End of life care in high-grade glioma patients in three European countries: a comparative study

The impact of palliative care contact on the use of hospital resources at the end of life for brain tumor patients; a nationwide register-based cohort study

PURPOSE

The aim of this nationwide retrospective cohort study was to evaluate the timing of the first specialist palliative care (SPC) contact and its impact on the use of hospital resources at the end of life in patients with brain tumors.

MATERIALS AND METHODS

The analysis comprised 373 brain tumor patients who died during 2019 in Finland. Patients were divided into two groups according to the time of first SPC contact: early, i.e. first SPC contact more than 30 days before death, and late, i.e. no SPC contact or 30 days or less before death.

RESULTS

216 (58%) were male, with a mean age of 67 years (range 18-94). SPC contact was established for 102 (27%) patients and the median time of first SPC contact before death was 76 days. Patients with an early SPC contact had fewer outpatient clinic contacts (28% vs. 53%; p-value < 0.001) and fewer hospitalization (10% vs. 37%; p-value < 0.001) in secondary care compared with patients with late SPC contact. Early SPC contact had no impact on emergency department contacts. Patients with early SPC contact were more likely to die at long term care facility or in SPC wards instead of hospital (p-value < 0.001) compared to patients with late SPC contact (hospital deaths 51% vs. 80%, respectively).

CONCLUSIONS

Early SPC contact reduced the burden on secondary care for brain tumor patients in the last months of life. Palliative care contact should be offered early to all brain tumor patients.

Defining end-of-life in glioblastoma multiforme: a systematic review

BACKGROUND

Glioblastoma multiforme is an incurable tumor with a poor prognosis, characterized by a median overall survival of only 15 months. A difficulty lies in identifying the end-of-life phase for individuals confronting both an incurable cancer and progressive neurological deterioration. The lack of a precise definition of this phase affects the reliability of research results on this topic.

PURPOSE

To determine how the end-of-life phase is characterized and conceptualized in people with glioblastoma, and to identify precise identification criteria for future research and clinical application.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Electronic databases including PubMed, Web of Science, Science Direct, and Psych Info were systematically searched for relevant articles published until January 2025. Eligible studies included adults diagnosed with glioblastoma in the terminal palliative phase, along with their family caregivers or healthcare professionals. Quality assessment was performed.

RESULTS

Eighteen studies fulfilled the inclusion criteria, yet only eight provided definitional elements. Notably, these definitions varied considerably and lacked consensus. Furthermore, none of the studies referred to validated scales or scores for determining the end-of-life phase, nor did they aim to develop such measures.

CONCLUSION

The lack of a standardized end-of-life definition in glioblastoma multiforme complicates clinical decision-making and research. A Delphi-based approach involving consultation with experts in the field is deemed imperative. A consensus is essential to improve prognostic accuracy, guide evidence-based interventions, optimize resource allocation, and foster ethical reflection.

Caregivers' Perspective and Burden of the End-of-Life Phase of Patients with Glioblastoma: A Multicenter Retrospective Study

BACKGROUND

Glioblastoma is the most common aggressive primary brain tumor in adults. Changes in cognition, personality, and behavior of patients as well as side effects of treatments cause unique challenges for providing care and may impact caregiver burden in different ways.

METHODS

This retrospective study included 45 patients with a diagnosis of glioblastoma treated between January 2022 and June 2023 in 2 neurosurgical departments. We investigated the quality of life and the experiences of patients with glioblastoma and caregivers in the end-of-life phase using a validated questionnaire consisting of 38 questions related to the caregiver's view of the patient's terminal phase and another 26 questions regarding caregiver's experiences and emotions during the last 3 months of the patient's life.

RESULTS

Fatigue, reduced consciousness, and sadness were the most common patient symptoms reported by their caregivers. The reported quality of life of caregivers was low and in accordance with the quality of life that they attributed to the patient. Symptoms of burnout and feelings of insufficient information emphasize the urgent need for psychological support and training dedicated to caregivers.

CONCLUSIONS

The end-of-life phases of patients with glioblastoma represent a critical factor that significantly affects not only the patient but also the caregiver's burden, caregiving tasks, and time. A multidisciplinary support program is needed to address and improve caregivers' burden.

Glioblastoma in the oldest old: Clinical characteristics, therapy, and outcome in patients aged 80 years and older

Background

Incidence rates of glioblastoma in very old patients are rising. The standard of care for this cohort is only partially defined and survival remains poor. The aims of this study were to reveal current practice of tumor-specific therapy and supportive care, and to identify predictors for survival in this cohort.

