Impact of early palliative interventions on the outcomes of care for patients with non-small cell lung cancer

Deterioration of Performance Status during Palliative Radiotherapy Suggests a Significant Short Survival Duration: Indicating the Necessities for Considering Radiotherapy Discontinuation

Discontinuation of palliative radiotherapy due to a patient's declining general condition poses a clinical dilemma for palliative care physicians. This study aimed to investigate the survival duration of patients whose performance status (PS) deteriorated during palliative radiotherapy and inform decisions regarding early treatment discontinuation. We retrospectively analyzed data from patients referred from our institute's palliative care department who underwent ≥10 fractions of palliative radiotherapy between March 2017 and December 2021. PS was assessed using the Eastern Cooperative Oncology Group (ECOG) scale. Survival duration was calculated from the final day of palliative radiotherapy to death using the Kaplan-Meier method. A total of 35 patients underwent palliative radiotherapy. Seven (20%) experienced deterioration in ECOG PS during treatment. Their median survival duration was significantly shorter at 22 days (95% confidence interval: 1-94 days) compared to 125 days (95% confidence interval: 82-150 days) for the 28 patients whose PS remained stable (p = 0.0007). Deterioration in ECOG PS during palliative radiotherapy signifies a markedly shorter survival duration. Careful assessment of a patient's condition throughout treatment is crucial, and early discontinuation should be considered if their general health worsens rather than strictly adhering to the initial schedule.

Involvement of Palliative Care in Malignant Pleural Mesothelioma Patients and Associations with Survival and End-of-Life Outcomes

Malignant pleural mesothelioma is a rare, aggressive, and incurable cancer with a poor prognosis and high symptom burden. For these patients, little is known about the impact of palliative care consultation on outcomes such as mortality, hospital admissions, or emergency department visits. The aim of this study is to determine if referral to supportive and palliative care in patients with malignant pleural mesothelioma is associated with survival and decreased hospital admissions and emergency department visits. This is a retrospective chart review. Study participants include all malignant pleural mesothelioma patients seen at The Ottawa Hospital-an acute care tertiary center-between January 2002 and March 2019. In total, 223 patients were included in the study. The mean age at diagnosis was 72.4 years and 82.5% were male. Of the patients diagnosed between 2002 and 2010, only 11 (9.6%) were referred to palliative care. By comparison, of those diagnosed between 2011 and 2019, 49 (45.4%) were referred to palliative care. Median time from diagnosis to referral was 4.1 months. There was no significant difference in the median survival of patients referred for palliative care compared to those who did not receive palliative care (p = 0.46). We found no association between receiving palliative care and the mean number of hospital admissions (1.04 vs. 0.91) from diagnosis to death, and an increase in mean number of emergency department visits in the palliative care group (2.30 vs. 1.18). Although there was increased utilization of palliative care services, more than half of the MPM patients did not receive palliative care despite their limited survival. There was an increase in emergency department visits in the palliative care group; this may represent an increase in the symptom burden (i.e., indication bias) in those referred to palliative care.

[Survey on the presence of palliative care knowledge and palliative care structures in German emergency departments]

Patients with life-limiting or palliative illnesses represent a challenge for emergency departments because, despite the growing availability of specialized outpatient palliative care resources at home, patients often present during symptom exacerbations or when family caregivers become overwhelmed. Also, as life-limiting illnesses are frequently first diagnosed there and treatment goals are adjusted, it appears advantageous to establish early connections between emergency patients with palliative needs and palliative care resources. The objective of this study was to conduct a survey evaluating the availability of fundamental palliative care knowledge and palliative care structures in clinical acute and emergency medicine. For this purpose, an online survey was distributed via emergency medicine blogs, targeting physicians working in emergency departments. In total, 383 fully completed questionnaires were analyzed. It was found that the respondents often encounter patients with palliative needs. However, both outpatient and inpatient palliative resources are not universally accessible, and where, for instance, consultation services are available, there is a lack of consensus regarding the appropriate timing for their utilization. Structures for end of life care are largely in place, although time and personnel are often insufficiently available. There is an expressed interest in further education and training in palliative care. In conclusion, as emergency departments serve as the interface between outpatient and inpatient care, an interdisciplinary and holistic approach can be employed to lay the groundwork for ongoing palliative care, benefiting patients with palliative needs.

