 55.5 years; p < 0.001); sickest at baseline (mean Elixhauser comorbidity index 3.76; trigger: 3.49; usual care: 1.84; p < 0.001); and had highest in-hospital death [34 (13.8%), trigger: 10 (7.1%), usual care: 7 (0.5%); p < 0.001] and hospice discharge [54 (22.0%), trigger: 18 (12.9%), usual care: 14 (1.1%); p < 0.001]. Conclusions: Trigger criteria may promote earlier palliative care referral, yet criteria tailored for neuro-oncology are undeveloped.
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Affiliation(s)
- Rita C Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hung-Mo Lin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Neifert
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stacie G Deiner
- Dartmouth Hitchcock and Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Jess W Brallier
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jonathan S Gal
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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16
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Price M, Howell EP, Dalton T, Ramirez L, Howell C, Williamson T, Fecci PE, Anders CK, Check DK, Kamal AH, Goodwin CR. Inpatient palliative care utilization for patients with brain metastases. Neurooncol Pract 2021; 8:441-450. [PMID: 34277022 DOI: 10.1093/nop/npab016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients. Methods We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults. Results We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001). Conclusions In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.
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Affiliation(s)
- Meghan Price
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth P Howell
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tara Dalton
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ramirez
- Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, North Carolina, USA
| | - Claire Howell
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Theresa Williamson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Carey K Anders
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Devon K Check
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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17
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Forst DA. Palliative and Supportive Care in Neuro-oncology. ACTA ACUST UNITED AC 2020; 26:1673-1685. [PMID: 33273177 DOI: 10.1212/con.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the supportive care needs of patients with primary brain tumors and their caregivers, outlines the management of selected common symptoms of patients with brain tumors, and describes challenges and opportunities in providing palliative care for this population. RECENT FINDINGS Patients with primary malignant brain tumors generally have a poor prognosis and experience progressive neurologic decline and significant physical and psychological symptoms. Management of these symptoms, including fatigue, mood disorders, and the manifestations of cerebral edema, can be challenging. Caregivers for these patients have high rates of psychological distress and report significant caregiving burden. Although the benefit of early palliative care for patients with other advanced solid tumors is well established, our understanding of the role of palliative care in neuro-oncology is incomplete, and thus palliative care and hospice services remain underutilized. SUMMARY Patients with brain tumors and their caregivers have significant supportive care needs, which often differ from the needs of patients with cancers outside of the nervous system. Clinicians face challenges associated with managing patients' symptoms and adequately facilitating prognostic understanding and decision making. Palliative care and hospice services may offer important benefits for this population.
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18
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Eggen AC, Reyners AKL, Shen G, Bosma I, Jalving M, Leighl NB, Liu G, Richard NM, Mah K, Shultz DB, Edelstein K, Rodin G. Death Anxiety in Patients With Metastatic Non-Small Cell Lung Cancer With and Without Brain Metastases. J Pain Symptom Manage 2020; 60:422-429.e1. [PMID: 32145337 DOI: 10.1016/j.jpainsymman.2020.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/20/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Death anxiety is common in patients with metastatic cancer, but its relationship to brain metastases and cognitive decline is unknown. Early identification of death anxiety and its determinants allows proactive interventions to be offered to those in need. OBJECTIVES To identify psychological, physical, and disease-related (including brain metastases and cognitive impairment) factors associated with death anxiety in metastatic non-small cell lung cancer (mNSCLC) patients. METHODS A cross-sectional pilot study with mNSCLC outpatients completing standardized neuropsychological tests and validated questionnaires measuring death anxiety, cognitive concerns, illness intrusiveness, depression, demoralization, self-esteem, and common cancer symptoms. We constructed a composite for objective cognitive function (mean neuropsychological tests z-scores). RESULTS Study measures were completed by 78 patients (50% females; median age 62 years [range 37-82]). Median time since mNSCLC diagnosis was 11 months (range 0-89); 53% had brain metastases. At least moderate death anxiety was reported by 43% (n = 33). Objective cognitive impairment was present in 41% (n = 32) and perceived cognitive impairment in 27% (n = 21). Death anxiety, objective, and perceived cognitive impairment did not significantly differ between patients with and without brain metastases. In univariate analysis, death anxiety was associated with demoralization, depression, self-esteem, illness intrusiveness, common physical cancer symptoms, and perceived cognitive impairment. In multivariate analysis, demoralization (P < 0.001) and illness intrusiveness (P = 0.001) were associated with death anxiety. CONCLUSION Death anxiety and brain metastases are common in patients with mNSCLC but not necessarily linked. The association of death anxiety with both demoralization and illness intrusiveness highlights the importance of integrated psychological and symptom management. Further research is needed on the psychological impact of brain metastases.
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Affiliation(s)
- Annemarie C Eggen
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Anna K L Reyners
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Gerald Shen
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Ingeborg Bosma
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mathilde Jalving
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Natasha B Leighl
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Geoffrey Liu
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Nadine M Richard
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - David B Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Kim Edelstein
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
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Abstract
PURPOSE OF REVIEW The concept of palliative care is becoming increasingly important in the management of glioma patients. However, the right time for implementation, as well as the individual degree of integration of palliative care aspects, are still a matter of debate. This review updates recent evidence of palliative care in glioma and raises questions for future developments. RECENT FINDINGS According to the disease-specific aspects of palliative care in glioma management, there is an increasing need for a specialized 'neurooncological' palliative care approach.The implementation of palliative care for glioma patients and caregivers avoids unnecessary hospitalization and reduces health-related costs. Moreover, palliative care may be offered in different settings (inpatient/outpatient) according to local health structures, but definitely improves the QOL of glioma patients and their caregivers. SUMMARY There are considerable differences between countries with respect to palliative care in glioma. Major aspects of good-quality care throughout the countries are optimized symptom control, support for patients and proxies by an interdisciplinary team and to provide realistic information to patients and caregivers. The availability of neurooncological palliative teams and multidisciplinary support programs increases well being of glioma patients and caregivers as well as releases pressure on healthcare systems.
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20
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Caregivers of Patients With Brain Metastases: A Description of Caregiving Responsibilities and Psychosocial Well-being. J Neurosci Nurs 2020; 52:112-116. [PMID: 32175992 DOI: 10.1097/jnn.0000000000000500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND There are increasing numbers of cancer patients with brain metastases, and there is a high potential for caregiving burden. Little work has explored caregiving responsibilities and psychosocial well-being in informal family caregivers (FCGs) of cancer patients with brain metastases. This study aimed to address this gap in the literature. METHODS Data were drawn from baseline pilot study data. Caregivers completed demographic information and provided a self-report of their caring responsibilities and psychosocial well-being via questionnaire. RESULTS Participants were 21 FCGs of patients with brain metastases. Many caregivers are devoting extensive time to providing care; there was high variability in the number and types of caregiving activities reported. Although many caregivers report feeling well supported, other aspects of psychosocial well-being were less robust, including anxiety, depression, burden, and coping self-efficacy. CONCLUSION Although FCGs reported mitigating factors such as social support, they still experience significant distress. Findings support previous work suggesting that neuro-oncology caregiving is burdensome, with adverse effects on health and well-being. Foundational work, such as this, will set the stage to identify areas for future intervention.
