Palliative performance scale and survival among outpatients with advanced cancer

Effect of logotherapy counseling program on chronic sorrow, dignity, and meaning in life of palliative care patients: a randomized controlled trial

PURPOSE

Palliative care patients experience chronic sorrow with loss in dignity and meaning in life. Logotherapy is an effective way to cope with loss. This study aimed to evaluate the effect of logotherapy on chronic sorrow, dignity, and meaning in life of palliative care patients.

METHODS

This study was conducted with 58 adults hospitalized due to advanced cancer and assigned to either intervention or control group by simple randomization. Data were collected with descriptive information form, Palliative Performance Scale, Patient Dignity Inventory (PDI), Prolonged Grief Disorder Scale-Patient Form (PGDS-PF), and Meaning in Life Questionnaire (MIL) on admission, at the 4th and 8th weeks. The intervention group received eight sessions of logotherapy. The control group received routine care.

RESULTS

The mean scores of PGDS-PF (p = 0.01), PDI (p = 0.01), and searched meaning subdimension of MIL (MIL-SM) (p = 0.11) decreased in the intervention group compared to controls, both at the 4th and 8th week evaluation. The mean score of the present meaning subdimension of MIL (MIL-PM) (p = 0.02) increased at the 4th week evaluation but decreased at a non-statistically significant level at the 8th week. The mean scores of PGDS-PF and PDI increased in the control group while MIL-PM and MIL-SM decreased, both at the 4th and 8th week evaluation.

CONCLUSIONS

Logotherapy was found effective in decreasing the sorrow and dignity-related distress of palliative care patients, while increasing finding meaning in life. Logotherapy is recommended to be used by palliative care professionals to empower patients.

TRIAL REGISTRATION

Clinicaltrials registration number and date: NCT05129059, 19/01/2021.

Prognoses Associated With Palliative Performance Scale Scores in Modern Palliative Care Practice

Importance

The Palliative Performance Scale (PPS) is one of the most widely used prognostic tools for patients with serious illness. However, current prognostic estimates associated with PPS scores are based on data that are over a decade old.

Objective

To generate updated prognostic estimates by PPS score, care setting, and illness category, and examine how well PPS predicts short- and longer-term survival.

Design, Setting, and Participants

This prognostic study was conducted at a large academic medical center with robust inpatient and outpatient palliative care practices using electronic health record data linked with data from California Vital Records. Eligible participants included patients who received a palliative care consultation between January 1, 2018, and December 31, 2020. Data analysis was conducted from November 2022 to February 2024.

Exposure

Palliative care consultation with a PPS score documented.

Main Outcomes and Measures

The primary outcomes were predicted 1-, 6-, and 12-month mortality and median survival of patients by PPS score in the inpatient and outpatient settings, and performance of the PPS across a range of survival times. In subgroup analyses, mortality risk by PPS score was estimated in patients with cancer vs noncancer illnesses and those seen in-person vs by video telemedicine in the outpatient setting.

Results

Overall, 4779 patients (mean [SD] age, 63.5 [14.8] years; 2437 female [51.0%] and 2342 male [49.0%]) had a palliative care consultation with a PPS score documented. Of these patients, 2276 were seen in the inpatient setting and 3080 were seen in the outpatient setting. In both the inpatient and outpatient settings, 1-, 6-, and 12-month mortality were higher and median survival was shorter for patients with lower PPS scores. Prognostic estimates associated with PPS scores were substantially longer (2.3- to 11.7-fold) than previous estimates commonly used by clinicians. The PPS had good ability to discriminate between patients who lived and those who died in the inpatient setting (integrated time-dependent area under the curve [iAUC], 0.74) but its discriminative ability was lower in the outpatient setting (iAUC, 0.67). The PPS better predicted 1-month survival than longer-term survival. Mortality rates were higher for patients with cancer than other serious illnesses at most PPS levels.

Conclusions and Relevance

In this prognostic study, prognostic estimates associated with PPS scores were substantially longer than previous estimates commonly used by clinicians. Based on these findings, an online calculator was updated to assist clinicians in reaching prognostic estimates that are more consistent with modern palliative care practice and specific to the patient's setting and diagnosis group.

Building capacity for palliative care delivery in primary care settings: Mixed-methods evaluation of the INTEGRATE Project

OBJECTIVE

To evaluate an intervention aimed at building capacity to deliver palliative care in primary care settings.