Methods

Patients aged 80 years or older at the time of glioblastoma diagnosis were retrospectively identified in 6 clinical centers in Switzerland and France. Demographics, clinical parameters, and survival outcomes were annotated from patient charts. Cox proportional hazards modeling was performed to identify parameters associated with survival.

Results

Of 107 patients, 45 were diagnosed by biopsy, 30 underwent subtotal resection, and 25 had gross total resection. In 7 patients, the extent of resection was not specified. Postoperatively, 34 patients did not receive further tumor-specific treatment. Twelve patients received radiotherapy with concomitant temozolomide, but only 2 patients had maintenance temozolomide therapy. Fourteen patients received temozolomide alone, 35 patients received radiotherapy alone, 1 patient received bevacizumab, and 1 took part in a clinical trial. Median progression-free survival (PFS) was 3.3 months and median overall survival (OS) was 4.2 months. Among patients who received any postoperative treatment, median PFS was 3.9 months and median OS was 7.2 months. Karnofsky performance status (KPS) ≥70%, gross total resection, and combination therapy were associated with better outcomes. The median time spent hospitalized was 30 days, accounting for 23% of the median OS. End-of-life care was mostly provided by nursing homes (n = 20; 32%) and palliative care wards (n = 16; 26%).

Conclusions

In this cohort of very old patients diagnosed with glioblastoma, a large proportion was treated with best supportive care. Treatment beyond surgery and, in particular, combined modality treatment were associated with longer OS and may be considered for selected patients even at higher ages.

Clinical Feature Ranking Based on Ensemble Machine Learning Reveals Top Survival Factors for Glioblastoma Multiforme

Glioblastoma multiforme (GM) is a malignant tumor of the central nervous system considered to be highly aggressive and often carrying a terrible survival prognosis. An accurate prognosis is therefore pivotal for deciding a good treatment plan for patients. In this context, computational intelligence applied to data of electronic health records (EHRs) of patients diagnosed with this disease can be useful to predict the patients' survival time. In this study, we evaluated different machine learning models to predict survival time in patients suffering from glioblastoma and further investigated which features were the most predictive for survival time. We applied our computational methods to three different independent open datasets of EHRs of patients with glioblastoma: the Shieh dataset of 84 patients, the Berendsen dataset of 647 patients, and the Lammer dataset of 60 patients. Our survival time prediction techniques obtained concordance index (C-index) = 0.583 in the Shieh dataset, C-index = 0.776 in the Berendsen dataset, and C-index = 0.64 in the Lammer dataset, as best results in each dataset. Since the original studies regarding the three datasets analyzed here did not provide insights about the most predictive clinical features for survival time, we investigated the feature importance among these datasets. To this end, we then utilized Random Survival Forests, which is a decision tree-based algorithm able to model non-linear interaction between different features and might be able to better capture the highly complex clinical and genetic status of these patients. Our discoveries can impact clinical practice, aiding clinicians and patients alike to decide which therapy plan is best suited for their unique clinical status.

Advance care planning (ACP) in glioblastoma patients: Evaluation of a disease-specific ACP program and impact on outcomes

BACKGROUND

The feasibility of implementing an advance care planning (ACP) program in daily clinical practice for glioblastoma patients is unknown. We aimed to evaluate a previously developed disease-specific ACP program, including the optimal timing of initiation and the impact of the program on several patient-, proxy-, and care-related outcomes.

METHODS

The content and design of the ACP program were evaluated, and outcomes including health-related quality of life (HRQoL), anxiety and depression, and satisfaction with care were measured every 3 months over 15 months.

RESULTS

Eighteen patient-proxy dyads and two proxies participated in the program. The content and design of the ACP program were rated as sufficient. The preference for the optimal timing of initiation of the ACP program varied widely, however, most of the participants preferred initiation shortly after chemoradiation. Over time, aspects of HRQoL remained stable in our patient population. Similarly, the ACP program did not decrease the levels of anxiety and depression in patients, and a large proportion of proxies reported anxiety and/or depression. The needed level of support for proxies was relatively low throughout the disease course, and the level of feelings of caregiver mastery was relatively high. Overall, patients were satisfied with the provided care over time, whereas proxies were less satisfied in some aspects.