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21
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Golla H, Nettekoven C, Bausewein C, Tonn JC, Thon N, Feddersen B, Schnell O, Böhlke C, Becker G, Rolke R, Clusmann H, Herrlinger U, Radbruch L, Vatter H, Güresir E, Stock S, Müller D, Civello D, Papachristou I, Hellmich M, Hamacher S, Voltz R, Goldbrunner R. Effect of early palliative care for patients with glioblastoma (EPCOG): a randomised phase III clinical trial protocol. BMJ Open 2020; 10:e034378. [PMID: 31915175 PMCID: PMC6955518 DOI: 10.1136/bmjopen-2019-034378] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION: Randomised controlled trials (RCTs) have shown a positive effect of early integration of palliative care (EIPC) in various advanced cancer entities regarding patients' quality of life (QoL), survival, mood, caregiver burden and reduction of aggressiveness of treatment near the end of life. However, RCTs investigating the positive effect of EIPC for patients suffering from glioblastoma multiforme (GBM) are lacking. After modelling work identifying the specific needs of GBM patients and their caregivers, the aim of this study is to investigate the impact of EIPC in this particular patient group. METHODS AND ANALYSIS: The recruitment period of this multicenter RCT started in May 2019. GBM patients (n=214) and their caregivers will be randomly assigned to either the intervention group (receiving proactive EIPC on a monthly basis) or the control group (receiving treatment according to international standards and additional, regular assessment of QoL ('optimised' standard care)).The primary outcome is QoL assessed by subscales of the Functional Assessment of Cancer Therapy for brain tumour (FACT-Br) from baseline to 6 months of treatment. Secondary outcomes are changes in QoL after 12 (end of intervention), 18 and 24 months (end of follow-up), the full FACT-Br scale, patients' palliative care needs, depression/anxiety, cognitive impairment, caregiver burden, healthcare use, cost-effectiveness and overall survival. ETHICS AND DISSEMINATION: The study will be conducted in accordance with the Declaration of Helsinki and has been approved by the local ethics committees of the University Clinics of Cologne, Aachen, Bonn, Freiburg and Munich (LMU). Results of the trial will be submitted for publication in a peer-reviewed, open access journal and disseminated through presentations at conferences. TRIAL REGISTRATION NUMBER: German Register for Clinical Studies (DRKS) (DRKS00016066); Pre-results.
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Affiliation(s)
- Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Charlotte Nettekoven
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
- Department of General Neurosurgery, Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Cologne, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Munich (LMU), Munich, Germany
| | - Jörg-Christian Tonn
- Department of Neurosurgery, Faculty of Medicine and University Hospital, University of Munich (LMU), Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, Faculty of Medicine and University Hospital, University of Munich (LMU), Munich, Germany
| | - Berend Feddersen
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Munich (LMU), Munich, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Faculty of Medicine and University Hospital, University of Freiburg, Freiburg, Germany
| | - Christopher Böhlke
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Freiburg, Freiburg, Germany
| | - Gerhild Becker
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Freiburg, Freiburg, Germany
| | - Roman Rolke
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, RWTH Aachen University, Aachen, Germany
- Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany
| | - Hans Clusmann
- Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany
- Department of Neurosurgery, Faculty of Medicine and University Hospital, RWTH Aachen University, Aachen, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neurooncology, Department of Neurology, Faculty of Medicine and University Hospital, University of Bonn, Bonn, Germany
| | - Lukas Radbruch
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Bonn, Bonn, Germany
| | - Hartmut Vatter
- Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany
- Department of Neurosurgery, Faculty of Medicine and University Hospital, University of Bonn, Bonn, Germany
| | - Erdem Güresir
- Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany
- Department of Neurosurgery, Faculty of Medicine and University Hospital, University of Bonn, Bonn, Germany
| | - Stephanie Stock
- Faculty of Medicine and University Hospital, Institute for Health Economics and Clinical Epidemiology (IGKE), University of Cologne, Cologne, Germany
| | - Dirk Müller
- Faculty of Medicine and University Hospital, Institute for Health Economics and Clinical Epidemiology (IGKE), University of Cologne, Cologne, Germany
| | - Daniele Civello
- Faculty of Medicine and University Hospital, Institute for Health Economics and Clinical Epidemiology (IGKE), University of Cologne, Cologne, Germany
| | - Irini Papachristou
- Faculty of Medicine and University Hospital, Center for Clinical Studies (ZKS), University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Faculty of Medicine and University Hospital, Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany
| | - Stefanie Hamacher
- Faculty of Medicine and University Hospital, Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital, Center for Clinical Studies (ZKS), University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital, Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of General Neurosurgery, Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital, Center for Health Services Research (ZVFK), University of Cologne, Cologne, Germany
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22
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Dillen K, Ebke M, Koch A, Becker I, Ostgathe C, Voltz R, Golla H. Validation of a palliative care outcome measurement tool supplemented by neurological symptoms (HOPE+): Identification of palliative concerns of neurological patients. Palliat Med 2019; 33:1221-1231. [PMID: 31280657 DOI: 10.1177/0269216319861927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is growing interest to integrate palliative care and its structures into the care of neurological patients. However, in Germany there is no comprehensive assessment tool capturing the symptoms of patients with advanced neurological diseases. AIM To validate a newly developed palliative care measurement tool based on an extension of the validated core documentation system Hospice and Palliative Care Evaluation considering additional neurological issues (HOPE+). DESIGN Prospective, observational study using HOPE+ and as external criteria, the Eastern Cooperative Oncology Group (ECOG) performance status and the 12 months "surprise" question (12-SQ) in a neurological population, and assessment for its construct validity and diagnostic accuracy. SETTING/PARTICIPANTS All newly admitted patients to the Department of Neurorehabilitation, Dr. Becker Rhein-Sieg-Clinic aged 18-100 years (#DRKS00010947). RESULTS Data from 263 patients (63 ± 14 years of age) were analyzed. HOPE+ revealed a moderately correlated six-factor structure (r = -0.543-0.525). Correlation analysis to evaluate discriminant validity using ECOG as external criterion was high (rs(261) = 0.724, p < 0.001) and confirmed for severely affected patients by adding the 12-SQ ("No"-group: 48.00 ± 14.92 vs "Yes"-group: 18.67 ± 7.57, p < 0.009). Operating characteristics show satisfactory diagnostic accuracy (area under the curve: 0.746 ± 0.049, 95% confidence interval = 0.650-0.842). CONCLUSION HOPE+ demonstrates promising psychometric properties. It helps to assess palliative care issues of patients in neurological settings and, in combination with the 12-SQ, conceivably conditions when to initiate the palliative care approach in a population underrepresented in palliative care structures so far.
