Concepts and definitions for "supportive care," "best supportive care," "palliative care," and "hospice care" in the published literature, dictionaries, and textbooks

Ecology of End-of-life Medical Care for Advanced Cancer Patients in China

AIMS

Cancer is a leading cause of death worldwide. Approximately 30% of global cancer-related deaths occur in mainland China. However, there is a paucity of information regarding the end-of-life care-seeking behavior of patients with advanced cancer in China. Our study was to investigate end-of-life care-seeking behavior and to quantify the association between sociodemographic characteristics and the location and pattern of end-of-life care.

METHODS

We conducted a mortality follow-back survey using caregivers' interviews to estimate the number of individuals pre 1000 who died between 2013 and 2021 in the last 3 months of life. We collected data on hospitalization, outpatient visits, cardiopulmonary resuscitation, palliative care and hospice utilization, and place of death, stratified by age, gender, marital status, household income, residential zone, insurance type, and the primary end-of-life decision-maker of the decedents.

RESULTS

We analyzed data from 857 deceased cancer patients, representing an average of 1000 individuals. Among these patients, 861 experienced at least moderate or more severe pain, 774 were hospitalized at least once, 468 received intensive treatment, 389 had at least one outpatient visit, 270 died in the hospital, 236 received cardiopulmonary resuscitation and 99 received specialist hospice care.

CONCLUSIONS

Our study provides insights into the end-of-life care-seeking behavior of advanced cancer patients in China and our findings serve as a useful benchmark for estimating the use of end-of-life medical care. It highlights the need for the establishment of an accessible and patient-centered palliative care and hospice system.

Exploring the Impact and Lived Experiences of Hospice Staff Working in End-of-Life Care: An Interpretative Phenomenological Analysis (IPA)

Current research surrounding the experiences of hospice staff is significantly underdeveloped. Additionally, the stigmatisation of death in Western society has formed delusions of hospice care amongst the general public. These findings gained an insight of the lived experiences of six hospice staff across England and Wales, through an interpretative phenomenological analysis. Eight superordinate themes were identified; 'COVID-19 as a barrier to care delivery', 'Discomfort is key for personal growth', 'Self-preservation is paramount', 'Psychological impact of hospice environment', 'Internal conflict surrounding life and death', 'Complexities of a firm belief system', 'Utopian view of hospices' and 'Colleagues are a pillar of support'. All narratives shared overarching themes on growth, acceptance, and morality. These findings have future implications at the organisational level, identifying areas for adjustment for employee wellbeing. Furthermore, this may also educate aspiring end-of-life care staff in preparation for the reality of hospice environments.

Complexities in supportive care for people with metastatic breast cancer: a qualitative study

PURPOSE

The complexity of metastatic breast cancer, its rapidly evolving treatment, and the changing trajectory toward long-term survivorship create unique challenges for the provision of supportive care. The experiences of health professionals enacting supportive care in contexts of those living long-term with incurable cancer have received limited research attention. This qualitative study aimed to gain further insight into health professionals' experiences of supportive care in this context.

METHOD

Semi-structured interviews were conducted via phone and online with 25 health and community-care professionals who support people living with metastatic breast cancer in Australia. A mix of sampling strategies was used. Thematic analysis was undertaken. Findings were interpreted through an ethics of care lens.

RESULTS

Three key themes were identified. First, participants experienced supportive care as highly relational. Second, they encountered numerous moral and ethical dilemmas in enacting supportive care. Finally, enacting supportive care was complicated by fragmented and sporadic provision in a system in which supportive care is differentially valued across professions and settings.

CONCLUSION

Findings draw attention to complexities in enacting supportive care in the context of metastatic breast cancer, with implications to patients and professionals. To improve the quality of care provided to patients and minimise the risk of professional burnout, greater attention is needed in supportive care guidelines to the ethical, moral, and emotional complexities experienced by professionals in this context.

IMPLICATIONS FOR CANCER SURVIVORS

People living with metastatic breast cancer are a growing proportion of cancer survivors. The knowledge gained through this study may help professionals to better meet the supportive care needs of people living with metastatic breast cancer, a treatable but not curable condition.

Is it early enough? The authentic meaning of the pediatric palliative approach between early and late referral in pediatric oncology: a case study

The literature widely supports the benefits of early integration of palliative care into pediatric oncological care; however, many barriers to its successful integration remain. Integrating palliative care as early as possible in the oncology pathway is critical, but other criteria are relevant to positive results. This paper aims to contribute to the early/late referral dualism in pediatric palliative care (PPC) and highlight the importance of a collaborative approach between oncologists and palliative care teams. This study investigates the impact of early versus late referral to PPC, intersecting it with the synergy work between services and the related outcomes. The four pediatric cancer cases were selected based on clinical (e.g., disease duration, multiple treatments, and pain management), management (e.g., involvement of multiple services and multiple home-hospital transitions), and relevance of multidisciplinary team (e.g., difficult clinical decisions and ethical discussions) criteria. A mixed-methods approach was employed, combining qualitative case analysis using clinical diaries, literature review, and practice guidelines development. Critical clinical information, time course, clinician-family communication, and patient involvement were analyzed. The outcomes show how simultaneous care creates continuous discussion and dialogue between professionals. The results indicate the importance of better communication and care coordination to improve patient and family satisfaction, highlighting the uniqueness of the pediatric field and the relationship with children and families. Through the discussion of clinical cases and a literature review, we provide practical guidance for clinicians working in oncology and PPC. These findings underscore the crucial need for a multidisciplinary approach in pediatric oncology, advocating policy changes to support early PPC integration and translate it into complementarity best operating practices. In conclusion, besides assessing the timeliness of referral to the PPC service, the synergy, harmony, and choral work of the professionals involved are equally valuable for a quality-of-life-oriented care plan.

Nomenclature in Palliative and Kidney Supportive Care: Not Just at the End-of-Life

The multidimensional view of disease is fundamental in the care of complex diseases such as chronic kidney disease (CKD). It is appropriate to define and unify concepts that allow the different professionals involved in care to provide a multidisciplinary approach tailored to the needs of each individual. Given the increasing incidence of CKD worldwide and the fact that the disease may progress at different rates, there is a need to establish personalized, comprehensive approaches for each patient and their families at an earlier stage. This approach goes beyond the simple control of uremic symptoms or congestion and consists of addressing not only symptomatic but also functional, social and coping problems at an early stage, facilitating decision making both in the CKD and in acute situations, potentially irreversible or interventions that do not improve life expectancy. To ensure excellence in care, it is important to assess indicators of palliative care and kidney support, such as the presence of advance and shared care planning, the inclusion of psychosocial, ethical, spiritual and bereavement care. This enables the provision of comprehensive, humanized, and high-quality care for patients and their families. Palliative and kidney care is not just about patients in the last days of life. Defining, unifying, and evaluating the concepts will allow them to be applied in a timely manner at each specific moment of the CKD trajectory.

The role of specialist palliative care in individuals "living beyond cancer": a narrative review of the literature

PURPOSE

Many patients living beyond cancer experience significant unmet needs, although few of these patients are currently reviewed by specialist palliative care teams (SPCTs). The aim of this narrative review was to explore the current and potential role of SPCTs in this cohort of patients.