CONCLUSIONS

The content and design of the developed disease-specific ACP program were rated as satisfactory. Whether the program has an actual impact on patient-, proxy-, and care-related outcomes proxies remain to be investigated.

Disparities in place of death for patients with primary brain tumors and brain metastases in the USA

PURPOSE

Patients with primary or metastatic brain tumors often require intensive end-of-life care, for which place of death may serve as a quality metric. Death at home or hospice is considered a more "ideal" location. Comprehensive information on place of death of people with brain tumors is lacking.

METHODS

Using CDC Wonder Database data, those who died in the USA from a solid cancer from 2003 to 2016 were included and place of death for those with primary brain, brain metastases, and solid non-brain tumors were compared. Multivariate logistic regression tested for disparities in place of death.

RESULTS

By 2016, 51.1% of patients with primary brain tumors and 45.2% with brain metastases died at home. 15.9% of patients with primary brain tumors and 23.6% with brain metastases died in the hospital. Black patients were least likely to die at home or hospice. For patients with primary brain tumors, being married (OR = 2.25 (95%CI 2.16-2.34), p < 0.01) and having an advanced degree (OR = 1.204 (95%CI 1.15-1.26), p < 0.01) increased odds of home/hospice death; older age (OR = 0.50 (95%CI 0.46-0.54), p < 0.01) decreased odds for home/hospice death. For patients with brain metastases, being married (OR = 2.19 (95%CI 2.11-2.26), p < 0.01) increased odds of home/hospice death and male sex (OR = 0.87 (095%CI .85-0.89), p < 0.01) and older age (OR = 0.59 (95%CI 0.47-0.75), p < 0.01) decreased odds of home/hospice death.

CONCLUSION

Disparities exist in place of death in the brain tumor population. Focused interventions are indicated to increase the utilization of hospice in those with metastatic cancer, under-represented minority groups, and the elderly population.

Evaluation of an online tool about the expected course of disease for glioblastoma patients – a qualitative study

Background

Patients with glioblastoma have a short life-expectancy, with median survival rates of nine to twelve months. Providing information about the expected course of disease can be complicated. Therefore, an online tool has been developed. The objective of this tool is to better inform patients and proxies, and decrease their uncertainties and improve their quality of life. This study aims to gather experiences of an initial cohort of patient-proxy dyads, to identify if the tool meets the previously mentioned objectives.

Methods

This is a qualitative study based on thematic analysis. Interviews were conducted with fifteen patient-proxy dyads. For these interviews, a combined method of think-aloud sessions and semi-structured interviews was used. Audiotapes of these interviews were transcribed verbatim and thematically analyzed.

Results

The analysis revealed four major themes: unmet information needs, improvement possibilities, effects of the tool and clinical implementation. Participants indicated that this tool could decrease uncertainties and increase their perceived quality of life. Also, they often mentioned that it could have a positive effect on the efficiency and quality of consultations.

Conclusion

Participants considered this tool to be useful and effective in decreasing uncertainties for both patients with glioblastoma and their proxies. Moreover, participants brought up that this tool could positively influence the efficiency and quality of consultations. This could lead to more patient participation and empowerment, and could therefore enhance shared decision making and timely advanced care planning.

Easing the Journey-an Updated Review of Palliative Care for the Patient with High-Grade Glioma

PURPOSE OF REVIEW

High-grade gliomas (HGG) are rare brain tumors that cause disproportionate suffering and mortality. Palliative care, whose aim is to relieve the symptoms and stressors of serious illness, may benefit patients with HGG and their families. In this review, we summarize the extant literature and provide recommendations for addressing the symptom management and communication needs of brain tumor patients and their caregivers at key points in the illness trajectory: initial diagnosis; during upfront treatment; disease recurrence; end-of-life period; and after death during bereavement.

RECENT FINDINGS

Patients with HGG experience highly intrusive symptoms, cognitive and functional decline, and emotional and existential distress throughout the disease course. The caregiver burden is also substantial during the patient's illness and after death. There is limited evidence to guide the palliative management of these issues. Palliative care is likely to benefit patients with HGG, yet further research is needed to optimize the delivery of palliative care in neuro-oncology.

Causes of Death and End-of-Life Care in Patients With Intracranial High-Grade Gliomas: A Retrospective Observational Study

BACKGROUND AND OBJECTIVES

To understand patterns of care and circumstances surrounding end of life in patients with intracranial gliomas.