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Affiliation(s)
- Kim Dillen
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Markus Ebke
- Neurological Centre for Rehabilitation-MEDIAN-Clinics, Bad Salzuflen, Germany.,Dr. Becker Rhein Sieg Clinic, Nümbrecht, Germany
| | - Andreas Koch
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Integrated Oncology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Clinical Trials, University of Cologne, Cologne, Germany.,Center for Health Services Research (ZVFK), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Integrated Oncology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
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23
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Rosenberg J, Massaro A, Siegler J, Sloate S, Mendlik M, Stein S, Levine J. Palliative Care in Patients With High-Grade Gliomas in the Neurological Intensive Care Unit. Neurohospitalist 2019; 10:163-167. [PMID: 32549938 DOI: 10.1177/1941874419869714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Palliative care improves quality of life in patients with malignancy; however, it may be underutilized in patients with high-grade gliomas (HGGs). We examined the practices regarding palliative care consultation (PCC) in treating patients with HGGs in the neurological intensive care unit (NICU) of an academic medical center. Methods We conducted a retrospective cohort study of patients admitted to the NICU from 2011 to 2016 with a previously confirmed histopathological diagnosis of HGG. The primary outcome was the incidence of an inpatient PCC. We also evaluated the impact of PCC on patient care by examining its association with prespecified secondary outcomes of code status amendment to do not resuscitate (DNR), discharge disposition, 30-day mortality, and 30-day readmission rate, length of stay, and place of death. Results Ninety (36% female) patients with HGGs were identified. Palliative care consultation was obtained in 16 (18%) patients. Palliative care consultation was associated with a greater odds of code status amendment to DNR (odds ratio [OR]: 18.15, 95% confidence interval [CI]: 5.01-65.73), which remained significant after adjustment for confounders (OR: 27.20, 95% CI: 5.49-134.84), a greater odds of discharge to hospice (OR: 24.93, 95% CI: 6.48-95.88), and 30-day mortality (OR: 6.40, 95% CI: 1.96-20.94). Conclusion In this retrospective study of patients with HGGs admitted to a university-based NICU, PCC was seen in a minority of the sample. Palliative care consultation was associated with code status change to DNR and hospice utilization. Further study is required to determine whether these findings are generalizable and whether interventions that increase PCC utilization are associated with improved quality of life and resource allocation for patients with HGGs.
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Affiliation(s)
- Jon Rosenberg
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Allie Massaro
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - James Siegler
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Stacey Sloate
- Wharton School of the University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Mendlik
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Division of Palliative Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Joshua Levine
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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24
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Francis SR, Hall EO, Delmar C. Ethical dilemmas experienced by spouses of a partner with brain tumour. Nurs Ethics 2019; 27:587-597. [PMID: 31319743 DOI: 10.1177/0969733019857790] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Caring for a partner with primary malignant brain tumour can be a dramatic life-changing event. Primary malignant brain tumour is known to give poor life expectancy and severe neurological and cognitive symptoms, such as changed behaviour and personality, which demand greater caring responsibilities from spouses. AIM The aim of the study is to explore ethical dilemmas spouses experience in the everyday care of a partner in treatment for primary malignant brain tumour. RESEARCH DESIGN, PARTICIPANTS AND RESEARCH CONTEXT A phenomenological and hermeneutic qualitative descriptive design was adopted as a method for collecting and analysing data. Ten spouses were interviewed twice using an in-depth, semi-structured interview guide. The interviews took place at the spouses' homes or at the hospital. ETHICAL CONSIDERATION Ethical matters were considered throughout the research process. Permission from The National Committee on Health Research Ethics and the Danish Data Protection Agency was obtained. FINDINGS The analysis showed that the spouses perceived daily ethical dilemmas in caring for a partner with primary malignant brain tumour. Their life as well as their partner's life had changed considerably. The main theme that emerged therefore was 'oscillating in a changing relationship'. This theme was further elaborated in three subthemes that in more detail demonstrated the dilemmas: 'doing the right thing in unpredictable daily situations'; 'torn between patience and guilt'; and 'living in a time of uncertainty, hope and despair'. CONCLUSION Caring for a partner with changed behaviour and personality due to primary malignant brain tumour may involve exhausting ethical caring dilemmas. Spouses' married life may change to a semi-professional asymmetrical relationship, which is challenged by the oscillation between acting responsibly for their partners' well-being and caring dilemmas with no answer for what the right thing to do is. Mixed feelings of right and wrong, patience and guilt, hope and despair seem to be spousal companions through their partners' progressing illness.
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Affiliation(s)
| | - Elisabeth Oc Hall
- Aarhus University, Denmark; University of the Faroe Islands, Faroe Islands
| | - Charlotte Delmar
- Aarhus University, Denmark; UiT - The Arctic University of Norway, Norway; VID, Norway
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25
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Seeber AA, Pols AJ, Hijdra A, Grupstra HF, Willems DL, de Visser M. Advance care planning in progressive neurological diseases: lessons from ALS. BMC Palliat Care 2019; 18:50. [PMID: 31196046 PMCID: PMC6567602 DOI: 10.1186/s12904-019-0433-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/27/2019] [Indexed: 02/08/2023] Open
Abstract
Background There is increasing awareness of the need for an integrated palliative care approach in chronic progressive neurological diseases. Advance care planning (ACP) is an integral part of this approach. As a systematically organized and ongoing communication process about patients’ values, goals and preferences regarding medical care during serious and chronic illness, ACP aims to involve patients in decision-making before they become cognitively and communicatively incapable. However, it remains underutilized in daily neurological practice except for speciality clinics such as ALS centers. Our aim was to study ACP in the tertiary ALS center Amsterdam and to investigate patients’ reflections on it. Subsequently we used this knowledge to formulate recommendations for integration of ACP in the care of patients with other chronic progressive neurological diseases. Methods Non-participating observations of all appointments of patients with amyotrophic lateral sclerosis (ALS) or progressive muscular atrophy (PMA) with the treating physician, in various stages of disease, during 6 consecutive months, followed by single in-depth interviews, and an inductive analysis. Results Twenty-eight Dutch patients participated, varying in age, gender, disease onset and severity of physical decline. ACP started directly when the diagnosis was given, by means of a general outlook on the future with progressive disability and immediate introduction to a customized multidisciplinary team. During follow-up ACP was realized by regular appointments in which monitoring of the patient’s status and clear communication strategies formed the basis of tailor-made discussions on treatment options. Patients accepted this policy as careful professional guidance. Conclusions ACP is a professional communication process throughout the whole course of progressive disease. It is feasible to integrate ACP into follow-up of patients with ALS and PMA from diagnosis onwards. Supported by recent literature, we argue that such a well-structured approach would also enhance the quality of care and life of patients with other chronic progressive neurological diseases. Electronic supplementary material The online version of this article (10.1186/s12904-019-0433-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antje A Seeber
- Department of Neurology, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. .,Section of Medical Ethics, Department of General Practice, Amsterdam University Medical Center, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, Amsterdam, The Netherlands.
| | - A Jeannette Pols
- Section of Medical Ethics, Department of General Practice, Amsterdam University Medical Center, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, Amsterdam, The Netherlands
| | - Albert Hijdra
- Department of Neurology, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Hepke F Grupstra
- Department of Rehabilitation, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, The Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Amsterdam University Medical Center, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, Amsterdam, The Netherlands
| | - Marianne de Visser
- Department of Neurology, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
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26
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Protopapa M, Kouloulias V, Nikoloudi S, Papadimitriou C, Gogalis G, Zygogianni A. From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC. JOURNAL OF ONCOLOGY 2019; 2019:3267409. [PMID: 30853981 PMCID: PMC6378013 DOI: 10.1155/2019/3267409] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/15/2019] [Indexed: 12/25/2022]
Abstract
Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.