Assessing the implementation and effectiveness of early integrated palliative care in long-term care facilities in France: an interventional mixed-methods study protocol

BACKGROUND

Majority of residents in long-term care facilities (LTCF) have limited and delayed access to palliative care even though many suffer from incurable chronic illnesses that will likely require the provision of palliative care. We present the study protocol of "PADI-Palli", an intervention aims to advance early integrated palliative care into standard care delivered in LTCF. This study will assess the effectiveness of early integrated palliative care on palliative care accessibility for older persons in LTCF, and identify the key factors for the successful implementation of early integrated palliative care and its sustainability in the LTCF context.

METHODS

This multicentre interventional study utilises a pragmatic research design with a convergent parallel mixed-methods approach. The qualitative study will use a case study design and the quantitative study will use a stepped wedge cluster randomised trial. In total, 21 participating LTCF from three French regions will be randomly allocated to one of seven clusters. The clusters will cross over from the usual care to the active intervention condition over the course of the study. The primary outcome relates to the accurate identification of palliative care needs and early access to palliative care for LTCF residents. Secondary outcomes are quality of care, quality of life for residents and their families, and quality of life at work for professionals. Measurements will be performed before and after the intervention. Implementation and evaluation of PADI-Palli intervention is grounded in the Consolidated Framework for Implementation Research.

DISCUSSION

Existing evidence demonstrates that early integrated palliative care in cancer care leads to a significant improvement in patient outcomes and processes of care. Little is known, however, about early integrated palliative care in the context of LTCF for older persons. This study has the potential to fill this gap in the literature by providing evidence on the effectiveness of early integrated palliative care for older persons in LTCF. Moreover, this study will provide a better understanding of the relevant contextual elements that facilitate or hinder early integrated palliative care implementation and transferability. If proven effective, this intervention can be scaled to other care settings in which older persons require palliative care.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04708002; National registration: ID-RCB number: 2020-A01832-37.

Palliative care on the radiation oncology ward-improvements in clinical care through interdisciplinary ward rounds

INTRODUCTION

Palliative care is essential for patients with terminal diseases and aims at effective symptom control. This may stand in opposition to radiation treatment as an oncological treatment modality. The hereby presented work demonstrates the successful integration of a palliative care service in the radiation oncology ward.

METHODS

Since 2015, 1018 patients were seen by the palliative care service on the radiation oncology ward and have been analyzed in this single center study. To assess teaching efficacy of the consultation service, a survey was conducted among 15 radiation oncology residents.

RESULTS

Cooperation between the two departments proved to be efficient with rising patient numbers. Palliative care was able to guide appropriate postdischarge care with the number of patients dying on the radiation oncology ward decreasing significantly (p = 0.009). The main topics for consultation were pain medication (92.3%), organization of postdischarge care (92.3%), and psycho-oncological support (84.6%). Most residents had a positive image of the palliative care service and consented on adjectives like "enriching", "empathic", "collegial", "professionally founded", and a "low threshold for consultation". All participants agreed that cooperation deepened their knowledge on palliative care.

CONCLUSION

A synergistic cooperation between a palliative care consultation service and a radiation oncology department addresses patient symptoms on an individual level. It confers advanced knowledge on palliative care which is essential for resident education and patient treatment.

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

End-of-life care of patients with esophageal or gastric cancer: decision making and the goal of care

BACKGROUND

Overall survival (OS) with advanced esophageal or gastric cancer is poor. To avoid overly aggressive treatments at the end-of-life and assure adequate end-of-life quality, the decision to focus on symptom-centered palliative care (PC) and terminate anticancer treatments, i.e., the PC decision, should be made in time.

MATERIAL AND METHODS

We reviewed the charts of patients (N = 160) with esophageal or gastric cancer treated at the Department of Oncology at Helsinki University Central Hospital in 2013 and deceased by December 2014. The use of acute services (Emergency department (ED) visits and hospitalizations) and places of death were compared according to the timing of the PC decision. Reasons for ED visits and hospitalizations were collected.