DESIGN

The INTEGRATE Project was a 3-year pilot project involving interprofessional palliative care education and an integrated care model to promote early identification and support of patients with palliative care needs. A concurrent mixed-methods evaluation was conducted using descriptive data, provider surveys before and after implementation, and interviews with providers and managers.

SETTING

Four primary care practices in Ontario.

PARTICIPANTS

All providers in each practice were invited to participate. Providers used the "surprise question" as a prompt to determine patient eligibility for inclusion.

MAIN OUTCOME MEASURES

Provider attitudes toward and confidence in providing palliative care, use of palliative care tools, delivery of palliative care, and perceived barriers to delivering palliative care.

RESULTS

A total of 294 patients were identified for early initiation of palliative care, most of whom had multiple comorbid conditions. Results demonstrated improvement in provider confidence to deliver palliative care (30% mean increase, P < .05) and self-reported use of palliative care tools and services (25% mean increase, P < .05). There was substantial variation across practices regarding the percentage of patients identified using the surprise question (0.2% to 1.5%), the number of advance care planning conversations initiated (50% to 90%), and mean time to conversation (13 to 76 days). This variation is attributable, in part, to contextual differences across practices.

CONCLUSION

A standardized model for the early introduction of palliative care to patients can be integrated into the routine practice of primary care practitioners with appropriate training and support. Additional research is needed to understand the practice factors that contribute to the success of palliative care interventions in primary care and to examine patient outcomes.

Changes in the palliative performance scale may be as important as the initial palliative performance scale for predicting survival in terminal cancer patients

OBJECTIVE

The accurate estimation of expected survival in terminal cancer patients is important. The palliative performance scale (PPS) is an important factor in predicting survival of hospice patients. The purpose of this study was to examine how initial status of PPS and changes in PPS affect the survival of hospice patients in Korea.

METHOD

We retrospectively examined 315 patients who were admitted to our hospice unit between January 2017 and December 2018. The patients were divided based on the PPS of ≥50% (group A) and ≤40% (group B). We performed survival analysis for factors associated with the length of survival (LOS) in group A. Based on the hospice team's weekly evaluation of PPS, we examined the effect of initial levels and changes in group A on the prognosis of patients who survived for 2 weeks or more.

RESULTS

At the time of admission to hospice, 265 (84.1%) patients were PPS ≥50%, and 50 (15.9%) were PPS ≤40%. The median LOS of PPS ≥50% and PPS ≤40% were 15 (2-158 days) and 9 (2-43 days), respectively. Male, gastrointestinal cancer, and lower initial PPS all predicted poor prognosis in group A. Male, gastrointestinal cancer, and a PPS change of 10% or greater, compared with initial status 1 week and 2 weeks of hospitalization, were all predictors of poor prognosis in group A patients who survived for 2 weeks or longer.

SIGNIFICANCE OF RESULTS

Our research demonstrates the significance of PPS change at 1 week and 2 weeks, suggesting the importance of evaluating not only initial PPS but also change in PPS.

Duration of palliative care before death in international routine practice: a systematic review and meta-analysis

BACKGROUND

Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature.

METHODS

We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death).

RESULTS

One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries.

CONCLUSIONS

Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.

Palliative care needs and utilisation of different specialist services in the last days of life for people with lung cancer

OBJECTIVES

To (a) compare palliative care needs of lung cancer patients on their final admission to community-based and inpatient palliative care services; and (b) explore whether and how these care needs affect their utilisation of different palliative care services in the last days of life.

METHODS

Descriptive study involving 17,816 lung cancer patients who received the last episode of palliative care from specialist services and died between 1 January 2013 and 31 December 2018.

RESULTS

Both groups of patients admitted to community-based and inpatient palliative care services generally experienced relatively low levels of symptom distress, but high levels of functional impairment and dependency. "Unstable" versus "stable" palliative care phase (Odds ratio = 11.66; 95% Confidence Interval: 9.55-14.24), poorer functional outcomes and severe levels of distress from many symptoms predicted greater likelihood of use of inpatient versus community-based palliative care.

CONCLUSIONS

Most inpatient palliative care admissions are not associated with high levels of symptom severity. To extend the period of home care and rate of home death for people with lung cancer, additional investment is required to improve their access to sufficiently skilled palliative care staff, multi-disciplinary teams and 24-hour home support in community settings.

The Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) has a substantial mortality risk with increased rates in the elderly. We hypothesized that age is not sufficient, and that frailty measured by preadmission Palliative Performance Scale would be a predictor of outcomes. Improved ability to identify high-risk patients will improve clinicians' ability to provide appropriate palliative care, including engaging in shared decision-making about life-sustaining therapies.

AIM

To evaluate whether preadmission Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19.

DESIGN

Retrospective observational cohort study of patients admitted with COVID-19. Palliative Performance Scale was calculated from the chart. Using logistic regression, Palliative Performance Scale was assessed as a predictor of mortality controlling for demographics, comorbidities, palliative care measures and socioeconomic status.

SETTING/PARTICIPANTS

Patients older than 18 years of age admitted with COVID-19 to a single urban public hospital in New Jersey, USA.

RESULTS

Of 443 admitted patients, we determined the Palliative Performance Scale score for 374. Overall mortality was 31% and 81% in intubated patients. In all, 36% (134) of patients had a low Palliative Performance Scale score. Compared with patients with a high score, patients with a low score were more likely to die, have do not intubate orders and be discharged to a facility. Palliative Performance Scale independently predicts mortality (odds ratio 2.89; 95% confidence interval 1.42-5.85).

CONCLUSIONS

Preadmission Palliative Performance Scale independently predicts mortality in patients hospitalized with COVID-19. Improved predictors of mortality can help clinicians caring for patients with COVID-19 to discuss prognosis and provide appropriate palliative care including decisions about life-sustaining therapy.

Factors predicting the risk of loss of decisional capacity for medical assistance in dying: a retrospective database review

BACKGROUND

Bill C-14, the legislation that legalized medical assistance in dying (MAiD) in Canada in 2016, outlines eligibility criteria and includes both a mandated 10-day reflection period and a requirement that the patient have capacity to consent at the time MAiD is provided. We examined clinical factors associated with shortened reflection periods or loss of capacity before provision of MAiD.

METHODS

This retrospective database review involved patients who requested MAiD at a tertiary care hospital in Toronto, Canada, between June 2016 and April 2019. We used logistic regression analyses to examine the association between the combined outcome of unanticipated loss of decisional capacity, shortening of the reflection period or death and the clinical risk factors of interest (age, sex, location of MAiD request [inpatient v. outpatient], score on palliative performance scale [PPS] and diagnosis [cancer v. noncancer]). We generated receiver operating characteristic curves to identify the PPS score (encompassing 5 functional domains: ambulation, activity level, self-care, intake and level of consciousness) that best predicted loss of capacity, shortening of the reflection period or death.

RESULTS

In total, 155 patients requested assessment for MAiD, and 136 of these were included in the statistical analyses. For 68 patients, the reflection period was not shortened; the other 68 patients lost capacity, died or required shortening of the reflection period. In contrast to the results for age, sex, location of request and diagnosis, the PPS score was associated with loss of capacity or shortening of the reflection period (odds ratio 4.63, 95% confidence interval 2.87-8.23, per 10-point decrease in PPS score). PPS scores less than or equal to 40% balanced sensitivity, specificity and negative predictive value while emphasizing sensitivity to prevent false negative errors.

INTERPRETATION

The PPS score at the time of MAiD request was strongly associated with loss of capacity or shortening of the reflection period, with lower scores incrementally increasing the risk of these outcomes. For patients with a PPS score of 40% or below, close monitoring is warranted, potentially with plans made to allow rapid provision of MAiD should their clinical condition deteriorate.

Feasibility of e-Pain Reporter: A Digital Pain Management Tool for Informal Caregivers in Home Hospice