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Affiliation(s)
- Maria Protopapa
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Vassilis Kouloulias
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 2nd Department of Radiology, Attikon University General Hospital, Greece
| | - Styliani Nikoloudi
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Christos Papadimitriou
- National and Kapodistrian University of Athens, Medical School, Medical Oncology Unit, 2nd Surgery Clinic, Aretaieion University Hospital of Athens, Greece
| | - Giannis Gogalis
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Anna Zygogianni
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
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27
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IJzerman-Korevaar M, Snijders TJ, de Graeff A, Teunissen SCCM, de Vos FYF. Prevalence of symptoms in glioma patients throughout the disease trajectory: a systematic review. J Neurooncol 2018; 140:485-496. [PMID: 30377935 PMCID: PMC6267240 DOI: 10.1007/s11060-018-03015-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/09/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Glioma patients suffer from a wide range of symptoms which influence quality of life negatively. The aim of this review is to give an overview of symptoms most prevalent in glioma patients throughout the total disease trajectory, to be used as a basis for the development of a specific glioma Patient Reported Outcome Measure (PROM) for early assessment and monitoring of symptoms in glioma patients. METHODS A systematic review focused on symptom prevalence in glioma patients in different phases of disease and treatment was performed in MEDLINE, CINAHL and EMBASE according to PRISMA recommendations. We calculated weighted means for prevalence rates per symptom. RESULTS The search identified 2.074 unique papers, of which 32 were included in this review. In total 25 symptoms were identified. The ten most prevalent symptoms were: seizures (37%), cognitive deficits (36%), drowsiness (35%), dysphagia (30%), headache (27%), confusion (27%), aphasia (24%), motor deficits (21%), fatigue (20%) and dyspnea (20%). CONCLUSIONS Eight out of ten of the most prevalent symptoms in glioma patients are related to the central nervous system and therefore specific for glioma. Our findings emphasize the importance of tailored symptom care for glioma patients and may aid in the development of specific PROMs for glioma patients in different phases of the disease.
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Affiliation(s)
- Margriet IJzerman-Korevaar
- Department of Medical Oncology, Cancer Center, University Medical Center Utrecht, University Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Tom J Snijders
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, University Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, Cancer Center, University Medical Center Utrecht, University Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Saskia C C M Teunissen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Filip Y F de Vos
- Department of Medical Oncology, Cancer Center, University Medical Center Utrecht, University Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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28
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Seibl-Leven M, von Reeken C, Goldbrunner R, Grau S, Ruge MI, Galldiks N, Dunkl V, Kocher M, Voltz R, Golla H. Clinical routine assessment of palliative care symptoms and concerns and caregiver burden in glioblastoma patients: an explorative field study. J Neurooncol 2018; 138:321-333. [PMID: 29464662 DOI: 10.1007/s11060-018-2800-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/09/2018] [Indexed: 12/12/2022]
Abstract
The implementation of self-reported outcome measurements into clinical routine was tested to help facilitate early access to palliative care (PC) for glioblastoma (GBM)-patients. Measures detail PC symptoms and concerns and caregiver burden. Between January 2014 and December 2016, a total of 337 GBM-patients were discussed during meetings of the neuro-oncology tumor board to examine further treatment options. Each patient, along with their caregivers, was requested to participate in self-assessment using the palliative outcome scale (POS) and the Zarit Burden Interview (ZBI). Analyses encompassed summary statistics, non-parametric tests, visual graphic analysis, content analysis and assessing the utilization of the specialized PC consulting service (SPCCS). Ninety-five (28%) GBM-patients and 71 (21%) caregivers completed the self-assessment. Of these, 20 patients and 12 caregivers repeated the assessment at least once more during follow-up. POS total scores were similar in the group of patients with initial diagnosis [10 (0-31)] and those with later disease stages like recurrent diagnosis [9 (0-25)], but ZBI total scores differed [14 (0-51) vs. 24 (2-62)]. Single item analysis demonstrated that anxiety and worries about the future predominated. Caregivers were torn between high engagement in caring and feeling overburdened. Still, requests for the SPCCS showed no increase. Actual implementation of measures like POS and ZBI for detecting PC concerns and caregiver burden with GBM-patients in the field remains challenging as indicated by the limited response rate and lack of increased requests for the SPCCS. Modified clinical routines including strengthening awareness of PC, and allowing proxy-assessment might help to overcome barriers.
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Affiliation(s)
- Matthias Seibl-Leven
- Center of Neurosurgery, University Hospital of Cologne, Cologne, Germany.,Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany
| | - Christian von Reeken
- Department of Palliative Medicine, University Hospital of Cologne, Kerpener Strasse 62, 50924, Cologne, Germany
| | - Roland Goldbrunner
- Center of Neurosurgery, University Hospital of Cologne, Cologne, Germany.,Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany
| | - Stefan Grau
- Center of Neurosurgery, University Hospital of Cologne, Cologne, Germany.,Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany
| | - Maximilian Ingolf Ruge
- Center of Neurosurgery, University Hospital of Cologne, Cologne, Germany.,Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany.,Department of Stereotactic and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Norbert Galldiks
- Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany.,Department of Neurology, University Hospital of Cologne, Cologne, Germany.,Institute for Neuroscience and Medicine (INM-3), Forschungszentrum Juelich, Juelich, Germany
| | - Veronika Dunkl
- Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany.,Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Martin Kocher
- Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany.,Department of Radiation Oncology, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany.,Department of Palliative Medicine, University Hospital of Cologne, Kerpener Strasse 62, 50924, Cologne, Germany.,Center for Clinical Trials, University Hospital of Cologne, Cologne, Germany.,Medical Faculty, Center for Health Services Research (ZVFK), University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Center of Integrated Oncology (CIO), Universities of Cologne and Bonn, Cologne, Germany. .,Department of Palliative Medicine, University Hospital of Cologne, Kerpener Strasse 62, 50924, Cologne, Germany.
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29
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Heckel M, Hoser B, Stiel S. Caring for patients with brain tumors compared to patients with non-brain tumors: Experiences and needs of informal caregivers in home care settings. J Psychosoc Oncol 2017; 36:189-202. [PMID: 28902576 DOI: 10.1080/07347332.2017.1379046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND/OBJECTIVE Informal caregivers of patients with advanced cancer experience a challenging time, especially while caring for the patient at home. The aim of this study is to compare experiences, perceived burdens, and needs during home care of informal caregivers of brain tumor patients and informal caregivers of non-brain tumor patients. METHODS 28 informal caregivers (17 brain tumor group, 11 non-brain tumor group) participated in this study. Semi-structured interviews were conducted to gather information retrospectively. Data was analyzed using principles of thematic analysis method. RESULTS The results support existing evidence that the themes assessment of the situation, dealing with the situation, effects of the situation, and support by others are of importance to all informal caregivers. Caregivers in the brain tumor group put more emphasis on information and perception of the situation by others than caregivers in the non-brain tumor group. CONCLUSION The emerging need for information of caregivers and the effects for caregivers of changes in the perception of the situation by others should be addressed to better support informal caregivers of brain tumor patients.