RESULTS

The median OS from diagnosis of advanced cancer was 6 months. Anti-cancer treatments were never started for 34% of the patients. The PC decision was made early (>30 days before death) for 54% of the patients and late (≤30 days before death) or not at all for 46%. Patients with late or no PC decision died more often in tertiary/secondary hospital (29 versus 7%, p = 0.001) and had more ED visits (49 versus 29%, p < 0.001) and hospitalizations (53 versus 28%, p = 0.001) in their last month, and visited the PC unit less often (18 versus 69%, p < 0.001), than the patients with early PC decision. The ED visits were most commonly related to cancer progression, and clinical deterioration (17%), fever (16%), and dysphagia (15%) were the most common symptoms.

CONCLUSION

The decision to focus on PC and terminate anticancer treatments, i.e., the PC decision, was made late or not at all in every other patient, leading to increased tertiary/secondary hospital service use and deaths at tertiary/secondary hospital. Early decision-making increased end-of-life care at specialized PC services or at home, implying better end-of-life care.

Palliative non-small cell lung cancer treatment and end-of-life care stratified by sex and childlessness: an important interplay in unmarried patients?

PURPOSE

To analyze the interplay of sex and presence of children in unmarried patients with non-small cell lung cancer, because previous studies suggested sex-related disparities. Adult children may participate in treatment decisions and provision of social support or home care.

METHODS

Retrospective single-institution analysis of 186 unmarried deceased patients, managed according to national guidelines outside of clinical trials. Due to the absence of other oncology care providers in the region and the availability of electronic health records, all aspects of longitudinal care were captured.

RESULTS

Eighty-eight female and 98 male patients were included, the majority of whom had children. Comparable proportions in all four strata did not receive active therapy. Involvement of the palliative care team was similar, too. Patients without children were more likely to receive systemic therapy (39% utilization in women with children, 67% in women without children, 41% in men with children, 52% in men without children; p = 0.05). During the last 3 months of life, female patients spent significantly more days in hospital than their male counterparts. Place of death was not significantly different. Home death was equally uncommon in each group. In the multivariate analysis, survival was associated with age and cancer stage, in contrast to sex and presence of children.

CONCLUSION

In contrast to studies from other healthcare systems, unmarried male patients were managed in a largely similar fashion to their female counterparts and with similar survival outcome. Unexpectedly, patients without children more often received systemic anti-cancer treatment.

A point prevalence study of palliative care need and referral rates in adult inpatients

AIM AND OBJECTIVES

To gain an understanding of palliative care need and service utilisation in adult inpatients. The objectives were to 1) Determine the size and characteristics of the population of adult inpatients who were appropriate for palliative care referral, 2) Establish what percentage of patients, who were appropriate for a palliative care referral, had been referred to and/or were receiving palliative care.

BACKGROUND

Internationally there is evidence of high levels of unmet palliative care need. Early access to palliative care is associated with improved outcomes including improved quality of life and reduced healthcare costs.

DESIGN

An observational point prevalence study was reported using the STROBE guidelines.

METHODS

Data were collected directly from inpatient medical records at a 578-bed tertiary private-not-for-profit hospital by three Registered Nurses on 3 June 2021. Palliative care need was assessed using the prognostic criteria for the 12 conditions outlined in the Gold Standards Framework.

RESULTS

A total of 270 inpatients met study inclusion criteria. At a hospital population level, 29% (n = 78) of adult inpatients could have benefitted from palliative care. Of the 78 patients assessed as meeting criteria for palliative care, 29% (n = 23) were currently receiving palliative care with a majority of patients 71% (n = 55) not receiving palliative care.

CONCLUSIONS

This study prospectively collected data and included all 12 conditions outlined in the Gold Standards Framework and found a high level of palliative care need. There was evidence of a high level of unmet palliative care need across conditions and treating specialities.

RELEVANCE TO CLINICAL PRACTICE

Estimates of palliative care need can be used to improve access to palliative care and assess operational requirements, including the staffing levels required to meet the level of palliative care need for adult inpatients.

Defining and implementing early palliative care for persons diagnosed with a life-limiting chronic illness: a scoping review protocol

OBJECTIVE

This review will explore definitions of early palliative care and describe how it has been implemented for those diagnosed with a life-limiting chronic illness.