METHODS

A search strategy was developed for Medline, and adapted for Embase, CINAHL, and PsycInfo. Additionally, websites of leading oncology, cancer survivorship, and specialist palliative care organisations were examined. The focus of the search was on individuals living beyond cancer rather than other groups of cancer survivors.

RESULTS

111 articles were retrieved from the search for full text review, and 101 other sources of information were identified after hand searching the reference lists of the full text articles, and the aforesaid websites. The themes of the review encompass the definition of palliative care/specialist palliative care, current models of specialist palliative care, core activities of SPCTs, relevant expertise of SPCTs, and potential barriers to change in relation to extending their support and expertise to individuals living beyond cancer. The review identified a paucity of evidence to support the role of SPCTs in the management of patients living beyond cancer.

CONCLUSIONS

Individuals living beyond cancer have many unmet needs, and specific services are required to manage these problems. Currently, there is limited evidence to support the role of specialist palliative care teams in the management of this cohort of people, and several potential barriers to greater involvement, including limited resources, and lack of relevant expertise.

Chatbot Performance in Defining and Differentiating Palliative Care, Supportive Care, Hospice Care

CONTEXT

Artificial intelligence (AI) chatbot platforms are increasingly used by patients as sources of information. However, there is limited data on the performance of these platforms, especially regarding palliative care terms.

OBJECTIVES

We evaluated the accuracy, comprehensiveness, reliability, and readability of three AI platforms in defining and differentiating "palliative care," "supportive care," and "hospice care."

METHODS

We asked ChatGPT, Microsoft Bing Chat, Google Bard to define and differentiate "palliative care," "supportive care," and "hospice care" and provide three references. Outputs were randomized and assessed by six blinded palliative care physicians using 0-10 scales (10 = best) for accuracy, comprehensiveness, and reliability. Readability was assessed using Flesch Kincaid Grade Level and Flesch Reading Ease scores.

RESULTS

The mean (SD) accuracy scores for ChatGPT, Bard, and Bing Chat were 9.1 (1.3), 8.7 (1.5), and 8.2 (1.7), respectively; for comprehensiveness, the scores for the three platforms were 8.7 (1.5), 8.1 (1.9), and 5.6 (2.0), respectively; for reliability, the scores were 6.3 (2.5), 3.2 (3.1), and 7.1 (2.4), respectively. Despite generally high accuracy, we identified some major errors (e.g., Bard stated that supportive care had "the goal of prolonging life or even achieving a cure"). We found several major omissions, particularly with Bing Chat (e.g., no mention of interdisciplinary teams in palliative care or hospice care). References were often unreliable. Readability scores did not meet recommended levels for patient educational materials.

CONCLUSION

We identified important concerns regarding the accuracy, comprehensiveness, reliability, and readability of outputs from AI platforms. Further research is needed to improve their performance.

Hospice and palliative care utilization in 16 004 232 medicare claims: comparing trauma to surgical and medical inpatients

Background

Hospice and palliative care (PC) utilization is increasing in geriatric inpatients, but limited research exists comparing rates among trauma, surgical and medical specialties. The goal of this study was to determine whether there are differences among these three groups in rates of hospice and PC utilization.

Methods

Patients from Centers for Medicare & Medicaid Services (CMS) Inpatient Standard Analytical Files for 2016-2020 aged ≥65 years were analyzed. Patients with a National Trauma Data Standard-qualifying ICD-10 injury code with abbreviated injury score ≥2 were classified as 'trauma'; the rest as 'surgical' or 'medical' using CMS MS-DRG definitions. Patients were classified as having PC if they had an ICD-10 diagnosis code for PC (Z51.5) and as hospice discharge (HD) if their hospital disposition was 'hospice' (home or inpatient). Use proportions for specialties were compared by group and by subgroups with increasing risk of poor outcome.

Results

There were 16M hospitalizations from 1024 hospitals (9.3% trauma, 26.3% surgical and 64.4% medical) with 53.7% women, 84.5% white and 38.7% >80 years. Overall, 6.2% received PC and 4.1% a HD. Both rates were higher in trauma patients (HD: 3.6%, PC: 6.3%) versus surgical patients (HD: 1.5%, PC: 3.0%), but lower than in medical patients (HD: 5.2%, PC: 7.5%). PC rates increased in higher risk patient subgroups and were highest for inpatient HD.

Conclusions

In this large study of Medicare patients, HD and PC rates varied significantly among specialties. Trauma patients had higher HD and PC utilization rates than surgical, but lower than medical. The presence of comorbidities, frailty and/or severe traumatic brain injury (in addition to advanced age) may be valuable criteria in selection of trauma patients for hospice and PC services. Further studies are needed to inform the most efficient use of hospice and PC resources, with particular focus on both timing and selection of subgroups most likely to benefit from these valuable yet limited resources.

Level of evidence

Level III, therapeutic/care management.

Soins de soutien au Nouveau-Brunswick (Canada): analyse de l’environnement

Le diagnostic et le traitement du cancer laissent rarement les survivants et leurs proches physiquement et psychologiquement indemnes. Les services dont ils ont besoin dépassent le seul traitement médical, c’est-à-dire qu’il leur faut une variété de soins de soutien répondant à leurs besoins physiques, sociaux, informationnels et émotionnels. La présente étude a pour objectif de répertorier les services de soutien destinés aux survivants du cancer, aux membres de leur famille et à leurs proches aidants qui sont disponibles dans la province du Nouveau-Brunswick, au Canada. Pour ce faire, nous avons procédé à une analyse de l’environnement, ce qui nous a permis de constater que les services disponibles dans la province ne sont pas facilement repérables ou accessibles. On a observé tout particulièrement des lacunes dans les services aux survivants, à leur famille et à leurs proches, en phase post-traitement.

Supportive care services in New Brunswick, Canada: An environmental scan

Cancer diagnosis and treatment often have significant physical and psychological implications for both the survivor and their family/caregivers. Necessary services extend beyond medical treatment and include a variety of supportive care services (SCS) that address individuals' physical, social, educational, and emotional needs. This study seeks to map the SCS available in the province of New Brunswick (NB), Canada, for cancer survivors, their families, and their caregivers. An environmental scan was conducted to assess current SCS available in NB. While some SCS exist in NB, they are not always easily accessible or identifiable, and gaps in services were prevalent. In particular, a gap in services was found for individuals who are no longer actively receiving cancer treatment, as well as for family members and caregivers.

Enhanced supportive care in cancer centres: national cross-sectional survey

OBJECTIVES

'Early' specialist palliative care (SPC) has been shown to improve outcomes for patients with advanced cancer, yet patients are often referred late. 'Enhanced supportive care' (ESC) aims to facilitate earlier integrated supportive care for those with incurable cancer. This study aimed to explore clinicians' understanding of ESC/SPC delivery through description of current service provision.

METHODS

This national cross-sectional survey of 53 cancer centres had two parts. Part 1: Service details, was directed to lead ESC/SPC nurses or consultants about service configuration, and Part 2: Clinician understanding, targeting conceptual understanding of service aims including ESC/SPC teams and oncology consultants (n=262 surveys). Multiple-choice questions explored service provision, referral triggers and evidence of integration with oncology, with free-text responses. Quantitative results were analysed with Fischer's exact test. Qualitative free text was line-by-line coded by two authors independently to derive themes.