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Affiliation(s)
- Maria Heckel
- a Department of Palliative Medicine , University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) , Germany
| | - Bettina Hoser
- a Department of Palliative Medicine , University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) , Germany
| | - Stephanie Stiel
- b Institute for General Practice, Hannover Medical School , Hannover , Germany
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30
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Renovanz M, Hechtner M, Kohlmann K, Janko M, Nadji-Ohl M, Singer S, Ringel F, Coburger J, Hickmann AK. Compliance with patient-reported outcome assessment in glioma patients: predictors for drop out. Neurooncol Pract 2017; 5:129-138. [PMID: 31385978 DOI: 10.1093/nop/npx026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Patient-reported outcomes are of high importance in clinical neuro-oncology. However, assessment is still suboptimal. We aimed at exploring factors associated with the probability for a) drop out of study and b) death during follow-up. Methods Patients were assessed twice during follow-up visits scheduled within 3 to 5 months of each other by using 3 validated patient-reported outcome measures (t1: first assessment, t2: second assessment). As "death" was seen as a competing risk for drop out, univariate competing risk Cox regression models were applied to explore factors associated with dropping out (age, gender, WHO grade, living situation, recurrent surgery, Karnofsky Performance Status, time since diagnosis, and patient-reported outcomes assessed by Distress Thermometer, EORTC-QLQ-C30, EORTC-QLQ-BN20, and SCNS-SF-34G). Results Two hundred forty-six patients were eligible, 173 (70%) participated. Patients declining participation were diagnosed with glioblastomas more often than with other gliomas (56% vs 39%). At t2, 32 (18%) patients dropped out, n = 14 death-related, n = 18 for other reasons. Motor dysfunction (EORTC-QLQ-BN20) was associated with higher risk for non-death-related drop out (HR: 1.02; 95% CI, 1.00-1.03; P = .03). Death-related drop out was associated with age (HR: 1.09; 95% CI, 1.03-1.14; P = .002), Karnofsky Performance Status (HR: 0.92; 95% CI, 0.88-0.96; P < .001), lower physical functioning (EORTC-QLQ-C30; HR: 0.98; 95% CI, 0.96-1.00; P = .04) and lower motor functioning (EORTC-QLQ-BN20; HR: 1.020; 95% CI, 1.00-1.04; P = .02). Conclusion Patients with motor dysfunction and poorer clinical condition seem to be more likely to drop out of studies applying patient-reported outcome measures. This should be taken into account when planning studies assessing glioma patients and for interpretation of results of patient-reported outcome assessments in clinical routine.
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Affiliation(s)
- Mirjam Renovanz
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University Mainz, Mainz Germany
| | - Marlene Hechtner
- Division of Epidemiology and Health Services Research, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes-Gutenberg-University Mainz, Mainz Germany
| | - Karoline Kohlmann
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University Mainz, Mainz Germany
| | - Mareile Janko
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University Mainz, Mainz Germany
| | - Minou Nadji-Ohl
- Department of Neurosurgery Klinikum Stuttgart, Katharinenhospital, Stuttgart Germany
| | - Susanne Singer
- Division of Epidemiology and Health Services Research, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes-Gutenberg-University Mainz, Mainz Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University Mainz, Mainz Germany
| | - Jan Coburger
- Department of Neurosurgery, University Medical Center Ulm/Günzburg, Günzburg Germany
| | - Anne-Katrin Hickmann
- Department of Neurosurgery Klinikum Stuttgart, Katharinenhospital, Stuttgart Germany.,Department of Neurosurgery Hirslanden Klinikum, Luzern Switzerland
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31
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Factors associated with supportive care needs in glioma patients in the neuro-oncological outpatient setting. J Neurooncol 2017; 133:653-662. [PMID: 28527007 DOI: 10.1007/s11060-017-2484-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023]
Abstract
Objective of this study aimed at assessing glioma patients' supportive care needs in a neurosurgical outpatient setting and identifying factors that are associated with needs for support. In three neuro-oncological outpatient departments, glioma patients were assessed for their psychosocial needs using the Supportive Care Needs Survey short-form (SCNS-SF34-G). Associations between clinical, sociodemographic, treatment related factors as well as distress (measured with the distress thermometer) and supportive care needs were explored using multivariable general linear models. One-hundred and seventy three of 244 eligible glioma patients participated, most of them with primary diagnoses of a high-grade glioma (81%). Highest need for support was observed in 'psychological needs' (median 17.5, range 5-45) followed by 'physical and daily living needs' (median 12.5, range 0-25) and 'health system and information needs' (median 11.3, range 0-36). Needs in the psychological area were associated with distress (R2 = 0.36) but not with age, sex, Karnofsky performance status (KPS), extend of resection, currently undergoing chemotherapy and whether guidance during assessment was offered. Regarding 'health system and information needs', we observed associations with distress, age, currently undergoing chemotherapy and guidance (R2 = 0.31). In the domain 'physical and daily living needs' we found associations with KPS, residual tumor, as well as with distress (R2 = 0.37). Glioma patients in neuro-oncological departments report unmet supportive care needs, especially in the psychological domain. Distress is the factor most consistently associated with unmet needs requiring support and could serve as indicator for clinical neuro-oncologists to initiate support.
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Screening for symptom burden and supportive needs of patients with glioblastoma and brain metastases and their caregivers in relation to their use of specialized palliative care. Support Care Cancer 2017; 25:2761-2770. [PMID: 28357650 DOI: 10.1007/s00520-017-3687-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/21/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Patients with brain tumors have a high symptom burden and multiple supportive needs. Needs of caregivers are often unattended. This study aims to determine screening-based symptom burden and supportive needs of patients and caregivers with regard to the use of specialized palliative care (SPC). METHODS Seventy-nine patients with glioblastoma and brain metastases and 46 caregivers were screened with standardized questionnaires following diagnosis and 2 months later. The screening assessed symptom burden, quality of life (QoL), distress, and supportive needs. RESULTS The most relevant symptoms were drowsiness, tiredness, and low well-being (53-58%). The most prevalent patient supportive needs were the need for information about available resources, the illness, and possible lifestyle changes (50-56%). The most prevalent caregiver needs were information about the illness, lifestyle changes, and about available resources (56-74%). Patients who received SCP and their caregivers had higher symptom burden and supportive needs than those without SPC. They reported moderate improvement in pain, distress, and QoL, while patients without SPC also improved their QoL, but had small to moderate deteriorations in pain, drowsiness, nauseas, well-being, and other problems. Distress of caregivers with SPC improved with moderate to large effect sizes but still was on a high level and remained stable for those without SPC. CONCLUSIONS Symptom burden and supportive needs were high, but even more caregivers than patients expressed high distress and supportive needs. SPC appears to reach the target group, both patients and caregivers with elevated symptom burden. Targeted interventions are needed to improve tiredness and drowsiness.