INTRODUCTION

People with life-limiting chronic illnesses who receive palliative care interventions have increased quality of life, better symptom management, and are more likely to have advance care plans than patients who do not have life-limiting chronic illness. It is therefore best practice to encourage early identification of persons in need of palliative care services. However, there is uncertainty over what is considered to be "early palliative care" and this presents a barrier to evaluating associated outcomes.

INCLUSION CRITERIA

All literature that defines an early palliative care approach in adults (aged 18 years and older) with a life-limiting chronic illness in any health care setting will be included in this review. All countries and sociocultural settings will be included.

METHODS

This scoping review will follow JBI methodology. A comprehensive search of academic and gray literature using MEDLINE (Ovid), CINAHL (EBSCO), Embase (Ovid), PsycINFO (Ovid), Web of Science Core Collection, Ovid Cochrane Library, and ProQuest (Health and Medicine and Sociology Collections) will be utilized. Articles will be screened for inclusion by two independent reviewers. Results will be extracted using a customized tool and summarized in a final report using a narrative synthesis presented in table form.

Multidisciplinary team care in advanced lung cancer

Lung cancer is the most common cause of cancer mortality globally. A vast majority of lung cancer cases are diagnosed at advanced stages. Management of advanced lung cancer requires several diagnostic and therapeutic procedures provided by various specialists. To optimise the entire diagnostic and therapeutic process, a concept of care provided simultaneously by a multidisciplinary team (MDT) has been developed and implemented in specialised centres worldwide. Observational studies suggest that integrated and coordinated care increases adherence to clinical guidelines, significantly shortens the interval from diagnosis to treatment, and may increase survival and quality of life (QoL). Prospective studies are warranted to assess the real impact of MDT on treatment outcomes and to further refine this approach.

The impact of the duration of the palliative care period on cancer patients with regard to the use of hospital services and the place of death: a retrospective cohort study

Background

In order to avoid unnecessary use of hospital services at the end-of-life, palliative care should be initiated early enough in order to have sufficient time to initiate and carry out good quality advance care planning (ACP). This single center study assesses the impact of the PC decision and its timing on the use of hospital services at EOL and the place of death.

Methods

A randomly chosen cohort of 992 cancer patients treated in a tertiary hospital between Jan 2013 –Dec 2014, who were deceased by the end of 2014, were selected from the total number of 2737 identified from the hospital database. The PC decision (the decision to terminate life-prolonging anticancer treatments and focus on symptom centered palliative care) and use of PC unit services were studied in relation to emergency department (ED) visits, hospital inpatient days and place of death.

Results

A PC decision was defined for 82% of the patients and 37% visited a PC unit. The earlier the PC decision was made, the more often patients had an appointment at the PC unit (> 180 days prior to death 72% and < 14 days 10%). The number of ED visits and inpatient days were highest for patients with no PC decision and lowest for patients with both a PC decision and an PC unit appointment (60 days before death ED visits 1.3 vs 0.8 and inpatient days 9.9 vs 2.9 respectively, p < 0.01). Patients with no PC decision died more often in secondary/tertiary hospitals (28% vs. 19% with a PC decision, and 6% with a decision and an appointment to a PC unit).

Conclusions

The PC decision to initiate a palliative goal for the treatment had a distinct impact on the use of hospital services at the EOL. Contact with a PC unit further increased the likelihood of EOL care at primary care.

Initial Experience after Transition to Immune Checkpoint Inhibitors in Patients with Non-small Cell Lung Cancer Treated in a Rural Healthcare Region

Objective

The aim of this study was to investigate the patterns of palliative care, terminal care, and hospital deaths in deceased patients with non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICI).

Methods

This study involves a retrospective analysis of a group of 32 patients treated with first- or second-line ICI regimens. The group was compared with a matched contemporary cohort of patients who received systemic treatment that did not include an ICI. The 1:1 matching was based on sex, age, stage of cancer (IV versus lower), and initial treatment after diagnosis (locoregional versus systemic).