METHODS

We retrospectively analyzed end-of-life circumstances in patients with intracranial high-grade gliomas at Columbia University Irving Medical Center who died from January 2014 through February 2019, including cause of death, location of death, and implementation of comfort measures and resuscitative efforts.

RESULTS

There were 152 patients (95 men, 57 women; median age at death 61.5 years, range 24-87 years) who died from 1/2014-2/2019 with adequate data surrounding end-of-life circumstances. Clinical tumor progression (n=117, 77.0%) was the most common cause of death with all patients transitioned to comfort measures. Other causes included, but were not limited to, infection (19, 12.5%); intratumoral hemorrhage (5, 3.3%); seizures (8, 5.3%); cerebral edema (4, 2.6%); pulmonary embolism (4, 2.6%); autonomic failure (2, 1.3%); and hemorrhagic shock (2, 1.3%). Multiple mortal events were identified in 10 (8.5%). Seventy-three patients (48.0%) died at home with hospice. Other locations were inpatient hospice (40, 26.3%); acute care hospital (34, 22.4%) including 27 (17.8%) with and 7 (4.6%) without comfort measures; skilled nursing facility (4, 3.3%) including 3 (2.0%) with and 1 (0.7%) without comfort measures; or religious facility (1, 0.7%) with comfort measures. Acute cardiac and/or pulmonary resuscitation was performed in 20 patients (13.2%).

DISCUSSION

Clinical tumor progression was the most common (77.0%) cause of death followed by infection (12.5%). Hospice or comfort measures were ultimately implemented in 94.7% of patients, though resuscitation was performed in 13.2%. Improved understanding of circumstances surrounding death, frequency of use of hospice services, and frequency of resuscitative efforts in patients with gliomas may allow physicians to more accurately discuss end-of-life expectations with patients and caregivers, facilitating informed care planning.

A descriptive analysis of end-of-life discussions for high-grade glioma patients

Background

End-of-life discussions (EOLDs) in patients with high-grade glioma (HGG) have not been well described. Therefore, this study examined the appropriateness of timing and the extent of patient involvement in EOLDs and their impact on HGG patients.

Methods

A cross-sectional survey was conducted among 105 bereaved families of HGG patients at a university hospital in Japan between July and August 2019. Fisher's exact test and the Wilcoxon rank-sum test were used to assess the association between patient participation in EOLDs and their outcomes.

Results

In total, 77 questionnaires were returned (response rate 73%), of which 20 respondents replied with refusal documents. Overall, 31/57 (54%) participated in EOLDs at least once in acute hospital settings, and a significant difference was observed between participating and nonparticipating groups in communicating the patient's wishes for EOL care to the family (48% vs 8%, P = .001). Moreover, >80% of respondents indicated that the initiation of EOLDs during the early diagnosis period with patients and families was appropriate. Most EOLDs were provided by neurosurgeons (96%), and other health care providers rarely participated. Additionally, patient goals and priorities were discussed in only 28% of the EOLDs. Patient participation in EOLDs was not associated with the quality of EOL care and a good death.

Conclusions

Although participation in EOLDs is relatively challenging for HGG patients, this study showed that participation in EOLDs may enable patients to express their wishes regarding EOL care. It is important to initiate EOLDs early on through an interdisciplinary team approach while respecting patient goals and priorities.

Caregiver perceptions of end-of-life care in patients with high-grade glioma

Background

Patients dying from high-grade gliomas (HGG) suffer from high symptom burden in the end-of-life (EoL) phase. Family caregivers are most informed about the patient's symptoms and disease course. The aim of this study is to assess caregiver perception on quality of EoL care of HGG patients.

Methods

Caregivers prospectively participated in the Toolkit After-Death Bereaved Family Member Interview, part of the Toolkit of Instruments to Measure End-of-Life Care (TIME survey). This validated survey assesses EoL care in areas such as physical comfort and emotional support, advance care planning, focus on the individual, attention to family, and coordination of care. The quality of EoL care was measured by domain scores (0 = care was always optimal, 1 = care was always suboptimal) or with a 0-10 scale.

Results

Of the 55 enrolled family caregivers, 44 completed the interview and rated the overall care high (8.90 ± 1.36/10), perceived that patients' wishes were respected (9.46 ± 0.95) and that they died in dignity (9.65 ± 0.98). Caregivers perceived high satisfaction with information and decision-making (0.18), advance care planning (0.19), focus on the individual (0.16), and care coordination (0.11). Attention to family (0.25) needed improvement. Only 41% of caregivers were confident that they knew what to do at the time of death and 46% felt that the healthcare team did not provide them with someone to turn to in distress.