Informal hospice caregivers often have difficulty managing patient pain at home. We developed a digital application, e-Pain Reporter, for informal caregivers to record and providers to monitor patient pain and pain management. The purpose of this study was (1) to assess the feasibility of informal caregivers using the e-Pain Reporter for 9 days in home hospice by investigating recruitment and retention and caregiver satisfaction with and frequency of use of the e-Pain Reporter and (2) describe patient pain characteristics and caregiver's barriers to pain management and self-efficacy in providing patient care in the home. One-group pre-post design was used. Patient-caregiver dyads were recruited from 1 hospice agency. Caregivers were asked to report all patient pain and pain management using the e-Pain Reporter. Feasibility of the e-Pain Reporter was assessed by the average number of times caregivers recorded breakthrough and daily pain and caregiver satisfaction with the app. The 27-item Barriers Questionnaire II and 21-item Caregiver Self-efficacy Scale were administered at baseline. Fourteen dyads enrolled, 2 patients died, and 12 dyads completed the study. Mean number of pain reports over 9 days was 10.5. Caregivers reported high overall satisfaction with the e-Pain Reporter. Barriers scores were moderately high, suggesting erroneous beliefs and misconceptions about pain reporting and use of analgesics, but self-efficacy in managing pain was also high (93% confidence). Findings suggest that the e-Pain Reporter is a feasible method to report and monitor caregiver management of pain at home. Caregiver high barriers and high overconfidence suggest the need for an educational component to the e-Pain Reporter to address misconceptions about pain and pain management.

Palliative Performance Scale: cross cultural adaptation and psychometric validation for Polish hospice setting

BACKGROUND

Measuring functional status in palliative care may help clinicians to assess a patient's prognosis, recommend adequate therapy, avoid futile or aggressive medical care, consider hospice referral, and evaluate provided rehabilitation outcomes. An optimized, widely used, and validated tool is preferable. The Palliative Performance Scale Version 2 (PPSv2) is currently one of the most commonly used performance scales in palliative settings. The aim of this study is the psychometric validation process of a Polish translation of this tool (PPSv2-Polish).

METHODS

Two hundred patients admitted to a free-standing hospice were evaluated twice, on the first and third day, for test-retest reliability. In the first evaluation, two different care providers independently evaluated the same patient to establish inter-rater reliability values. PPSv2-Polish was evaluated simultaneously with the Karnofsky Performance Score (KPS), Eastern Cooperative Oncology Group (ECOG) Performance Status (ECOG PS), and Barthel Activities of Daily Living (ADL) Index, to determine its construct validity.

RESULTS

A high level of full agreement between test and retest was seen (63%), and a good intra-class correlation coefficient of 0.85 (P < 0.0001) was achieved. Excellent agreement between raters was observed when using PPSv2-Polish (Cohen's kappa 0.91; P < 0.0001). Satisfactory correlations with the KPS and good correlations with ECOG PS and Barthel ADL were noticed. Persons who had shorter prognoses and were predominantly bedridden also had lower scores measured by the PPSv2-Polish, KPS and Barthel ADL. A strong correlation of 0.77 between PPSv2-Polish scores and survival time was noted (P < 0.0001). Moderate survival correlations were seen between KPS, ECOG PS, and Barthel ADL of 0.41; - 0.62; and 0.58, respectively (P < 0.0001).

CONCLUSION

PPSv2-Polish is a valid and reliable tool measuring performance status in a hospice population and can be used in daily clinical practice in palliative care and research.

Integrating early palliative care into routine practice for patients with cancer: A mixed methods evaluation of the INTEGRATE Project

OBJECTIVE

With increasing evidence from controlled trials on benefits of early palliative care, there is a need for studies examining implementation in real-world settings. The INTEGRATE Project was a 3-year real-world project that promoted early identification and support of patients with cancer who may benefit from palliative care. This study assesses feasibility, stakeholder experiences, and early impact of the INTEGRATE Project METHODS: The INTEGRATE Project was implemented in four cancer centers in Ontario, Canada, and consisted of interdisciplinary provider education and an integrated care model. Providers used the Surprise Question to identify patients for inclusion. A mixed methods evaluation of INTEGRATE was conducted using descriptive data, interviews with providers and managers, and provider surveys.

RESULTS

A total of 760 patients with cancer (lung, glioblastoma, head and neck, gastrointestinal) were included. Results suggest improvement in provider confidence to deliver palliative care and to initiate the Advanced Care Planning (ACP) conversation. The majority of patients (85%) had an ACP or goals of care (GOC) conversation initiated within a mean time to conversation of 5-46 days (SD 20-93) across centers. A primary care report was transmitted to family doctors 48-100% of the time within a mean time to transmission of 7-54 days (SD 9-27) across centers. Enablers and barriers influencing success of the model were also identified.