Results

The median overall survival from diagnosis was 9.8 months [95% confidence interval (CI): 7.4-12.2 months] in the non-ICI patients and 11.6 months (95% CI: 5.9-17.3 months) in the ICI group (p: 0.09). Death resulting from toxicity was recorded in two patients (non-ICI) and one patient (ICI), respectively (p: 0.8). Hospital death was more common after ICI (19 versus 11 patients, p: 0.08). During the last three months of life, non-ICI patients spent a median of 11 days (range: 0-28) in the hospital, compared with 20 days (range: 0-45) for ICI patients (p: 0.005). More ICI patients (21 versus 14) received systemic therapy during the last three months of life (p: 0.13). However, treatment rates during the last four weeks were comparable (eight non-ICI and six ICI patients, respectively; p: 0.8).

Conclusion

We did not identify any concerns regarding the fatal toxicity of ICI treatment. Due to several different baseline parameters, there are reasons to believe that hospitalization and hospital death in the ICI group were mainly related to unevenly distributed disease characteristics and not to ICI administration itself. Since real-world data from rural patient cohorts might differ from those obtained in clinical trials, it is necessary to conduct additional and larger studies about ICI-associated patterns of terminal care.

How Effective Is Palliative Care in Improving Patient Outcomes?

OPINION STATEMENT

As palliative care (PC) continues its rapid growth, an emerging body of evidence is demonstrating that its approach of interdisciplinary supportive care benefits many patient populations, including in the oncology setting. As studies and data proliferate, however, questions persist about who, what, why, when, and how PC as well as the ideal time for a PC consult and length of involvement. When comparing outcomes from chemotherapy trials, it is important to consider the dosing regimens used in the various studies. In the same way, it is important to account for the "dose" of the PC interventions utilized across studies, and apples to apples comparisons are needed in order to draw accurate conclusions about PC's benefits. Studies which include a true interdisciplinary PC intervention consistently show improvements in patient quality of life, as well as cost savings, with further study needed for other outcomes. These benefits cannot be extrapolated to care which may be labeled "palliative care," but which does not meet the standard of true interdisciplinary PC. The ultimate question is: Does PC indeed improve outcomes?

Intensity of care, expenditure, place and cause of death people with lung cancer in the year before their death: A French population based study

INTRODUCTION

Health care utilization of people with lung cancer (LC) the last year of life, their causes of death and place of death and the associated expenditure have been poorly described together. Then we conducted an observational study.

METHODS

People with LC covered by the French health Insurance general scheme (77% of the population) who died in 2015 were identified in the national health data system, together with their health care utilization and, in 95% of cases, their causes of death.

RESULTS

A total of 22,899 individuals were included (mean age: 68 years, SD±11.4), 72% of whom died in short-stay hospitals (SSH), 4% in hospital-at-home, 8% in Rehab hospital, 2% in skilled nursing homes and 14% at home. One-half of these people had also a chronic respiratory tract disease and 18% another cancer. Hospital palliative care (HPC) was identified for 65% of people, but for only 9% prior to their end-of-life stay. During the last month of life, 49% of people had two or more SSH stays, 15% were admitted to an intensive care unit, 23% received a chemotherapy session (13% during the last 14 days). The main cause of death was cancer for 92% of individuals (LC for 82%) The mean expenditure during the last year of life was €43,329 per individual.

DISCUSSION

This study indicates high rates of intensive care unit admissions and chemotherapy during the last month of life and a SSH hospital-centered management with intensive use of HPC mainly during the end-of-life stay.

Referral Characteristics of Palliative Care Service in Patients With Advanced Non-Small Cell Lung Cancer in a Tertiary Cancer Center

BACKGROUND

The American Society of Clinical Oncology recently recommends patients with metastatic non-small cell lung cancer (NSCLC) should be offered palliative care services earlier. We sought to investigate the timing of palliative care referral of Chinese patients with NSCLC in our center.

METHOD

Retrospective medical data including demographic characteristics and referral information were collected for analysis. Overall survival (OS) was calculated as the time since cancer diagnosis till patient's death. The time interval from palliative care (PC) referral to a patient's death (PC-D) was calculated. The PC-D/OS ratio was calculated to illustrate the comparison of the duration of PC in the overall length of disease.