Conclusions

Caregivers reported high overall satisfaction with EoL HGG care, though attention to family and communication needed improvement. Focus should therefore be on improved caregiver communication to improve EoL care, caregiver burnout, and bereavement in HGG populations.

Palliative Care in High-Grade Glioma: A Review

High-grade glioma (HGG) is characterized by debilitating neurologic symptoms and poor prognosis. Some of the suffering this disease engenders may be ameliorated through palliative care, which improves quality of life for seriously ill patients by optimizing symptom management and psychosocial support, which can be delivered concurrently with cancer-directed treatments. In this article, we review palliative care needs associated with HGG and identify opportunities for primary and specialty palliative care interventions. Patients with HGG and their caregivers experience high levels of distress due to physical, emotional, and cognitive symptoms that negatively impact quality of life and functional independence, all in the context of limited life expectancy. However, patients typically have limited contact with specialty palliative care until the end of life, and there is no established model for ensuring their palliative care needs are met throughout the disease course. We identify low rates of advance care planning, misconceptions about palliative care being synonymous with end-of-life care, and the unique neurologic needs of this patient population as some of the potential barriers to increased palliative interventions. Further research is needed to define the optimal roles of neuro-oncologists and palliative care specialists in the management of this illness and to establish appropriate timing and models for palliative care delivery.

Prediagnostic presentations of glioma in primary care: a case-control study

Aim:

This study aimed to assess the prevalence of symptoms glioma patients may present with to the general practitioner, and whether these can be distinguished from patients with other CNS disorders or any other condition.

Methods:

Glioma patients were matched to CNS patients and ‘other controls’ using anonymized general practitioner registries. Prevalences were evaluated in the 5 years prior to diagnosis.

Result:

CNS patients reported significantly more motor symptoms in the period 60–24 months, (p = 0.039). Moreover, <6 months before diagnosis CNS patients differed significantly in mood disorders/fear compared with ‘other controls’ (p = 0.012) but not glioma patients (p = 0.816).

Conclusion:

Glioma patients could not be distinguished from both control groups with respect to the number or type of prediagnostic symptoms.

Palliative Care in Patients With High-Grade Gliomas in the Neurological Intensive Care Unit

Background

Palliative care improves quality of life in patients with malignancy; however, it may be underutilized in patients with high-grade gliomas (HGGs). We examined the practices regarding palliative care consultation (PCC) in treating patients with HGGs in the neurological intensive care unit (NICU) of an academic medical center.

Methods

We conducted a retrospective cohort study of patients admitted to the NICU from 2011 to 2016 with a previously confirmed histopathological diagnosis of HGG. The primary outcome was the incidence of an inpatient PCC. We also evaluated the impact of PCC on patient care by examining its association with prespecified secondary outcomes of code status amendment to do not resuscitate (DNR), discharge disposition, 30-day mortality, and 30-day readmission rate, length of stay, and place of death.

Results

Ninety (36% female) patients with HGGs were identified. Palliative care consultation was obtained in 16 (18%) patients. Palliative care consultation was associated with a greater odds of code status amendment to DNR (odds ratio [OR]: 18.15, 95% confidence interval [CI]: 5.01-65.73), which remained significant after adjustment for confounders (OR: 27.20, 95% CI: 5.49-134.84), a greater odds of discharge to hospice (OR: 24.93, 95% CI: 6.48-95.88), and 30-day mortality (OR: 6.40, 95% CI: 1.96-20.94).

Conclusion

In this retrospective study of patients with HGGs admitted to a university-based NICU, PCC was seen in a minority of the sample. Palliative care consultation was associated with code status change to DNR and hospice utilization. Further study is required to determine whether these findings are generalizable and whether interventions that increase PCC utilization are associated with improved quality of life and resource allocation for patients with HGGs.

Advance care planning in glioblastoma patients: development of a disease-specific ACP program

BACKGROUND

It is unknown if the implementation of an advance care planning (ACP) program is feasible in daily clinical practice for glioblastoma patients. We aimed to develop an ACP program and assess the preferred content, the best time to introduce such a program in the disease trajectory, and possible barriers and facilitators for participation and implementation.

METHODS

A focus group with health care professionals (HCPs) and individual semi-structured interviews with patients and proxies (of both living and deceased patients) were conducted.