RESULTS

56% (30/53) of SPC and ESC teams and 14% (14/100) of oncologists responded. Those involved in ESC self-reported greater integration with oncology compared with non-ESC teams, for example, joint case discussions (64.3%, 9/14 vs 23.1%, 3/13, p=0.05), and timelier patient referral ((>6 months before death vs <6 months) (10/14 vs 4/13, p=0.06)). Qualitative themes described ambiguity in definitions of supportive and palliative terms and a perception of timelier identification of patients when ESC was involved.

CONCLUSION

Providers of ESC perceive greater integration with oncology and potentially timelier referral for patients compared with teams not delivering ESC. Terminology around SPC and ESC remains uncertain across England.

Variability in the perception of palliative care and end-of-life care among hematology professionals from the same reference center in Bahia, Brazil: A descriptive cross-sectional study

BACKGROUND

There are several illness-specific cultural and system-based barriers to palliative care (PC) integration and end-of-life (EOL) care in the field of oncohematology.

OBJECTIVES

This study aimed to investigate the variability in the perceptions of PC and EOL care.

DESIGN AND SETTING

A cross-sectional study was conducted in the Hematology Division of our University Hospital in Salvador, Bahia, Brazil.

METHODS

Twenty physicians responded to a sociodemographic questionnaire and an adaptation of clinical questionnaires used in previous studies from October to December 2022.

RESULTS

The median age of the participants was 44 years, 80% of the participants identified as female, and 75% were hematologists. Participants faced a hypothetical scenario involving the treatment of a 65-year-old female with a poor prognosis acute myeloid leukemia refractory to first-line treatment. Sixty percent of the participants chose to follow other chemotherapy regimens, whereas 40% opted for PC. Next, participants considered case salvage for the patient who developed septic shock following chemotherapy and were prompted to choose their most probable conduct, and the conduct they thought would be better for the patient. Even though participants were from the same center, we found a divergence from the most probable conduct among 40% of the participants, which was due to personal convictions, legal aspects, and other physicians' reactions.

CONCLUSIONS

We found considerable differences in the perception of PC and EOL care among professionals, despite following the same protocols. The study also demonstrated variations between healthcare professionals' beliefs and practices and persistent historical tendencies to prioritize aggressive interventions.

A Critical Overview of the Construct of Supportive Care Need in the Cancer Literature: Definitions, Measures, Interventions and Future Directions for Research

The growing amount of evidence about the role of supportive care in enhancing cancer patients' outcomes has made healthcare providers more sensitive to the need for support that they experience during cancer's trajectory. However, the lack of a consensus in the definition of supportive care and lack of uniformity in the theoretical paradigm and measurement tools for unmet needs does not allow for defined guidelines for evidence-based best practices that are universally accepted. Contemporary cancer literature confirms that patients continue to report high levels of unmet supportive care needs and documents the low effectiveness of most of the interventions proposed to date. The aim of this critical review is to consolidate the conceptual understanding of the need for supportive care, providing definitions, areas of expertise and a careful overview of the measurement tools and intervention proposals developed to date. The possible reasons why the currently developed interventions do not seem to be able to meet the needs, and the issues for future research were discussed.

Psychometric Properties of the Italian Version of the Short-Form Supportive Care Needs Survey Questionnaire (SCNS-SF34-It): A Multicenter Validation Study

This study aimed to evaluate psychometric properties of the Italian version of the Short-Form Supportive Care Needs Survey Questionnaire (SCNS-SF34) in a cancer population. A multicenter prospective observational study was carried out in outpatient and inpatient settings. The evaluated psychometric properties were as follows: the five-domain structure, the internal consistency, the convergent validity with the Edmond Symptom Assessment System (ESAS) questionnaire, the discriminant validity and test-retest reliability. A total of 714 patients with different types, stages and treatment settings of cancer were recruited. A total of 56% of participants were women, the median age 59 years (range 18-88). The prevalence of patients reporting at least one unmet need was 78.7%. The factor analysis explained 71.3% of the total variance, confirming the five-domain structure of the original model. Internal consistency was good, with Cronbach's alpha values ranging from 0.87 ("psychosocial need", "patient support and health system", "information") to 0.90 ("sexuality"). The convergent validity of the SCNS-SF34-It with the ESAS scale was low, suggesting that these questionnaires cover different concepts. The SCNS-SF34-It was able to discriminate differences between groups, and the test-retest reliability was good (ICC 0.72-0.84). The SCNS-SF34-It proved to be a reliable instrument for use in clinical practice for evaluating unmet needs in the Italian population of cancer patients. This study was not registered.

Informational and Practical Needs of Expectant Mothers with Chronic Hepatitis B in Ghana

Hepatitis B virus infection is a global public health problem with disproportionately high endemicity in Africa and Ghana. The current national prevalence of hepatitis B among pregnant women in Ghana stands at 7.44%, highlighting the considerable threat of chronic hepatitis B on pregnant women and their general well-being. The study explored the informational and practical needs of pregnant women with chronic hepatitis B in Ghana. Fourteen pregnant women were selected purposefully using the exploratory descriptive qualitative design. Data were analyzed using thematic analysis. The findings showed that pregnant women with chronic hepatitis B lacked knowledge about the infection and were in great need of hepatitis B-related information. The study also revealed significant financial implications for treating the infection, necessitating policy reforms and stakeholder actions. To achieve effective coping, better health-seeking, and health-promoting behaviors for better health outcomes, it is crucial to provide targeted care that comprehensively covers the specific needs of pregnant women with chronic hepatitis B. It is also essential to consider including hepatitis B management in the National Health Insurance package to improve care quality.

Interventions for Family Caregivers of Patients Receiving Palliative/Hospice Care at Home: A Scoping Review

There is a need for understanding the breadth of interventions for caregivers of individuals receiving hospice care at home, given the important role caregivers play in caring and the negative outcomes (e.g., depression) associated with their caregiving. Previous reviews were limited in scope to certain types of interventions or patient populations. The objective of this scoping review was to broadly examine the interventions targeting caregivers who provide care to terminally ill patients in home, with the purpose of (1) describing the characteristics of these interventions, (2) discussing key outcomes, limitations, and knowledge gaps, (3) highlighting intervention strengths, and (4) proposing future research directions. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Intervention studies that met the inclusion criteria and that were published up until October 2022 were obtained from the following databases: Ovid MEDLINE, Ovid EMBASE, CINAHL (EBSCO), and The Cochrane Library (Wiley). We analyzed 76 studies describing 55 unique interventions that took place in 14 countries. Interventions were largely delivered by nurses (n = 18, 24%), followed by an interdisciplinary team (n = 16, 21%), a health care provider (n = 10, 13%), research staff (n = 10, 13%), social worker (n = 5, 7%), and others (n = 11, 15%). Six interventions (8%) were self-administered. The most measured outcome was caregiver quality of life (n = 20, 26%), followed by anxiety (n = 18, 24%) and burden (n = 15, 20%). Missing data on patient and caregiver characteristics (i.e., age, gender) were common, and less than half of studies (n = 32, 42%) reported race/ethnicity data. Our review highlighted the current state of interventions for caregivers of patients receiving hospice care at home. Many of the interventions were in the early phases of development, raising the need for future studies to look at efficacy, effectiveness, and the ability to implement interventions in real-world settings.