RESULTS

The mean age of 155 patients with advanced NSCLC was 62.83 years. Before referral to PC, 128 patients received anticancer treatment including surgeon (46.5%). Sixty-three (40.6%) patients died in palliative care unit. The median OS of 144 patients with end cutoff was 19 months (mean = 31.49, 95% confidence interval [CI] = 25.86-37.12). The median PC-D was 41 days (mean = 73.84, 95% CI = 60.37-87.40). The mean interval of PC-D/OS of 144 patients with definitely death time was 0.22 (SD: 0.27, 95% CI: 0.17-0.26). The median interval was 0.089. More than half of patients (n = 75, 51.8%) underwent PC less than 1% time (PC-D/OS < 0.1) of their whole disease course. Patients who were indigenous to Shanghai (P = .013) and who had brain metastasis (P = .072) had the potential longer PC-D/OS ratio. A high proportion of patients reported loss of appetite (92.8%) and fatigue (91.4%) at the initial of referral to PC.

CONCLUSION

This retrospective study, in a population of patients with advanced NSCLC, gave detailed information about PC services in a tertiary cancer center.

Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations

BACKGROUND

Medical aid in dying (MAiD) was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.

METHODS

A retrospective chart review of all MAiD requests between December 2015 and June 2017 at two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.

RESULTS

Of 80 patients requesting MAiD, 54% (43) received the intervention. The median number of days between the request for MAiD and the patient's death was 6 days. The majority of palliative care consults (32%) came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 (prolongation of life remains a priority) at the time of the MAiD request and 19% were receiving life-prolonging interventions.

INTERPRETATION

We highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians' approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend.

Effects of Shared Decision Making on Distress and Health Care Utilization Among Patients With Lung Cancer: A Systematic Review

CONTEXT

Lung cancer is associated with significant distress, poor quality of life, and a median prognosis of less than one year. Benefits of shared decision making (SDM) have been described for multiple diseases, either by the use of decisions aids or as part of supportive care interventions.

OBJECTIVES

The objective of this study was to summarize the effects of interventions facilitating SDM on distress and health care utilization among patients with lung cancer.

METHODS

We performed a systematic literature search in the CINAHL, Cochrane, EMBASE, MEDLINE, and PsychINFO databases. Studies were eligible when conducted in a population of patients with lung cancer, evaluated the effects of an intervention that facilitated SDM, and measured distress and/or health care utilization as outcomes.

RESULTS

A total of 12 studies, detailed in 13 publications, were included: nine randomized trials and three retrospective cohort studies. All studies reported on a supportive care intervention facilitating SDM as part of their intervention. Eight studies described effects on distress, and eight studies measured effects on health care utilization. No effect was found in studies measuring generic distress. Positive effects, in favor of the intervention groups, were observed in studies using anxiety-specific measures (n = 1) or depression-specific measures (n = 3). Evidence for reductions in health care utilization was found in five studies.

CONCLUSION

Although not supported by all studies, our findings suggest that facilitating SDM in the context of lung cancer may lead to improved emotional outcomes and less aggressive therapies. Future studies, explicitly studying the effects of SDM by using decision aids, are needed to better elucidate potential benefits.

Predictors of Location of Death for Children with Cancer Enrolled on a Palliative Care Service

BACKGROUND

In the U.S., more children die from cancer than from any other disease, and more than one third die in the hospital setting. These data have been replicated even in subpopulations of children with cancer enrolled on a palliative care service. Children with cancer who die in high-acuity inpatient settings often experience suffering at the end of life, with increased psychosocial morbidities seen in their bereaved parents. Strategies to preemptively identify children with cancer who are more likely to die in high-acuity inpatient settings have not been explored.

MATERIALS AND METHODS

A standardized tool was used to gather demographic, disease, treatment, and end-of-life variables for 321 pediatric palliative oncology (PPO) patients treated at an academic pediatric cancer center who died between 2011 and 2015. Multinomial logistic regression was used to predict patient subgroups at increased risk for pediatric intensive care unit (PICU) death.

RESULTS

Higher odds of dying in the PICU were found in patients with Hispanic ethnicity (odds ratio [OR], 4.02; p = .002), hematologic malignancy (OR, 7.42; p < .0001), history of hematopoietic stem cell transplant (OR, 4.52; p < .0001), total number of PICU hospitalizations (OR, 1.98; p < .0001), receipt of cancer-directed therapy during the last month of life (OR, 2.96; p = .002), and palliative care involvement occurring less than 30 days before death (OR, 4.7; p < .0001). Conversely, lower odds of dying in the PICU were found in patients with hospice involvement (OR, 0.02; p < .0001) and documentation of advance directives at the time of death (OR, 0.37; p = .033).