CONCLUSIONS

A standardized model for the early introduction of palliative care for patients with cancer can be integrated into the routine practice of oncology providers, with appropriate education, integration into existing clinical workflows, and administrative support.

Estimating the short-term prognosis to adjust the transfer of patients with terminal cancer to medium-stay palliative care units

BACKGROUND AND OBJECTIVES

Clinical management for terminal patients should consider various aspects, particularly the patient's functional assessment, which correlates well with the short-term prognosis. The prognosis could improve if the presence of symptoms strongly associated with a poorer progression were included. The study's main objective was to assess whether the prognosis according to the Palliative Performance Scale (PPS) improved with the presence/absence of pain-dyspnoea-delirium symptoms. The secondary objective was to determine caregiver satisfaction with the transfer to medium-stay palliative care units (MSPCUs), which are prepared for medium stays of approximately one month.

PATIENTS AND METHOD

We conducted a prospective, observational, multicentre (regional) study that analysed survival in MSPCUs according to the PPS dichotomized to>20% and≤20%. We estimated the mean survival functions using the Kaplan-Meier method and compared them according to the Cox proportional hazards ratios (HR). Caregiver satisfaction was studied using an anonymous self-administered Likert questionnaire.

RESULTS

The study included 130 patients. The PPS≤20% and PPS>20% subgroups had a median survival of 6 (3-13) days and 21 (11-42) days, respectively, with an unadjusted mortality HR 3.1-fold greater in the PPS≤20% subgroup. The HR did not change when adjusted for the symptoms. Eighty-three percent of the caregivers found the transfer beneficial, and 40% observed better patient care.

CONCLUSIONS

For patients transferred from general hospitals to MSPCUs, PPS scores≤20% were associated with survival shorter than one week, with a 3-fold higher mortality HR than patients with PPS scores>20%, without the analysis adjusted for the presence of pain-dyspnoea-delirium providing greater prognostic accuracy. The caregivers found benefits mainly in the convenience of the facilities and distance.

Using the Palliative Performance Scale to Estimate Survival for Patients at the End of Life: A Systematic Review of the Literature

BACKGROUND

The Palliative Performance Scale (PPS) has been widely used for survival prediction among patients with cancer; however, few studies have reviewed PPS scores in heterogeneous palliative care populations across multiple care settings.

OBJECTIVE

The aim of this systematic review was to determine how the PPS tool has been used to estimate survival at the end of life.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and the Cochrane Library were searched for the existing literature published from 2008 to 2017. We synthesized study characteristics, the PPS scores at baseline, and primary outcomes, and explored differences in survival estimates by diagnosis. The quality of the studies was assessed using the Good ReseArch for Comparative Effectiveness (GRACE) checklist.

RESULTS

Seventeen studies were included in this review (nine with cancer and eight with mixed diagnoses). All included studies reported that the PPS exhibited a significant association with survival. Survival estimates ranged from 1 to 3 days for patients with PPS scores of 10% compared with 5 to 36 days for those with scores of 30%. The categorical cut-points for the PPS scores were not consistently reported across studies.

CONCLUSION

This review provides a broad overview on the prognostic value of the PPS tool for survival among multiple patient populations across care settings. Consistent reporting of PPS scores would facilitate the comparison of survival estimates across end-of-life diagnoses.

Predictors of death in an Intensive Care Unit: contribution to the palliative approach

OBJECTIVE

To identify predictors of death in the Intensive Care Unit and relate eligible patients to preferential palliative care.

METHOD

A prospective cohort study that evaluated patients hospitalized for more than 24 hours, subdivided into G1 (patients who died) and G2 (patients who were discharged from hospital). For identifying the predictors for death outcome, the intensivist physician was asked the "surprise question" and clinical-demographic data were collected from the patients. Data were analyzed by descriptive/inferential statistics (p<0.05 significance).

RESULTS

170 patients were evaluated. The negative response to the "surprise question" was related to death outcome. A greater possibility of death (p<0.05) was observed among older and more frail patients with less functionality, chronic cardiac and/or renal insufficiencies or acute non-traumatic neurological insult, with multiorgan failure for more than 5 days, and hospitalized for longer.

CONCLUSION

Predictors of death were related to a subjective evaluation by the physician, the clinical condition of the patient, underlying diseases, the severity of the acute disease and the evolution of the critical illness. It is suggested that patients with two or more predictive criteria receive preferential palliative care.