The Duality of "Goals of Care" Language: A Qualitative Focus Group Study With Frontline Clinicians

CONTEXT

The phrase "goals of care" (GOC) is common in serious illness care, yet it lacks clarity and consistency. Understanding how GOC is used across healthcare contexts is an opportunity to identify and mitigate root causes of serious illness miscommunication.

OBJECTIVES

We sought to characterize frontline palliative and critical care clinicians' understanding and use of the phrase GOC in clinical practice.

METHODS

We conducted a secondary qualitative thematic analysis of focus group transcripts (n = 10), gathered as part of a parent study of care delivery for patients with respiratory failure. Participants (n = 59) were members of the palliative and critical care interprofessional teams at two academic medical centers.

RESULTS

Clinicians primarily use GOC as a shorthand signal among team members to indicate a patient is nearing the end of life. This signal can also indicate conflict with patients and families when clinicians' expectations-typically an expected "transition" toward a different type of care-are not met. Clinicians distinguish their clinical use of GOC from an "ideal" meaning of the phrase, which is broader than end of life and focused on patients' values. Palliative care specialists encourage other clinicians to shift toward the "ideal" GOC concept in clinical practice.

CONCLUSION

Frontline palliative and critical care clinicians understand a duality in GOC, as an idealized concept and as an expeditious signal for clinical care. Our findings suggest ambiguous phrases like GOC persist because of unmet needs for better ways to discuss and address diverse and complex priorities for patients with serious illness.

Anticancer Drugs Compared to No Anticancer Drugs in Patients with Advanced Hepatobiliary Cancer: A Mapping Review and Evidence Gap Map

Introduction

Despite being commonly recommended, the impact of anticancer drugs (ACDs) on patient-important outcomes beyond survival for advanced hepatobiliary cancers (HBCs) may not have been sufficiently assessed. We aim to identify and map the evidence regarding ACDs versus best supportive care (BSC) for advanced HBCs, considering patient-centered outcomes.

Methods

In this mapping review, we included systematic reviews, randomized controlled trials, quasi-experimental, and observational studies comparing ACDs (chemotherapy, immunotherapy, biological/targeted therapy) versus BSC for advanced HBCs. We searched MEDLINE (PubMed), EMBASE (Ovid), Cochrane Library, Epistemonikos, PROSPERO and clinicaltrials.gov for eligible studies. Two reviewers performed the screening and data extraction processes. We developed evidence maps for each type of cancer.

Results

We included 87 studies (60 for advanced liver cancer and 27 for gallbladder or bile duct cancers). Most of the evidence favored ACDs for survival outcomes, and BSC for toxicity. We identified several evidence gaps for non-survival outcomes, including quality of life or quality of end-of-life care.

Discussion

Patient-important outcomes beyond survival in advanced HBCs are insufficiently assessed by the available evidence. Future studies need to address these gaps to better inform decision-making processes.

Routine laboratory parameters to support decision on parenteral nutrition in palliative care

Introduction

Parenteral nutrition (PN) is widely used in palliative care (PC), but there is limited evidence to support its use at the end of life (EOL). This aim of this was to investigate the relationship between routine laboratory parameters and survival in patients receiving PN, and to develop a decision tree model to support clinicians decide whether to start or forgo PN.

Methods

The laboratory parameters of 113 patients with advanced diseases who were admitted to a specialized palliative care unit (PCU) were analyzed at two points in time: T0 = before PN, T1 = two weeks after initiation of PN. Univariate Mann-Whitney U-tests and multivariate linear regression models, as well as a decision tree analysis were computed; all in relation to survival time.

Results

The final regression model was significant with p = 0.001 (adjusted R2 = 0.15) and included two predictors for survival time after PN initiation: the CRP/albumin ratio and urea at T1 (ps = 0.019). Decision tree analysis revealed three important predictors for classification of survival time after PN initiation: CRP, urea, and LDH (all at T0).

Discussion

The decision tree model may help to identify patients likely to benefit from PN, thus supporting the clinical decision whether or not to start PN.

Enriching Lives: Geriatricians' Mission of Supportive Care for Older Persons

The growing older population, the increasing prevalence of chronic illnesses, and the pressing need to enhance the quality of end-of-life care have underscored the importance for geriatricians to focus on supportive and palliative measures. Within this context, the emphasis on delivering comprehensive and person-centered care has become crucial, ensuring that individuals not only receive medical treatment but also experience comfort during chronic illness and in their final days. Nevertheless, a significant number of older individuals often find themselves in hospitals during their last moments, sometimes undergoing aggressive medical interventions even when facing terminal conditions. The challenge lies in the early recognition of the end-of-life phase, initiating timely supportive and palliative care in conjunction with conventional treatments, adopting a multidisciplinary approach, and providing crucial support to grieving family members. Despite being a relatively recent field, geriatric palliative care (GPC) still requires further development. With this perspective, I aimed to shed light on the challenges and best practices for enhancing care for individuals facing chronic critical illnesses and frailty.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

Concurrent Care as the Next Frontier in End-of-Life Care

Importance

Hospice care is a unique type of medical care for people near the end of life and their families, with an emphasis on providing physical and psychological symptom management, spiritual care, and family caregiver support to promote quality of life. However, many people in the US who could benefit from hospice have very short stays or do not enroll at all due to current hospice policy. Changing policy to allow for concurrent availability of disease-directed therapy and hospice care-known as concurrent care-offers an opportunity to increase hospice use and lengths of stay.

Observations

Under Medicare payment policy, hospices are responsible for covering all costs related to patients' terminal conditions under a per diem rate. This payment structure has led to a de facto requirement that patients forgo costly therapies (including life-prolonging treatments or those with palliative intent) on enrollment in hospice because they are prohibitively expensive. In other countries, in Medicaid for children, and in the Veterans Health Administration in the US, there is greater flexibility in providing hospice services alongside life-prolonging care. Often paired with innovative payment models, concurrent care smooths practical, psychological, and physical care transitions when patient goals prioritize comfort. For example, allowing simultaneous receipt of hospice care and dialysis for people living with end-stage kidney disease-a group with relatively low hospice enrollment-can act as a bridge to hospice and potentially promote longer lengths of stay.

Conclusions and Relevance

Medicare and health care delivery systems are increasingly testing payment and care delivery models to improve hospice use via concurrent care, offering an important opportunity for innovation to better meet the needs of people living with serious illness and their families.

Assessment of supportive care needs among cervical cancer patients under treatment in Nepal: a cross-sectional study

BACKGROUNDS

The perceived supportive care needs (SCNs) of cancer patients are essential components of a care program. The first step in planning and intervening for supportive care is the proper identification of the SCNs of cancer patients. Cervical cancer (CC) is the most prevalent cancer among Nepali women. The authors assess SCNs and their predictors among CC patients under treatment by using a validated Nepali version supportive care need survey short form (SCNS- SF 34 N).

METHODS

This descriptive cross-sectional study was conducted in 5 cancer treatment hospitals in Nepal. A culturally adapted and psychometrically validated Nepali version SCNS -SF- 34 N was completed by a convenience sample of 218 CC patients. Data were analyzed by using descriptive (frequency, percentage, mean, median) and inferential (Chi-square P-value and binary logistic regression analysis) statistics.