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Abstract
The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course.
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Dirven L, Sizoo EM, Taphoorn MJB. Anaplastic gliomas: end-of-life care recommendations. CNS Oncol 2015; 4:357-65. [PMID: 26509292 DOI: 10.2217/cns.15.31] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite multimodal antitumor treatment, all patients with an anaplastic glioma will be confronted with incurability in due course and enter the end-of-life (EOL) phase; the period when the patients' condition declines and tumor-directed treatment is no longer effective. Although palliative care is important in all stages of the disease, it is of utmost importance in the EOL phase. The main goal of palliative care is to improve or maintain the quality of life of the patients and their relatives through the prevention and relief of suffering. This review focuses on different aspects of the EOL phase (symptoms and signs, EOL decision-making, advance care planning, organization of care and caregiver burden) and will provide recommendations to optimize palliative care.
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Affiliation(s)
- Linda Dirven
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands
| | - Eefje M Sizoo
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands
| | - Martin J B Taphoorn
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands.,Medical Center Haaglanden, Department of Neurology, The Hague, The Netherlands
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Thier K, Calabek B, Tinchon A, Grisold W, Oberndorfer S. The Last 10 Days of Patients With Glioblastoma: Assessment of Clinical Signs and Symptoms as well as Treatment. Am J Hosp Palliat Care 2015; 33:985-988. [PMID: 26472939 DOI: 10.1177/1049909115609295] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND High-grade gliomas are the most frequent primary brain tumors. Despite improvement in diagnostics and treatment, survival is still poor and quality-of-life issues are of major importance. Little is known regarding the clinical signs and symptoms of dying patients with glioblastoma. OBJECTIVE The aim of this study was to investigate signs and symptoms as well as therapeutic strategies in patients with glioblastoma in the end-of-life phase in order to improve end-of-life care. METHODS In this prospective single-center study, clinical data were obtained using a standardized protocol. We descriptively analyzed signs, symptoms, and therapeutic strategies on a daily basis. RESULTS A total of 57 patients, who died due to glioblastoma in a hospital setting, were included. The most frequent signs and symptoms in the last 10 days before death were decrease in level of consciousness (95%), fever (88%), dysphagia (65%), seizures (65%), and headache (33%). Concerning medication, 95% received opioids. There was a high need for nonsteroidal anti-inflammatory drugs (77%) and anticonvulsants (75%). Steroids were given to 56%. CONCLUSION Due to a decrease in level of consciousness and cognitive impairment, assessment of clinical signs and symptoms such as headache at the end of life is difficult. Based on the signs and symptoms in the last days before death in patients with glioblastoma, supportive drug treatment remains challenging. Our study emphasizes the importance of standardized guidelines for end-of-life care in patients with glioblastoma.
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Affiliation(s)
- Katrin Thier
- Department of Neurology, University Clinic St Pölten, KLPU and Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, St Pölten, Austria
| | - Bernadette Calabek
- Department of Neurology, University Clinic St Pölten, KLPU and Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, St Pölten, Austria
| | - Alexander Tinchon
- Department of Neurology, University Clinic St Pölten, KLPU and Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, St Pölten, Austria
| | - Wolfgang Grisold
- Department of Neurology, Kaiser-Franz-Josef-Hospital, Vienna, Austria
| | - Stefan Oberndorfer
- Department of Neurology, University Clinic St Pölten, KLPU and Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, St Pölten, Austria
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Pompili A, Telera S, Villani V, Pace A. Home palliative care and end of life issues in glioblastoma multiforme: results and comments from a homogeneous cohort of patients. Neurosurg Focus 2015; 37:E5. [PMID: 25434390 DOI: 10.3171/2014.9.focus14493] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Glioblastoma multiforme (GBM) is a rare tumor whose prognosis has remained poor over the years despite innovative radio- and chemotherapies, and important technical advances in neurosurgery such as intraoperative imaging, fluorescence, Cavitron ultrasonic surgical aspirator, and neuronavigation. Particular attention has been dedicated in the last years to the end of life (EOL) period in cancer patients for both ethical and socioeconomic issues. Good palliative care at home avoids improper and expensive hospitalizations, and helps and trains families, caregivers, and patients in facing a difficult situation. METHODS In 2012-2013 the authors' group cared for 197 patients with brain tumors. Of these there were 122 with GBMs: 64 died and 58 are still receiving assistance. The clinical conditions are periodically evaluated with the following scales: Barthel Index, Karnofsky Performance Scale, and Mini-Mental State Examination. Home care staff includes 2 neurologists, 5 nurses, 2 psychologists, 3 rehabilitation therapists, and 1 social worker. The intensity of care changes at the different stages of disease, ranging from low to medium levels of intensity at the progression stage (more than 1 access weekly) to high levels of intensity at the EOL stage (at least 3 accesses weekly). Control MRI studies are obtained every 3 months before terminal progression. RESULTS Overall in this sample of patients there were 2838 home visits and 11,714 days of assistance. Thirty-four patients (14 female and 20 male) died at home (53.1%); 22 (13 female and 9 male) at the hospice (34.4%); and 8 (4 female and 4 male) at the hospital (12.5%). A positive impact on caregivers for home assistance was recorded in 97% of cases, for nursing in 95%, communication in 90%, rehabilitation at home in 92%, and social work help in 85%. Also, 72% had an improvement in their quality of life scores due to rehabilitation. End of life palliative sedation with midazolam was necessary in 11% of cases to obtain good control of symptoms such as uncontrolled delirium, agitation, death rattle, or refractory seizures. Intramuscular phenobarbital is the authors' drug of choice for the severe seizures that occurred in 30% of cases. The reduction of steroid dosage is also used to decrease wakefulness. Steroids were withdrawn in 45% of patients dying at home, mild hydration was done in 87%, and tube feeding in 13%. The decision-making process at the EOL stage is time consuming, but the degree of distress of the family is inversely proportional to the extent of the preparatory period. CONCLUSIONS A previous paper showed the positive cost-effectiveness of home assistance for a larger group of patients dealing with any kind of malignant brain tumors. The same is enhanced for patients with GBM. This requires a well-trained neuro-oncology team that manages neurological deterioration, clinical complications, rehabilitation, and psychosocial problems with a multidisciplinary approach.
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Health-related quality of life in patients with high-grade gliomas: a quantitative longitudinal study. J Neurooncol 2015; 124:185-95. [PMID: 26026860 DOI: 10.1007/s11060-015-1821-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
Abstract
The diagnosis of a high-grade glioma usual is followed by functional impairment(s), cognitive decline and an impaired psycho-social well-being. This might well have a significant and negative impact on the health related quality of life. The purpose of this study was to explore physical activity levels, prevalence and severity of anxiety and depressive symptoms and health-related quality of life among patients with a highgrade glioma. This paper is based on a longitudinal mixed methods study. Patients (n = 30) completed questionnaires at 5 time points from time of diagnosis until the final follow-up after 1 year. Scores of Karnofsky Performance Status (KPS), physical activity, anxiety and depression and health-related quality of life (FACT-Br) are obtained. Patients' physical activity level and KPS decrease during the disease- and treatment trajectory. The majority of patients did not report any depressive symptoms, eight individuals (26.7 %) being depressed at various time points. Among a sub-group of participants who completed all study requirements for the entire study period the level of anxiety decreased significantly during the study. The FACT-Br sub-scale of emotional well-being increased significant, indicating a better HRQOL attend of followup. The diagnosis of a HGG leads to an ongoing functional decline measured as a decline of the KPS and a reduced physical activity during leisure time. Supportive care combined with rehabilitative and palliative approaches might well be valuable along the trajectory especially during the post-surgery period when anxiety is at its highest peak.