RESULTS

All predefined topics were considered relevant by participants, including the current situation, worries/fears, (supportive) treatment options, and preferred place of care/death. Although HCPs and proxies of deceased patients indicated that the program should be implemented relatively early in the disease trajectory, patient-proxy dyads were more ambiguous. Several patient-proxy dyads indicated that the program should be initiated later in the disease trajectory. If introduced early, topics about the end of life should be postponed. A frequently mentioned barrier for participation was that the program would be too confronting, while a facilitator was adequate access to information.

CONCLUSION

This study resulted in an ACP program specifically for glioblastoma patients. Although participants agreed on the program content, the optimal timing of introducing such a program was a matter of debate. Our solution is to offer the program shortly after diagnosis but let patients and proxies decide which topics they want to discuss and when. The impact of the program on several patient- and care-related outcomes will be evaluated in the next step.

Palliative Care, End-of-Life Care, and Advance Care Planning in Neuro-oncology

PURPOSE OF REVIEW

Despite new therapeutic approaches, most patients with high-grade glioma face limited overall survival and have a high symptom burden throughout their disease trajectory, especially in the end-of-life phase. This article provides an overview of the role of palliative care in neuro-oncology. Management recommendations are made for neurologic symptoms in patients with advanced brain tumors, including headaches, nausea, and fatigue. Special attention is given to how and when to involve subspecialty palliative care and hospice services to improve symptom management during active tumor treatment and in the end-of-life phase of patients with brain tumors. Advance care planning and end-of-life goals should be addressed early in the disease trajectory; this article provides a road map for these discussions.

RECENT FINDINGS

The high symptom burden of patients with brain tumors affects their quality of life as well as their ability to make treatment decisions. It is therefore warranted to involve patients with high-grade glioma in treatment decision making early in the disease course, with a focus on end-of-life care and advance care planning. Research in other World Health Organization grade IV cancers has shown that the early involvement of specialty palliative care improves quality of life and caregiver satisfaction. Patients with brain tumors should be actively screened for fatigue, and underlying factors such as hormone deficiencies, low blood counts, and sleep issues should be addressed before focusing interventions for tumor- and treatment-related fatigue.

SUMMARY

Palliative care can address typical symptoms, such as fatigue, nausea, and headaches that have the potential to severely disable patients with brain tumors. Advance care planning should be introduced proactively and early in the disease trajectory to ensure a dignified death and improved caregiver bereavement.

End-of-Life Care in High-Grade Glioma Patients. The Palliative and Supportive Perspective

High-grade gliomas (HGGs) are the most frequently diagnosed primary brain tumors. Even though it has been demonstrated that combined surgical therapy, chemotherapy, and radiotherapy improve survival, HGGs still harbor a very poor prognosis and limited overall survival. Differently from other types of primary neoplasm, HGG manifests also as a neurological disease. According to this, palliative care of HGG patients represents a peculiar challenge for healthcare providers and caregivers since it has to be directed to both general and neurological cancer symptoms. In this way, the end-of-life (EOL) phase of HGG patients appears to be like a journey through medical issues, progressive neurological deterioration, and psychological, social, and affective concerns. EOL is intended as the time prior to death when symptoms increase and antitumoral therapy is no longer effective. In this phase, palliative care is intended as an integrated support aimed to reduce the symptoms burden and improve the Quality Of Life (QOL). Palliative care is represented by medical, physical, psychological, spiritual, and social interventions which are primarily aimed to sustain patients&rsquo; functions during the disease time, while maintaining an acceptable quality of life and ensuring a dignified death. Since HGGs represent also a family concern, due to the profound emotional and relational issues that the progression of the disease poses, palliative care may also relieve the distress of the caregivers and increase the satisfaction of patients&rsquo; relatives. We present the results of a literature review addressed to enlighten and classify the best medical, psychological, rehabilitative, and social interventions that are addressed both to patients and to their caregivers, which are currently adopted as palliative care during the EOL phase of HGG patients in order to orientate the best medical practice in HGG management.

Palliative and end-of-life care in glioblastoma: defining and measuring opportunities to improve care

BACKGROUND

American Society for Clinical Oncology (ASCO) quality measures for terminal cancers recommend early advance care planning and hospice at the end of life. We sought to evaluate adherence to 5 palliative care quality measures and explore associations with patient outcomes in glioblastoma.