RESULTS

The study showed that 99% of the respondents were in need of some level (low, moderate, high) of supportive care. The psychological domain, physical daily living, health system information, patient care support and sexuality domain ranked from first to fifth for SCNs with mean and standard deviations 70.29 ± 18.84, 63.25 ± 23.15, 57.90 ± 21.11, 56.46 ± 21.92 and 46.06 ± 34.16, respectively. Binary logistic regression found causal association between SCNs and variables "occupation (p-value = 0.007), and type of hospital (p-value = 0.000)" at a 95% confidence level.

CONCLUSION

Nepali CC patients perceive and experience many unmet SCNs, with psychological SCNs being the first priority. It is essential that the SCNs of patients may need to be known by their close family members, care providers, CC related program. so that they can offer intervention as per patients' needs.

Acute Oncologic Complications: Clinical-Therapeutic Management in Critical Care and Emergency Departments

Introduction. It is now known that cancer is a major public health problem; on the other hand, it is less known, or rather, often underestimated, that a significant percentage of cancer patients will experience a cancer-related emergency. These conditions, depending on the severity, may require treatment in intensive care or in the emergency departments. In addition, it is not uncommon for a tumor pathology to manifest itself directly, in the first instance, with a related emergency. The emergency unit proves to be a fundamental and central unit in the management of cancer patients. Many cancer cases are diagnosed in the first instance as a result of symptoms that lead the patient's admittance into the emergency room. Materials and Methods. This narrative review aims to analyze the impact of acute oncological cases in the emergency setting and the role of the emergency physician in their management. A search was conducted over the period January 1981-April 2023 using the main scientific platforms, including PubMed, Scopus, Medline, Embase and Google scholar, and 156 papers were analyzed. Results. To probe into the main oncological emergencies and their management in increasingly overcrowded emergency departments, we analyzed the following acute pathologies: neurological emergencies, metabolic and endocrinological emergencies, vascular emergencies, malignant effusions, neutropenic fever and anemia. Discussion/Conclusions. Our analysis found that a redefinition of the emergency department connected with the treatment of oncology patients is necessary, considering not only the treatment of the oncological disease in the strict sense, but also the comorbidities, the oncological emergencies and the palliative care setting. The need to redesign an emergency department that is able to manage acute oncological cases and end of life appears clear, especially when this turns out to be related to severe effects that cannot be managed at home with integrated home care. In conclusion, a redefinition of the paradigm appears mandatory, such as the integration between the various specialists belonging to oncological medicine and the emergency department. Therefore, our work aims to provide what can be a handbook to detect, diagnose and treat oncological emergencies, hoping for patient management in a multidisciplinary perspective, which could also lead to the regular presence of an oncologist in the emergency room.

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

Supportive Care: The "Keystone" of Modern Oncology Practice

The Multinational Association of Supportive Care in Cancer (MASCC) defines supportive care as "the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side effects across the continuum of the cancer journey from diagnosis through treatment to post-treatment care. Supportive care aims to improve the quality of rehabilitation, secondary cancer prevention, survivorship, and end-of-life care". This article will provide an overview of modern supportive care in cancer, discussing its definition, its relationship with palliative care, models of care, "core" service elements (multi-professional/multidisciplinary involvement), the evidence that supportive care improves morbidity, quality of life, and mortality in various groups of patients with cancer, and the health economic benefits of supportive care. The article will also discuss the current and future challenges to providing optimal supportive care to all oncology patients.

Effects of music-based interventions on cancer-related pain, fatigue, and distress: an overview of systematic reviews

PURPOSE

To summarize the available evidence from systematic reviews with meta-analysis on the effects of music-based interventions in adults diagnosed with cancer.

METHODS

An overview of systematic reviews was conducted. CINHAL, Embase, PEDro, PubMed, Scopus, the Cochrane Library and Web of Science were searched from inception until November 2022. Systematic reviews with meta-analysis in individuals with cancer (any type), any comparator, and outcomes of cancer-related pain, fatigue, and psychosocial symptoms were eligible. The methodological quality of systematic reviews and the amount of spin of information in the abstract were assessed. The Graphical Representation of Overlap for OVErviews tool (GROOVE) was used to explore the overlap of primary studies among systematic reviews.

RESULTS

Thirteen systematic reviews, with over 9000 participants, containing 119 randomized trials and 34 meta-analyses of interest, were included. Music-based interventions involved passive music listening or patients' active engagement. Most systematic reviews lacked a comprehensive search strategy, did not assess the certainty in the evidence and discussed their findings without considering the risk of bias of primary studies. The degree of overlap was moderate (5.81%). Overall, combining music-based interventions and standard care seems to be more effective than standard care to reduce cancer-related pain, fatigue, and distress. Mixed findings were found for other psychosocial measures.

CONCLUSION

Music-based interventions could be an interesting approach to modulate cancer-related pain, fatigue, and distress in adults with cancer. The variability among interventions, together with important methodological biases, detract from the clinical relevance of these findings.

Stigma of Palliative Care among Patients with Advanced Cancer and Their Caregivers on Early Palliative Care

The early referral to palliative care (PC) represents a successful value-based model with proven benefits regarding the quality of life and clinical outcomes for advanced cancer patients and their caregivers. Yet, its provision remains typically confined to the last weeks of life as per the historical, late PC model. The stigma according to which PC represents end-of-life care has been identified as the root of the problem. To explore the presence and effects of the stigma in a clinical context, we surveyed 78 patients and 110 caregivers (mean age: 71.7 and 60.7, respectively) on early PC to study what their perception of PC was before their direct experience. The responses were analyzed through a qualitative descriptive approach. The participants explicitly mentioned a lack of knowledge about PC (53% of the sample), which they identified also among physicians and the population (13%); an identification of PC with the late PC model (53%); and a detrimental reaction to the proposal of an early PC referral (83%). However, the participants explicitly mentioned that a direct experience of early PC allowed for an acquired awareness of early PC meaning and benefits (52%), as well as a comprehension of its differences with late PC (34%); the regret for the delayed referral (8%); the perception of the word "palliative" as a barrier (21%); and the belief that early PC should be part of the cancer routine practice (25%). A comprehensive multi-level intervention is necessary for a widespread understanding of the essence of anticipated PC.

Specialist Palliative Care for Patients with Cancer: More Than End-of-Life Care

Palliative care has traditionally focused on end-of-life care for patients with advanced cancer. This has since expanded to include symptom management and quality-of-life improvement from the moment of cancer diagnosis. Specialist palliative care teams work across community and inpatient settings and focus on dealing with complex problems whilst supporting healthcare colleagues in providing generalist palliative care. This article will outline the principles of palliative care, models of palliative care delivery, the distinctions between palliative care and supportive care, and the role of specialist palliative care in cancer survivorship.

Economic burden of acute myeloid leukemia on patients in a resource-limited tertiary hospital in the Philippines

INTRODUCTION

The remission induction treatment for acute myeloid leukemia (AML) has remained unchanged in the resource-limited setting in the Philippines. AML treatment consists of induction chemotherapy followed by high dose consolidation chemotherapy or allogeneic hematopoietic stem cell transplantation. In the Philippines, the Filipino household bears the burden of health care cost of hospitalization expenditure. Insights into the treatment costs becomes an essential requirement as these guides the allocation of resources to scheme health programs.