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Koekkoek JAF, Dirven L, Reijneveld JC, Postma TJ, Grant R, Pace A, Oberndorfer S, Heimans JJ, Taphoorn MJB. Epilepsy in the end of life phase of brain tumor patients: a systematic review. Neurooncol Pract 2014; 1:134-140. [PMID: 31386028 DOI: 10.1093/nop/npu018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Indexed: 12/13/2022] Open
Abstract
Epileptic seizures are common in patients with primary or secondary malignant brain tumor. However, current knowledge on the occurrence of seizures during the end of life (EOL) phase of brain tumor patients is limited. Because symptom management with preservation of quality of life is of major importance for patients with a malignant brain tumor, particularly in the EOL, it is necessary to gain a deeper understanding of seizures and their management during this phase. We performed a systematic review of literature related to epilepsy in the EOL phase of brain tumor patients, based on the electronic resources PubMed, Embase, and Cinahl. The search yielded 442 unique records, of which 11 articles were eligible for further analysis after applying predefined inclusion criteria. Seizures occur relatively frequently in the EOL phase, particularly in patients with high-grade glioma. However, seizure management is often hampered by swallowing difficulties and impaired consciousness. Treatment decisions are largely dependent on expert opinion because a standardized approach for treating seizures in the terminal stage of brain tumor patients is still lacking.
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Affiliation(s)
- Johan A F Koekkoek
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
| | - Linda Dirven
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
| | - Jaap C Reijneveld
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
| | - Tjeerd J Postma
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
| | - Robin Grant
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
| | - Andrea Pace
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
| | - Stefan Oberndorfer
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
| | - Jan J Heimans
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
| | - Martin J B Taphoorn
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands (J.A.F.K., L.D., J.C.R., T.J.P., J.J.H., M.J.B.T.); Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands (J.A.F.K., M.J.B.T.); Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland (R.G.); Neuro-Oncology Unit, Regina Elena Cancer Institute, Rome, Italy (A.P.); Department of Neurology, Landesklinikum St. Pölten, Sankt Pölten, Austria (S.O.)
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Koekkoek JAF, Dirven L, Sizoo EM, Pasman HRW, Heimans JJ, Postma TJ, Deliens L, Grant R, McNamara S, Stockhammer G, Medicus E, Taphoorn MJB, Reijneveld JC. Symptoms and medication management in the end of life phase of high-grade glioma patients. J Neurooncol 2014; 120:589-95. [DOI: 10.1007/s11060-014-1591-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/16/2014] [Indexed: 10/24/2022]
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Golla H, Ale Ahmad M, Galushko M, Hampl J, Maarouf M, Schroeter M, Herrlinger U, Hellmich M, Voltz R. Glioblastoma multiforme from diagnosis to death: a prospective, hospital-based, cohort, pilot feasibility study of patient reported symptoms and needs. Support Care Cancer 2014; 22:3341-52. [DOI: 10.1007/s00520-014-2384-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/31/2014] [Indexed: 10/24/2022]
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Nauck F, Becker M, King C, Radbruch L, Voltz R, Jaspers B. To what extent are the wishes of a signatory reflected in their advance directive: a qualitative analysis. BMC Med Ethics 2014; 15:52. [PMID: 24981101 PMCID: PMC4083137 DOI: 10.1186/1472-6939-15-52] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 06/20/2014] [Indexed: 11/12/2022] Open
Abstract
Background Advance directives (ADs) are assumed to reflect the patients’ preferences, even if these are not clearly expressed. Research into whether this assumption is correct has been lacking. This study explores to what extent ADs reflect the true wishes of the signatories. Methods Semi-structured interviews (INT), pretest. Transcribed INT and the contents of ADs were inductively categorised (Mayring) and triangulated. Software: MAXQDA 2007. Participants: Patients receiving palliative care (PPC), healthy (H) and chronically ill (CI) individuals with an AD completed ≥3 months prior to recruitment. Results Between 08/2008 and 07/2009, 53 individuals (20 H, 17 CI, 16 PPC) were interviewed (mean age 63.2 years (55–70 years)), 34% male). Most important (in)consistencies between preferences as expressed in INT compared to ADs included preconditions for termination/rejection of life-sustaining measures, refusal of/demand for medical interventions and the nomination of proxies. Standardized AD forms were rarely tailored to the individual. We found a high tendency to use set phrases, such as want to die with dignity or do not want to suffer/vegetate. Likely events in the course of an existing progressive disease were not covered, even in ADs of PPC close to death. Conclusions Only some of the incongruities between verbally expressed preferences and the contents of the AD can be put down to use of standardized forms or lack of medical knowledge. Nevertheless, the non-involvement of a doctor in the process of making an AD must be seen as potentially problematic and seeking medical advice should be promoted by politics and physicians. Standardised forms should encourage amendments and present space for free text entries for all aspects covered. Set phrases need to be defined by the individual to enable them to be translated into a specific course of action.
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Affiliation(s)
| | | | | | | | | | - Birgit Jaspers
- Clinic for Palliative Medicine, University Medical Centre, Robert-Koch-Str, 40, 37075 Göttingen, Germany.
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Alt-Epping B, Bauer J, Schuler U, Nauck F, Strohscheer I. [Pain therapy in oncology: results of a nationwide survey]. Schmerz 2014; 28:157-65. [PMID: 24718746 DOI: 10.1007/s00482-014-1412-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pain is one of the most prevalent and distressing symptoms of patients suffering from cancer. In the field of oncology comprehensive expertise is pursued not only with respect to the administration of anticancer treatment but to all fields that relate to the needs of cancer patients. However, the results of studies have revealed persisting and relevant deficits in pain therapy in the setting of oncology. MATERIALS AND METHODS An online survey was performed involving all members of the German Society for Hematology and Medical Oncology (DGHO) with respect to training and continuing education in pain therapy, the relevance for routine oncology and knowledge, to determine the level of expertise in pain therapy and the assessment of tumor-specific therapy. RESULTS A total of 183 out of 1,962 questionnaires could be evaluated. Oncologists are often engaged in pain therapy and 80 % of the respondents perceived themselves as being primarily responsible for pain control. Education and assessment were identified as barriers to sufficient pain therapy. Case vignettes revealed only few relevant therapeutic misinterpretations. CONCLUSION This first survey of German oncologists exploring expertise in cancer pain therapy, showed similar problems in education and pain assessment as previous international studies. Despite the claimed responsibility for pain management, there were a small but relevant number of oncologists who showed serious therapeutic misinterpretations in case studies.