Correlation of Palliative Performance Scale and Survival in Patients With Cancer Receiving Home-Based Palliative Care

The main objective of this study was to examine whether and how the Palliative Performance Scale (PPS), a measure of a patient's function, was predictive of survival time for those in receipt of home-based palliative care. This was a prospective study, which included 194 cancer patients from November 17, 2013, to August 18, 2015. Data were collected from biweekly telephone interviews with caregivers. Kaplan-Meier survival curves were estimated to assess how survival time was correlated with initial PPS scores after admission to the home-based palliative care program. A multivariate extended Cox regression model was used to examine the association between PPS and survival. The results showed that patients with higher PPS scores, that is, better function, had a lower hazard ratio (0.977; 95% confidence interval: 0.965-0.989) and hence longer survival times. The PPS can be used in predicting survival time for home-based palliative care patients.

Use of Standardized Assessment Tools to Improve the Effectiveness of Palliative Care Rounds: A Quality Improvement Initiative

BACKGROUND

Optimal care for patients in the palliative care setting requires effective clinical teamwork. Communication may be challenging for health-care workers from different disciplines. Daily rounds are one way for clinical teams to share information and develop care plans for patients.

OBJECTIVE

The objective of this initiative was to improve the structure and process of daily palliative care rounds by incorporating the use of standardized tools and improved documentation into the meeting. We chose a quality improvement (QI) approach to address this initiative. Our aims were to increase the use of assessment tools when discussing patient care in rounds and to improve the documentation and accessibility of important information in the health record, including goals of care.

METHODS

This QI initiative used a preintervention and postintervention comparison of the outcome measures of interest. The initiative was tested in a palliative care unit (PCU) over a 22-month period from April 2014 to January 2016. Participants were clinical staff in the PCU.

RESULTS

Data collected after the completion of several plan-do-study-act cycles showed increased use and incorporation of the Edmonton Symptom Assessment System and Palliative Performance Scale into patient care discussions as well as improvement in inclusion of goals of care into the patient plan of care.

CONCLUSION

Our findings demonstrate that the effectiveness of daily palliative care rounds can be improved by incorporating the use of standard assessment tools and changes into the meeting structure to better focus and direct patient care discussions.

Polyethylene glycol microspheres loaded with irinotecan for arterially directed embolic therapy of metastatic liver cancer

AIM

To study tumor response, and tolerability of arterially directed embolic therapy (ADET) with polyethylene glycol embolics loaded with irinotecan for the treatment of colorectal cancer liver metastases (CRC-LM). Secondary objectives were to monitor quality of life, time to progression and survival of patients.

METHODS

Patients were included in the study if they were affected by CRC-LM, refractory to systemic chemotherapy, treated with ADET using polyethylene glycol embolics, and had liver involvement < 50%. Tumor response, performance status (PS), tumor marker antigens, and quality of life (QoL) were monitored at 1, 3 and 6 mo after ADET. QoL was assessed with the Palliative Performance Scale (PPS).

RESULTS

We treated 50 consecutive CRC-LM patients with ADET using polyethylene glycol embolics. Their tumor response one month after ADET was: 28% of complete response (CR), 48% of partial response (PR), 8% stable disease (SD), and 16% of progression. Tumor response 3 mo after ADET was CR 24%, PR 38%, SD 19% and progression disease (PD) 19%. Tumor response 6 mo after ADET was CR 18%, PR 44%, SD 21% and PD 18%. QoL was 90% PPS at each time point. Median time to progression for patients who progressed was 2.5 mo (range 0.8-6). Median follow-up was 14 mo (0.8-25 range). ADETs were performed with no complications. Observed side effects (mild or moderate intensity) were: Pain in 32% of patients, increase of transaminase levels in 20% and fever in 14%, whereas 30% of patients did not complain any adverse event.

CONCLUSION

The treatment of unresectable CRC-LM with ADET using polyethylene glycol microspheres loaded with irinotecan was effective in tumor response and resulted in mild toxicity, and good QoL.

Comparing the Palliative Care Needs of Those With Cancer to Those With Common Non-Cancer Serious Illness

BACKGROUND

Historically, palliative care has been focused on those with cancer. Although these ties persist, palliative care is rapidly integrating into the care of patients with common, non-cancer serious illnesses. Despite this, the bulk of literature informing palliative care practices stems from the care of cancer patients.