METHOD

This study involved a retrospective cohort analysis of AML patients who underwent treatment for AML. Review of the statements of account per admission per patient during treatment for remission induction, consolidation, relapsed and refractory disease and best supportive care from 2017 to 2019. Of the 251 eligible patients, 190 patients were included.

RESULT

The mean healthcare expenditure for remission induction chemotherapy (Phase 1) was US $2, 504.78 (Php 125,239.29). While 3 to 4 cycles of consolidation chemotherapy cost an average of US $3,222.72 (Php 162,103.20). For patients who had relapsed and refractory disease, an additional mean cost of US $3,163.32 (Php 159,115.28) and US $2, 914.72 (Php 146,610.55) were incurred, respectively. The average cost of palliative care was US $1,687.00 (Php 84,856.59).

CONCLUSION

The cost of chemotherapy and other therapeutics bear most of the weight of the direct healthcare cost. The cost of AML treatment represents a significant economic burden for patients and the institution. The cost increases as patients proceed through subsequent lines of treatment for induction failure. Existing subsidy for health insurance benefits could still be improved for appropriate source allocation of resources.

Early and late recurrence patterns of pancreatic ductal adenocarcinoma after pancreaticoduodenectomy: a multicenter study

BACKGROUND

Survival after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) remains poor because of high incidences of recurrence. The risk factors, patterns, and long-term prognosis in patients with early recurrence and late recurrence (ER and LR) for PDAC after PD were studied.

METHODS

Data from patients who underwent PD for PDAC were analyzed. Recurrence was divided into ER (ER ≤1 years) and LR (LR >1 years) using the time to recurrence after surgery. Characteristics and patterns of initial recurrence, and postrecurrence survival (PRS) were compared between patients with ER and LR.

RESULTS

Among the 634 patients, 281 (44.3%) and 249 (39.3%) patients developed ER and LR, respectively. In the multivariate analysis, preoperative CA19-9 levels, resection margin status, and tumor differentiation were significantly associated with both ER and LR, while lymph node metastasis and perineal invasion were associated with LR. Patients with ER, when compared with patients with LR, showed a significantly higher proportion of liver-only recurrence ( P <0.05), and worse median PRS (5.2 vs. 9.3 months, P <0.001). Lung-only recurrence had a significantly longer PRS when compared with liver-only recurrence ( P <0.001). Multivariate analysis demonstrated that ER and irregular postoperative recurrence surveillance were independently associated with a worse prognosis ( P <0.001).

CONCLUSION

The risk factors for ER and LR after PD are different for PDAC patients. Patients who developed ER had worse PRS than those who developed LR. Patients with lung-only recurrence had a significantly better prognosis than those with other recurrent sites.

What does 'good' palliative care look like for children and young people? A qualitative study of parents' experiences and perspectives

BACKGROUND

Worldwide, around 21 million children would benefit from palliative care and over 7 million babies and children die each year. Whilst provision of paediatric palliative care is advancing, there major gaps between what should be done, and what is being done, in clinical practice. In 2017, the National Institute for Health and Care Excellence (NICE) introduced a quality standard, to standardise and improve children's palliative care in England. However, there is little evidence about what good experiences of palliative care for children are, and how they relate to the quality standard for end-of-life care.

AIM

This study explored how the NICE quality standard featured in parental experiences of palliative care for children to understand what 'good' palliative care is.

DESIGN

Qualitative study, employing in-depth, telephone and video-call, semi-structured interviews. Data were analysed using thematic analysis, informed by Appreciative Inquiry.

SETTING/PARTICIPANTS

Participants were parents of children and young people (aged 0-17 years) in England, who were receiving palliative care, and parents whose child had died.

RESULTS

Fourteen mothers and three fathers were interviewed. Seven were bereaved. Parents were recruited via four children's hospices, one hospital, and via social media. Good palliative care is co-led and co-planned with trusted professionals; is integrated, responsive and flexible; encompasses the whole family; and enables parents to not only care for, but also to parent their child to end of life.

CONCLUSIONS

Findings have implications for informing evidence based practice and clinical guidelines, overall improving experiences of care.

Health Literacy of Surrogates and Communication Issues in Palliative Care Conversations in Critical Care: An Integrative Review

Worldwide, 56.8 million persons are estimated to require palliative care. Critically ill patients benefit from palliative care by improving their quality of life through symptom management. Resistance to palliative care exists from surrogate decision-makers because of low health literacy and communication issues with providers. This research reviewed the literature to identify how health literacy and health care communication influenced palliative care conversations with decision-making surrogates and health outcomes of critically ill patients. The review included articles between 2011 and 2022 using the terms communication, health literacy, palliative care, critical care, intensive care, ICU, surrogate decision maker, family, and caregiver in PubMed, CINAHL, and Google Scholar. Fourteen articles were included. Quality was assessed through Joanna Briggs Institute appraisal tools. Health literacy of surrogates was not found to be significant for patient outcomes. However, there were significant differences between clinician and surrogate communication influenced by surrogates' previous health care experiences. Early communication about prognosis was important for surrogates. Structured communication approaches were preferred by surrogates. Limitations of the review included primarily White participants, small variability of research sites, and a few number of articles. Future research needs to study the effects of surrogate health literacy of critically ill patients on willingness to accept palliative care.

Barriers to palliative care in hepatocellular carcinoma: A review of the literature

Hepatocellular carcinoma (HCC) is a deadly and burdensome form of liver cancer with an increasing global prevalence. Its course is unpredictable as it frequently occurs in the context of underlying end-stage liver disease, and the associated symptoms and adverse effects of treatment cause severe suffering for patients. Palliative care (PC) is a medical specialty that addresses the physical, emotional, and spiritual needs of patients and their carers in the context of life-limiting illness. In other cancers, a growing body of evidence has demonstrated that the early introduction of PC at diagnosis improves patient and carer outcomes. Despite this, the integration of palliative care at the diagnosis of HCC remains suboptimal, as patients usually receive PC only at the very terminal phase of their disease, even when diagnosed early. Significant barriers to the uptake of palliative care in the treatment algorithm of hepatocellular carcinoma fall under four main themes: data limitations, disease, clinician, and patient factors. Barriers relating to data limitations mainly encapsulated the risk of bias inherent in published work in the field of PC. Clinician-reported barriers related to negative attitudes towards PC and a lack of time for PC discussions. Barriers related to the disease align with prognostic uncertainty due to the unpredictable course of HCC. Significantly, there exists a paucity of evidence exploring patient-perceived barriers to timely PC implementation in HCC. Given that patients are often the underrepresented stakeholder in the delivery of PC, future research should explore the patient perspective in adequately designed qualitative studies as the first step.

Systemic oncological treatments in patients with advanced pancreatic cancer: a scoping review and evidence map

PURPOSE

To identify, describe, and organise currently available evidence regarding systemic oncological treatments (SOTs) (chemotherapy, targeted/biological therapies, and immunotherapy) compared to best supportive care (BSC) for patients with advanced pancreatic cancer (PC).