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Affiliation(s)
- B Alt-Epping
- Klinik für Palliativmedizin, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland,
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[Delirium in patients with neurological diseases: diagnosis, management and prognosis]. DER NERVENARZT 2014; 85:427-36. [PMID: 24668399 DOI: 10.1007/s00115-013-3934-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Delirium is a common acute neuropsychiatric syndrome. It is characterized by concurrent disturbances of consciousness and attention, perception, reasoning, memory, emotionality, the sleep-wake cycle as well as psychomotor symptoms. Delirium caused by alcohol or medication withdrawal is not the subject of the current review. Specific predisposing and precipitating factors have been identified in delirium which converge in a common final pathway of global brain dysfunction. The major predisposing factors are older age, cognitive impairment or dementia, sensory deficits, multimorbidity and polypharmacy. Delirium is always caused by one or more underlying pathologies which need to be identified. In neurology both primary triggers of delirium, such as stroke or epileptic seizures and also secondary triggers, such as metabolic factors or medication side effects play a major role. Nonpharmacological interventions are important in the prevention of delirium and lead to an improvement in prognosis. Delirium is associated with increased mortality and in the long term the development of cognitive deficits and functional impairment.
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Pace A, Villani V, Di Pasquale A, Benincasa D, Guariglia L, Ieraci S, Focarelli S, Carapella CM, Pompili A. Home care for brain tumor patients. Neurooncol Pract 2014; 1:8-12. [PMID: 26034609 DOI: 10.1093/nop/npt003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 11/26/2013] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Brain tumor patients are quite different from other populations of cancer patients due to the complexity of supportive care needs, the trajectory of disease, the very short life expectancy, and resulting need for a specific palliative approach. METHODS A pilot program of comprehensive palliative care for brain tumor patients was started in the Regina Elena National Cancer Institute of Rome in October 2000, supported by the Lazio Regional Health System. The aim of this model of assistance was to meet patient's needs for care in all stages of disease, support the families, and reduce the rehospitalization rate. The efficacy of the model of care was evaluated analyzing the place of death, caregiver satisfaction, rehospitalization rate, and the impact on costs to the health system. RESULTS From October 2000 to December 2012, 848 patients affected by brain tumor were enrolled in a comprehensive program of neuro-oncological home care. Out of 529 patients who died, 323 (61%) were assisted at home until death, 117 (22.2%) died in hospital, and 89 (16.8%) died in hospice. A cost-effectiveness analysis demonstrated a significant reduction in hospital readmission rates in the last 2 months of life compared with the control group (16.7% vs 38%; P < .001). CONCLUSIONS Our findings concerning death at home, rehospitalization rate, quality of life, and satisfaction of patients and their relatives with the care received suggest that a neuro-oncologic palliative home-care program has a positive impact on the quality of care for brain tumor patients, particularly at the end of life.
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Affiliation(s)
- Andrea Pace
- Department of Neuroscience , Regina Elena National Cancer Institute , Rome , Italy
| | - Veronica Villani
- Department of Neuroscience , Regina Elena National Cancer Institute , Rome , Italy
| | | | - Dario Benincasa
- Department of Neuroscience , Regina Elena National Cancer Institute , Rome , Italy
| | - Lara Guariglia
- Department of Neuroscience , Regina Elena National Cancer Institute , Rome , Italy
| | - Sonia Ieraci
- Department of Neuroscience , Regina Elena National Cancer Institute , Rome , Italy
| | - Silvia Focarelli
- Department of Neuroscience , Regina Elena National Cancer Institute , Rome , Italy
| | | | - Alfredo Pompili
- Department of Neuroscience , Regina Elena National Cancer Institute , Rome , Italy
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Simon ST, Altfelder N, Alt-Epping B, Bausewein C, Weingärtner V, Voltz R, Ostgathe C, Radbruch L, Lindena G, Nauck F. Is breathlessness what the professional says it is? Analysis of patient and professionals’ assessments from a German nationwide register. Support Care Cancer 2014; 22:1825-32. [DOI: 10.1007/s00520-014-2131-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/13/2014] [Indexed: 10/25/2022]
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Sizoo EM, Pasman HRW, Dirven L, Marosi C, Grisold W, Stockhammer G, Egeter J, Grant R, Chang S, Heimans JJ, Deliens L, Reijneveld JC, Taphoorn MJB. The end-of-life phase of high-grade glioma patients: a systematic review. Support Care Cancer 2013; 22:847-57. [PMID: 24337718 DOI: 10.1007/s00520-013-2088-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 11/26/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND High-grade gliomas (HGG) are rare and incurable; yet, these neoplasms result in a disproportionate share of cancer morbidity and mortality. Treatment of HGG patients is directed not merely towards prolonging life but also towards quality of life, which becomes the major goal in the end of life (EOL). The latter has received increasing attention over the last decade. METHODS We reviewed the literature related to the EOL phase of HGG patients from 1966 up to April 2012. Articles were retrieved from PubMed, Embase, Cinahl, PsycINFO and Cochrane database. We then selected papers for analysis using pre-determined inclusion criteria and subtracted information on the topics of interest. RESULTS The search yielded 695 articles, of which 17 were classified eligible for analysis according to pre-defined inclusion criteria. Reviewed topics were symptoms and signs, quality of life and quality of dying, caregiver burden, organization and location of palliative care, supportive treatment, and EOL decision making. Nearly all identified studies were observational, with only two non-randomized intervention studies. Symptom burden is high in the EOL phase and affects the quality of life of both patient and carer. Palliative care services are more intensively used compared to other cancer patients. Cognitive deficits increase as the disease progresses, hampering communication and decision making. CONCLUSION The EOL phase of HGG is substantially different from other patient groups, and more clinical studies in HGG on supportive medication, advance care planning and decision making are required. The organization of care, development of guidelines and interventions to decrease caregiver burden in the EOL phase are critical as well.
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Affiliation(s)
- Eefje M Sizoo
- Department of Neurology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands,
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Sizoo EM, Dirven L, Reijneveld JC, Postma TJ, Heimans JJ, Deliens L, Pasman HRW, Taphoorn MJB. Measuring health-related quality of life in high-grade glioma patients at the end of life using a proxy-reported retrospective questionnaire. J Neurooncol 2013; 116:283-90. [DOI: 10.1007/s11060-013-1289-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/21/2013] [Indexed: 11/12/2022]
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Philip J, Collins A, Brand CA, Moore G, Lethborg C, Sundararajan V, Murphy MA, Gold M. “I'm just waiting…”: an exploration of the experience of living and dying with primary malignant glioma. Support Care Cancer 2013; 22:389-97. [DOI: 10.1007/s00520-013-1986-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 09/11/2013] [Indexed: 11/29/2022]
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Collins A, Lethborg C, Brand C, Gold M, Moore G, Sundararajan V, Murphy M, Philip J. The challenges and suffering of caring for people with primary malignant glioma: qualitative perspectives on improving current supportive and palliative care practices. BMJ Support Palliat Care 2013; 4:68-76. [DOI: 10.1136/bmjspcare-2012-000419] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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