OBJECTIVES

We compared functionality, advanced care planning, hospital admissions, prognosis, quality of life, pain, dyspnea, fatigue, and depression between patients with cancer and three non-cancer diagnoses-end-stage renal disease (ESRD), heart failure (HF), and chronic obstructive pulmonary disease (COPD).

METHODS

We conducted a cross-sectional, retrospective analysis of the characteristics and symptoms of patient's with ESRD, HF, COPD, and cancer at time of first specialty palliative care referral. Using a web-based point of care quality assessment and reporting tool, Quality Data and Collection Tool-Palliative care, this analysis evaluated all eligible patients who received a palliative care consultation between October 1, 2012 and November 25, 2014. Data were obtained from 13 participating sites. The primary outcome for the study was functionality using the palliative performance scale. Hospital admission in the last 30 days, prognosis, patient's understanding of prognosis, advanced care planning including code status and appointed decision maker, pain, fatigue, depression, and dyspnea were also evaluated as secondary outcomes. We tested for an association between our outcomes with disease type (cancer vs. non-cancer) fitting multivariable logistic regression models.

RESULTS

We found that the patients with primary diagnoses other than cancer were less functional at time of referral (odds ratio: 1.6; 95% CI: 1.1, 2.3; P < 0.05).

CONCLUSION

Patients with COPD, ESRD, and HF were less functional and more likely to be hospitalized at time of referral to palliative care than cancer patients. These findings may be reflective of the slower and more varied trajectory of non-cancer serious illness. One aim of palliative care for those with non-cancer severe illness should be directed toward improving and assisting with functionality and decreasing frequency of hospital admissions. These interventions could take place in the palliative care office, but could also be integrated into hospital discharge plans.

The association between different opioid doses and the survival of advanced cancer patients receiving palliative care

Background

Concerns that opioids may hasten death can be a cause of the physicians’ reluctance to prescribe opioids, leading to inadequate symptom palliation. Our aim was to find if there was an association between different opioid doses and the survival of the cancer patients that participated in our palliative care program.

Methods

A retrospective study was conducted at Ramathibodi Hospital, Bangkok between January 2013 and December 2015. All of the cancer patients that were referred to palliative care teams by their primary physicians were included in the study. The study data included the patients’ demographics, disease status, comorbidities, functional status, type of services, cancer treatments, date of consultation, and the date of the patient’s death or last follow-up. The information concerning opioid use was collected by reviewing the medical records and this was converted to an oral morphine equivalent (OME), following a standard ratio. The time-varying covariate in the Cox regression analysis was applied in order to determine the association between different doses of opioids and patient survival.

Results

A total of 317 cancer patients were included in the study. The median (IQR) of the OME among our patients was 6.43 mg/day (0.53, 27.36). The univariate Cox regression analysis did not show any association between different opioid doses (OME ≤ 30 mg/day and > 30 mg/day) and the patients’ survival (p = 0.52). The PPS levels (p < 0.01), palliative care clinic visits (HR 0.32, 95%CI 0.24–0.43), home visits (HR 0.75, 95%CI 0.57–0.99), chemotherapy (HR 0.32, 95%CI 0.22–0.46), and radiotherapy (HR 0.53, 95%CI 0.36–0.78) were identified as factors that increased the probability of survival.

Conclusions

Our study has demonstrated that different opioid doses in advanced cancer patients are not associated with shortened survival period.

Anticholinergic Drug Burden in Noncancer Versus Cancer Patients Near the End of Life

CONTEXT

Anticholinergic drugs can cause several side effects, impairing cognition and quality of life (QOL). Cancer patients are often exposed to increasing cumulative anticholinergic load (ACL) as they approach death, but this burden has not been examined in patients with nonmalignant diseases.

OBJECTIVES

To determine ACL and its impact in noncancer versus cancer palliative care patients.

METHODS

We performed a secondary analysis of 244 subjects enrolled in a randomized controlled trial. ACL was quantified with the Anticholinergic Drug Scale. We used multivariable regression to calculate the effect of ACL on key outcomes, including drowsiness, fatigue, and QOL. Patients were stratified by diagnosis, and drugs were grouped as symptom management (SM) or disease management (DM).