METHODS

We conducted a scoping review and evidence mapping, adhering to PRISMA-ScR checklist. We searched MEDLINE, EMBASE, Cochrane Library, Epistemonikos, PROSPERO, and clinicaltrials.gov for eligible studies. We included systematic reviews (SRs), randomised controlled trials (RCTs), quasi-experimental, and observational studies evaluating SOTs compared to BSC or no treatment in patients with advanced PC. Two independent reviewers performed the screening process and data extraction. We developed evidence maps as an interactive visualization display, including the assessed interventions and outcomes.

RESULTS

Of the 50,601 records obtained from our search, we included 43 studies: 2 SRs, 16 RCTs, 4 quasi-experimental studies, 20 observational studies, and 1 protocol for a quasi-experimental study. Forty-two studies reported survival-related outcomes and most favoured SOTs, while five reported toxicity and most favoured BSC. Other patient-centred outcomes, such as quality of life, were scarcely reported.

CONCLUSIONS

This study highlights the current evidence gaps in studies assessing treatments for patients with advanced PC, mainly the lack of reports of non-survival-related outcomes, pointing out research areas that need further attention to make better recommendations for these patients.

Palliative care in multiple sclerosis

Main target in palliative care (PC) is burden care of patients and their families, with the aim to reduce suffering through the management of symptoms, rehabilitation, psychosocial issues, and spiritual well-being, using a multidisciplinary approach. Multiple sclerosis (MS) is a chronic disease which induces physical and psychosocial symptoms, with a significant impact on the quality of life. As a consequence, despite advances in research in disease-modifying drugs, MS remains a life-limiting disease with symptoms negatively impacting the lives of MS patients and their families. PC has been developed for end-of-life treatment in oncology, being little used in MS. Specific issues in MS, like pain due to spasticity, requires a different approach respect to cancer pain management. Moreover, it is difficult to anticipate life expectancy in people with severe MS, who often need palliative care for a long extended period. PC teams are trained to keep open full and competent lines of communication about symptoms and disease progression, advanced care planning, and end-of-life issues and wishes. Many studies investigated the effects of home-based PC in advanced MS, showing weak evidences about the efficacy of PC versus usual care in MS. However, current evidence does not support or refute the routine use of PC interventions for people with MS.

Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies

BACKGROUND

Frameworks are the conceptual underpinnings of the study. Both conceptual and theoretical frameworks are often used in palliative and end-of-life care studies to help with study design, guide, and conduct investigations. While an increasing number of investigators have included frameworks in their study, to date, there has not been a comprehensive review of frameworks that were utilized in palliative and end-of-life care research studies.

AIM

To summarize conceptual and theoretical frameworks used in palliative and end-of-life care research studies. And to synthesize which of eight domains from the National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care (fourth edition) each framework belongs to.

DESIGN

Systematic review.

DATA SOURCES

Four electronic databases (EMBASE, the Cumulative Index to Nursing and Allied Health, PsychINFO, and PubMed) were searched from July 2010 to September 2021.

RESULTS

A total 2231 citations were retrieved, of which 44 articles met eligibility. Across primary studies, 33,801 study participants were captured. Twenty-six investigators (59.1%) proposed previously unpublished frameworks. In 10 studies, investigators modified existing frameworks, mainly to overcome inherent limitations. In eight studies, investigators utilized existing frameworks referenced in previously published studies. There were eight orientations identified among 44 frameworks we reviewed (e.g. system, patient, patient-doctor).

CONCLUSIONS

We examined palliative and end-of-life research studies to identify and characterize conceptual or theoretical frameworks proposed or utilized. Of 44 frameworks we reviewed, 21 studies (47.7%) were aligned with a Clinical Practice Guideline's single domain, while the rest two or more of eight guidelines in quality palliative care domains.

Palliative Care and Physician Assisted Death

In the recent decade quite a few countries and regions legalised physician assisted death. While palliative care is already or becoming the standard end of life care in many countries, the increased availability of physician assisted death coupled with the secularisation of hospice in more settings require – where this has not happened yet – a clear response of palliative care specialists to patients’ requests for physician assisted death. The paper analyses the World Health Organisation’s current description of palliative care with a special focus on its prohibition of hastening death. Some palliative care professionals do not agree with the ban on hastening death, and these professionals’ non-conventional interpretation of palliative care actually seems to meet the wishes of some patients.

Hospice care delivery system requirements

BACKGROUND

Hospice care is a perceived need in the Iranian health system.

AIM

This qualitative study is explaining the stakeholders' perception of what is required to develop a hospice care system for patients living with cancer in Iran.

METHODS

A total of 21 participants (specialists, policymakers, healthcare providers, cancer patients and family caregivers) were selected through purposeful sampling and interviewed in-depth in 2020. Interviews were analysed through directed content analysis.

FINDINGS

A total of 1054 codes, 7 categories and 21 subcategories were extracted. The requirements include the need to provide: multiple settings and diverse services; participatory decision making; integration into the health system; specialised human resources; an organised system of accountability; the preparation of the existing health system; and wider capacity-building in existing Iranian society.

CONCLUSION

It is essential that Iranian services create a participatory comprehensive care plan, utilise expert manpower, integrate hospice care into the existing health system and organise a system of accountability. Policymakers should focus on the preparation of the health system and capacity building in society.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

CLINICALTRIALS

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

Symptoms and survivorship needs differences between "good sleepers" and "bad sleepers" in survivors of breast and gynecologic cancers

INTRODUCTION

Although 80% of cancer survivors report symptoms of insomnia, only 28-43% meet DSM-5 criteria for this diagnosis. We sought to characterize the association between patient-reported insomnia symptoms, patient outcomes, and supportive care variables, as well as explore clinically meaningful insomnia thresholds in a sample of women diagnosed with breast and gynecologic cancers.

METHODS

From July 2018-March 2019, all breast and gynecologic cancer survivors seen at the Stanford Women's Cancer Center were approached and invited to participate in the study (15% declined). Of those who consented, 273 survivors completed an online survey related to their sleep (ISI), quality of life (FACT-G), distress (PHQ-4), supportive care needs (SCNS-SF34), and symptom severity (MDASI). Survivors who scored <8 on ISI were categorized as "good sleepers," survivors with ISI ≥8 were categorized as "bad sleepers."

RESULTS

126 (46.2%) of survivors were "good sleepers," 147 (53.8%) were "bad sleepers." Good sleepers were older than bad sleepers (p < .05) but did not differ in any other demographic or any medical variables. Using hierarchical linear regression models, we found that good sleep (ISI <8) was associated with higher quality of life, lower psychological distress, increased social support, lower symptom severity, and lower supportive care needs, after accounting for demographic, medical, and treatment variables. The findings were largely replicated with an ISI cut off of 15.

CONCLUSIONS

Among women treated for breast and gynecologic cancers, survivors who were good sleepers had better psychosocial outcomes, fewer supportive care needs, and lower symptom severity compared to those who reported insomnia symptoms. Results also indicate that degree of sleep impairment, whether mild or severe, has similarly poor associations with most aspects of patient functioning and symptomatic burden. Further research is needed to determine causality of these findings.