CONCLUSION

Certain variables may predict PICU death for PPO patients, including delayed palliative care involvement. Preemptive identification of patients at risk for PICU death affords opportunities to study the effects of earlier palliative care integration and increased discussions around preferred location of death on end-of-life outcomes for children with cancer and their families.

IMPLICATIONS FOR PRACTICE

Children with cancer who die in high-acuity inpatient settings often experience a high burden of intensive therapy at the end of life. Strategies to identify patients at higher risk of dying in the pediatric intensive care unit (PICU) have not been explored previously. This study finds that certain variables may predict PICU death for pediatric palliative oncology patients, including delayed palliative care involvement. Preemptive identification of patients at risk for PICU death affords opportunities to study the effects of earlier palliative care integration and increased discussions around preferred location of death on end-of-life outcomes for children with cancer and their families.

A Systematic Review of Palliative Care Intervention Outcomes and Outcome Measures in Low-Resource Countries

CONTEXT

To meet the growing need for palliative care in low-resource countries, palliative care programs should be evidence based and contextually appropriate. This study was conducted to synthesize the current evidence to guide future programmatic and research efforts.

OBJECTIVES

This systematic review evaluated palliative care outcome measures, outcomes, and interventions in low-resource countries.

METHODS

After title searches, abstracts and full-text articles were screened for inclusion. Data were extracted to report on intervention models, outcome measures used, and intervention outcomes.

RESULTS

Eighteen papers were reviewed, reporting on interventions conducted across nine low-resource countries. These interventions evaluated home-based palliative care models; a community-managed model; palliative care integrated with hospitals, hospices, or HIV clinics; and models focused on patients' self-management. Three studies were randomized controlled trials. Other studies used nonrandomized trials, cohort studies, mixed methods, pre-post test evaluation, cost-accounting evaluation, and cross-sectional surveys. Thirteen studies measured physical outcomes, 10 using multidimensional instruments. Nine studies measured psychological outcomes, eight using multidimensional instruments. Nine studies measured social outcomes, seven using multidimensional instruments. Nine studies measured outcomes across multiple domains. Across outcomes evaluated, results were reported in the direction of benefit associated with palliative care interventions.

CONCLUSION

Many palliative care intervention models exist to serve patients in low-resource countries. Yet, limited high-quality evidence from low-resource countries is available to document intervention outcomes. Rigorous experimental studies and greater measurement of multidimensional aspects of palliative care are needed to advance the science of palliative care in low-resource settings.

Can early palliative care with anticancer treatment improve overall survival and patient-related outcomes in advanced lung cancer patients? A review of the literature

Purpose

Metastatic non-small-cell lung cancer (NSCLC), the leading cause of death from cancer worldwide, is a debilitating disease that results in a high burden of symptoms and poor quality of life; the estimated prognosis after the diagnosis has been established was less than 1 year until some years ago. At the present, the new targeted therapies and immunotherapy are changing the course of the disease. However, advanced NSCLC remains an incurable disease, with a poor prognosis for the majority of the affected patients, so that quality of life and relief from symptoms are primary objectives of treatment. Some evidences suggest that early palliative care (EPC) for these patients can improve quality of life and even survival.

Design

A systematic review of the studies evaluating the impact on objective and on patient-reported outcomes of the introduction of EPC in opposition to standard care (SC), for advanced lung cancer patients, was performed. Because of the small number of studies conducted in this area, retrospective studies were also considered for the review.

Results

Five studies were included because they matched the inclusion criteria previously defined as relevant for the study. The review found that both survival and quality of life were better for patients included in EPC groups.

Conclusions

While results of the studies included in this review are not always comparable because different methods and scales have been used, there is enough evidence for clinical oncologists to implement the use of EPC in clinical practice for advanced lung cancer patients.

Early Palliative Care and Its Impact on End-of-Life Care for Cancer Patients in Brazil

BACKGROUND

Integrating palliative care into standard oncology care has been recommended for cancer patients. Early palliative care is associated with less aggressive treatment at the end of life.