RESULTS

Overall, ACL in cancer and noncancer patients was not significantly different (2.6 vs. 2.4; P = 0.23). SM drugs caused greater anticholinergic exposure than DM drugs in both cancer and noncancer patients (2.3 vs. 0.5, and 1.5 vs. 1.3, respectively; both P < 0.05); however, DM drugs exposed noncancer patients to relatively more ACL than cancer patients (1.2 vs. 0.6, P < 0.0001). ACL was associated with worse fatigue (odds ratio, 1.08; CI, 1.002-1.17) and worse QOL (odds ratio, 0.89; CI, 0.80-0.98).

CONCLUSIONS

ACL is associated with worse fatigue and QOL and may not differ significantly between cancer and noncancer patients nearing end of life. SM drugs are more responsible for ACL in cancer and noncancer patients, although DM drugs contribute significantly to ACL in the latter group. We recommend more attention to reducing anticholinergic use in all patients with life-limiting illness.

Rates and risks for late referral to hospice in patients with primary malignant brain tumors

BACKGROUND

Primary malignant brain tumors (PMBTs) are devastating malignancies with poor prognosis. Optimizing psychosocial and supportive care is critical, especially in the later stages of disease.

METHODS

This retrospective cohort study compared early versus late hospice enrollment of PMBT patients admitted to the home hospice program of a large urban, not-for-profit home health care agency between 2009 and 2013.

RESULTS

Of 160 patients with PMBT followed to death in hospice care, 32 (22.5%) were enrolled within 7 days of death. When compared with patients referred to hospice more than 7 days before death, a greater proportion of those with late referral were bedbound at admission (97.2% vs 61.3%; OR=21.85; 95% CI, 3.42-919.20; P < .001), aphasic (61.1% vs 20.2%; OR = 6.13; 95% CI, 2.59-15.02; P < .001), unresponsive (38.9% vs 4%; OR = 14.76,;95% CI, 4.47-57.98; P < .001), or dyspneic (27.8% vs 9.7%; OR = 21.85; 95% CI, 3.42-10.12; P = .011). In multivariable analysis, male patients who were receiving Medicaid or charitable care and were without a health care proxy were more likely to enroll in hospice within 1 week of death.

CONCLUSIONS

Late hospice referral in PMBT is common. PMBT patients enrolled late in hospice are severely neurologically debilitated at the time hospice is initiated and therefore may not derive optimal benefit from multidisciplinary hospice care. Men, patients with lower socioeconomic status, and those without a health care proxy may be at risk for late hospice care and may benefit from proactive discussion about end-of-life care in PMBT, but prospective studies are needed.

Survival Prediction in Ambulatory Patients With Stage III/IV Non-Small Cell Lung Cancer Using the Palliative Performance Scale, ECOG, and Lung Cancer Symptom Scale

OBJECTIVES

Patients with advanced non-small cell lung cancer (NSCLC) have a life expectancy of less than 1 year. Therefore, it is important to maximize their quality of life and find a tool that can more accurately predict survival.

MATERIALS

The Palliative Performance Scale (PPS) is used to predict survival for patients with advanced disease based on functional dimensions. The value of the PPS in ambulatory patients with cancer has not been examined to date. The Lung Cancer Symptom Scale (LCSS) measures six major symptoms and their effect on symptomatic distress and activity. We evaluated 62 patients with stage III or IV NSCLC and Eastern Cooperative Oncology Group (ECOG) Scale Score ≥1 at baseline in a thoracic oncology clinic. In all, 62 patients had LCSS and PPS evaluated at baseline and 54 patients had 4-week follow-up using LCSS, PPS, and ECOG.

RESULTS

Fifty-four patients completed baseline and follow-up. Mean age was 63.7 years. Sixty-three percent were receiving chemotherapy at evaluation. Seventeen patients died. Mean baseline measures were LCSS 6.18 (1-14); PPS 66.6 (40-90); and ECOG 1.82 (1-4). Censored survival times were calculated from enrollment of the first patient for 380 days. A proportional hazardous model was computed for survival status. Hazard ratios for death were 1.25 (P = .013) for LCSS, 2.12 (P = .027) for ECOG, and 1.02 for PPS (P = .49).

CONCLUSIONS

The LCSS predicted prognosis best in this study. The PPS did not accurately predict prognosis in our patient population.