Contribution of Synthetic Data Generation towards an Improved Patient Stratification in Palliative Care

AI model development for synthetic data generation to improve Machine Learning (ML) methodologies is an integral part of research in Computer Science and is currently being transferred to related medical fields, such as Systems Medicine and Medical Informatics. In general, the idea of personalized decision-making support based on patient data has driven the motivation of researchers in the medical domain for more than a decade, but the overall sparsity and scarcity of data are still major limitations. This is in contrast to currently applied technology that allows us to generate and analyze patient data in diverse forms, such as tabular data on health records, medical images, genomics data, or even audio and video. One solution arising to overcome these data limitations in relation to medical records is the synthetic generation of tabular data based on real world data. Consequently, ML-assisted decision-support can be interpreted more conveniently, using more relevant patient data at hand. At a methodological level, several state-of-the-art ML algorithms generate and derive decisions from such data. However, there remain key issues that hinder a broad practical implementation in real-life clinical settings. In this review, we will give for the first time insights towards current perspectives and potential impacts of using synthetic data generation in palliative care screening because it is a challenging prime example of highly individualized, sparsely available patient information. Taken together, the reader will obtain initial starting points and suitable solutions relevant for generating and using synthetic data for ML-based screenings in palliative care and beyond.

Criteria for Referral of Patients With Advanced Heart Failure for Specialized Palliative Care

BACKGROUND

Patients with advanced heart failure have substantial supportive care needs. Specialist palliative care can be beneficial, but it is unclear who is most appropriate for referral and when patients should be referred.

OBJECTIVES

We conducted a Delphi study of international experts to identify consensus referral criteria for specialist palliative care for patients with advanced heart failure.

METHODS

Clinicians from 5 continents with expertise in the integration of cardiology and palliative care were asked to rate 34 disease-based, 24 needs-based, and 9 time-based criteria over 3 rounds. Consensus was defined a priori as ≥70% agreement. A criterion was coded as major if the experts endorsed that meeting that criterion alone was adequate to justify a referral.

RESULTS

The response rate was 44 of 46 (96%), 41 of 46 (89%), and 43 of 46 (93%) in the first, second, and third rounds, respectively. Panelists reached consensus on 25 major criteria for specialist palliative care referral. The 25 major criteria were categorized under 6 topics, including "advanced/refractory heart failure, comorbidities, and complications" (eg, cardiac cachexia, cardiorenal syndrome) (n = 8), "advanced heart failure therapies" (eg, chronic inotropes, precardiac transplant) (n = 4), "hospital utilization" (eg, emergency room visits, hospitalization) (n = 2), "prognostic estimate" (n = 1), "symptom burden/distress" (eg, severe physical/emotional/spiritual distress) (n = 6), and "decision making/social support" (eg, goals-of-care discussions) (n = 4). The majority (68%) of major criteria had ≥90% agreement.

CONCLUSIONS

International experts reached consensus on a large number of criteria for referral to specialist palliative care. With further validation, these criteria may be useful for standardizing palliative care access in the inpatient and/or outpatient settings.

The Implementation of Palliative Home Care in Southeast Asian Countries: An Integrative Review

In Asia where family caregiving is part of the culture, palliative home care becomes the most suitable service to keep patients close to their family and to reduce costs. There is a wide variety of palliative home care services due to different cultures and levels of involvement of the family. This review aims to explore the implementation of palliative home care in East and Southeast Asian countries. The articles reviewed in this study were obtained from 3 electronic databases: EbscoHost, PubMed, and Scopus. Journal articles that discussed palliative home care for patients with cancer in East and Southeast Asia countries were included. Review papers were excluded. Seven studies were used in the current review. In general, there are 6 services provided for palliative home care in this region, which are daily activity living care, planning and preparation for palliative home care, education and counseling, patients’ follow-up, symptom management, and direct care for family. Most of the programs involve family caregivers during the treatment. The palliative home care team consists of at least a doctor and a nurse. Symptom management is the most common service and direct care for family is the least offered palliative home care service in this region. Alleviating symptoms is one of the targets in palliative care, therefore involving family in symptom management for palliative home care is fundamental. Although caregiving is part of the culture, family members need to be supported to maintain their quality of life.

'End of life': a concept analysis

BACKGROUND

The concept of end of life (EOL), as in the term end-of-life care, is used synonymously in both palliative and terminal care. Practitioners and researchers both require a clearer specification of the end-of-life concept to be able to provide appropriate care in this phase of life and to conduct robust research on a well-described theoretical basis.

AIMS

The aim of this study was to critically analyse the end-of-life concept and its associated terminology.

METHOD

A concept analysis was performed by applying Rodgers' evolutionary concept analysis method.

FINDINGS

Time remaining, clinical status/physical symptoms, psychosocial symptoms and dignity were identified as the main attributes of the concept. Transition into the end-of-life phase and its recognition were identified as antecedents. This study demonstrates that end-of-life care emerged following the application of the 'end-of-life concept' to clinical practice.

CONCLUSION

The early recognition of the end-of-life phase seems to be crucial to ensuring an individual has well-managed symptoms and a dignified death.

Identification of early symptoms and changes in QoL and functioning among men with primary localized prostate cancer who later develop metastases: A matched, prospective study

OBJECTIVE

To identify early symptoms and changes in QoL among men with primary localized prostate cancer (PC) who later develop metastases.

METHODS

From an ongoing prospective study of 3.885 men with localized PC, primarily treated with radiotherapy (RT), a subsample of men developing metastatic PC (mPC) following the first year after the start of RT and that had died during the follow-up (mPC group, n = 107) were matched against men who did not develop metastases (non-mPC group, n = 214). Data were collected using the EORTC QLQ-C30 and PCSS instruments. Non-parametric tests were performed for comparisons at baseline, end of RT, 3 months, and 1, 2, 3, and 5 years after RT.

RESULTS

The final sample consists of 317 men (mPC n = 106; non-mPC n = 211) who had completed at least one questionnaire. Initially, symptom levels were generally low and QoL and functioning high in both groups. An increasing difference between the groups was found, where the mPC group gradually deteriorated from the 2-year follow-up. Significant differences were found for several outcomes at 3 and 5 years. In a sensitivity analysis, where metastatic patients were removed from the time-point of verified metastases, most differences did not remain significant. Significant deterioration over time was seen within both groups for some outcomes.

SIGNIFICANCE OF RESULTS

The results indicate that unmet supportive needs occur over time among these men. Worsening QoL or functioning and symptoms may be difficult to recognize when the development is gradual over several years, and with various access to systematic follow-up in late phases. This highlights the need for continuous monitoring of PC patients to detect needs for supportive interventions early and throughout the disease course, also among those with non-metastatic disease who have undergone curatively intended treatment.

Implementing Patient-Directed Cancer Education Materials Across Nigeria

As access to cancer care expands in low-income countries, developing tools to educate patients is paramount. We took a picture booklet, which was initially developed by the nonprofit Global Oncology for Malawi and Rwanda, and adapted it for use in Nigeria. The primary goal was to assess acceptability and provide education. The secondary goals were (1) to describe the collaboration, (2) to assess knowledge gained from the intervention, (3) to assess patient understanding of their therapy intent, and (4) to explore patient's experiences via qualitative analysis.

In this cross-continent collaboration supported by @StanfordCIGH, low literacy-friendly cancer education booklets developed by @GlobalOnc increased awareness and knowledge about cancer treatment in 4 diverse sites in Nigeria.