OBJECTIVE

To describe cancer patients receiving palliative care in Brazil, determining the time from entry into palliative care to death, and investigating whether late referral to palliative care is associated with aggressive end-of-life treatment.

DESIGN

This was a cross-sectional study of cancer patients receiving palliative care in Brazil.

SETTING/SUBJECTS

Subjects were 2985 cancer patients ≥18 years of age who received at least two palliative care visits at the São Paulo State Cancer Institute, in the city of São Paulo, Brazil, and died between 2010 and 2013.

MEASUREMENTS

We evaluated the time from the first palliative care consult to death, stratifying cases by the timing of entry into palliative care (≥3 or <3 months before death). The associations between early palliative care and indicators of aggressive treatment were assessed by Pearson's chi-square test and Fisher's exact test.

RESULTS

The overall median time between entry into palliative care and death was 34 days (mean, 72 days) and was significantly shorter in 2013 than in 2010 (p < 0.001). The number of emergency department visits was significantly lower among the patients who entered palliative care earlier (p < 0.001).

CONCLUSIONS

Among cancer patients in Brazil, late referral to palliative care is common. Patients who enter palliative care earlier appear to receive less aggressive end-of-life treatment.

Frequency and Prognostic Impact of Consistently Low Edmonton Symptom Assessment System Score in the Patients Treated with Palliative Radiotherapy

Introduction

Our department's standard work-flow includes assessment of all the patients with the Edmonton Symptom Assessment System (ESAS), a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of zero-10, before the palliative radiotherapy (PRT). Based on previous research, we hypothesized that the patients with minimal or moderate total symptom burden might have better overall survival after the PRT than those with at least one higher symptom score.

Methods

We performed a retrospective analysis of 94 patients and calculated actuarial survival from the first day of the PRT (Kaplan-Meier method). We identified the patients with the score zero for all ESAS items (no symptoms), at least one item with score one-two (minimal symptoms), and at least one item with the score three (moderate symptoms).

Results

High proportions of the patients had ESAS scores zero- two for nausea (80%), sadness/depression (65%) and constipation (64%). The mean values were often in the range of two-four. Only one patient reported scores of zero throughout the questionnaire. He was treated for hematuria, a symptom that is not part of the ESAS. Three patients reported scores of zero-two throughout the questionnaire. Except for the performance status zero-one, their baseline characteristics were heterogeneous. Two patients reported scores not exceeding three for all items. These patients had excellent performance status, too. None of the six patients (6%) with relatively low ESAS scores of zero-three received care by the hospital's multidisciplinary palliative team. Only one was using opioid analgesics. The median survival for this small subset of six patients was six months, identical to the result for all the patients with higher symptom burden (p = 0.62).

Conclusion

The proportion of the patients with ESAS scores zero-three throughout the questionnaire was 6%, which resulted in the limited statistical power for the survival comparisons. The survival outcomes were similar. Before PRT, 94% of the patients reported at least one ESAS item of severity four-10. The symptoms not included in the questionnaire, e.g., hematuria might result in erroneous assignment to the low-symptom-burden group and obscure the prognostic impact of low ESAS symptom burden.

The impact of early palliative care on the quality of care during the last days of life: what does the evidence say?

PURPOSE OF REVIEW

The aim of this review is to critically appraise the existing evidence on 'early palliative care' (EPC), discuss its relationship with advance care planning, and to reflect on the impact of EPC on the quality of care provided during the last days of life.

RECENT FINDINGS

There are indicators that EPC may help to avoid aggressive treatment, shorten hospital stay, improve overall quality of life, and to see more frequently dying and death at the preferred place of care.

SUMMARY

The evidence from randomized controlled trials supports the integration of palliative care early in the disease trajectory. However, in terms of outcomes and quality indicators for care in the last days of life, evidence is still lacking. Predominantly, when it comes to the outcomes which may be more difficult to assess, such as spiritual aspects, or the social network, for which more comprehensive information is needed. These outcomes should not be neglected in palliative care studies, particularly when they can provide meaningful information about patient and family adjustment, and focus on psychosocial aspects rather than physical symptom control.