METHODS

This is a retrospective analysis of 117 deceased glioblastoma patients over 5 years. Records were reviewed to describe adherence to palliative care quality measures and patient outcomes. Data regarding emotional assessments, advance directives, palliative care consultation, chemotherapy administration, hospice, location of death, and overall survival were collected.

RESULTS

Median overall survival was 12.9 months. By the second oncology visit, 22.2% (26/117) had an emotional assessment completed. Advance directives were documented for 52.1% (61/117) by the third neuro-oncology visit (30/61 health care proxy), yet 26.5% (31/117) did not have any advance directive before the last month of life. With regard to other ASCO quality measures, 36.8% (43/117) had a palliative care consult; 94.0% (110/117) did not receive chemotherapy in the last 14 days of life; 59.8% (70/117) enrolled in hospice >7 days before death; and 56.4% (66/117) died in a home setting. Patients who enrolled in hospice >7 days before death were 3.56 times more likely to die in a home setting than patients enrolled <7 days before death or with no hospice enrollment (P = .002, [OR 3.56; 95% CI, 1.57-8.04]).

CONCLUSIONS

Late advance directive documentation, minimal early palliative care involvement, and the association of early hospice enrollment with death in a home setting underscore the need to improve care and better define palliative care quality measures in glioblastoma.

End of life care for glioblastoma patients at a large academic cancer center

Glioblastoma (GBM) is a universally fatal disease, complicated by significant cognitive and physical disabilities, inherent to the disease course. The purpose of this study was to retrospectively analyze end-of-life care for GBM patients at an academic center and compare utilization of these services to national quality of care guidelines, with the goal of identifying opportunities to improve end-of-life care. Single center retrospective cohort study of GBM patients at Johns Hopkins Hospital (JHH) between 2009 and 2014, using electronic medical records and hospice records. Comprehensive medical record review of 100 randomly selected patients with GBM, who were actively treated at JHH. Secondary analysis of all JHH GBM patients (n = 45) who received hospice care at Gilchrist Services, our largest provider, during this time period. Of 100 patients, 76 were referred to hospice. Despite the poor survival and changes in mental capacity associated with this disease, only 40% of individuals had documentation of code status and only 17% had any documentation of advance directives (ADs). None had documentation by a health care provider of a formal symptom, psychosocial, or spiritual assessment at greater than 50% of clinic visits. Only 17% used chemotherapy in their last month of life. 37% were hospitalized in the last month of life for an average of 9 days. Of the Gilchrist Services patients, the median length of stay in hospice was 21 days and 64% of these patients died in their residence with hospice services. Documentation of palliative care and end-of-life measures could improve quality of care for GBM patients, especially in the use of ADs, symptom, spiritual, and psychosocial assessments, with earlier use of hospice to prevent end-of-life hospitalizations.

Factors associated with supportive care needs in glioma patients in the neuro-oncological outpatient setting

Objective of this study aimed at assessing glioma patients' supportive care needs in a neurosurgical outpatient setting and identifying factors that are associated with needs for support. In three neuro-oncological outpatient departments, glioma patients were assessed for their psychosocial needs using the Supportive Care Needs Survey short-form (SCNS-SF34-G). Associations between clinical, sociodemographic, treatment related factors as well as distress (measured with the distress thermometer) and supportive care needs were explored using multivariable general linear models. One-hundred and seventy three of 244 eligible glioma patients participated, most of them with primary diagnoses of a high-grade glioma (81%). Highest need for support was observed in 'psychological needs' (median 17.5, range 5-45) followed by 'physical and daily living needs' (median 12.5, range 0-25) and 'health system and information needs' (median 11.3, range 0-36). Needs in the psychological area were associated with distress (R² = 0.36) but not with age, sex, Karnofsky performance status (KPS), extend of resection, currently undergoing chemotherapy and whether guidance during assessment was offered. Regarding 'health system and information needs', we observed associations with distress, age, currently undergoing chemotherapy and guidance (R² = 0.31). In the domain 'physical and daily living needs' we found associations with KPS, residual tumor, as well as with distress (R² = 0.37). Glioma patients in neuro-oncological departments report unmet supportive care needs, especially in the psychological domain. Distress is the factor most consistently associated with unmet needs requiring support and could serve as indicator for clinical neuro-oncologists to initiate support.

Advance Care Planning in Glioblastoma Patients

Despite multimodal treatment with surgery, radiotherapy and chemotherapy, glioblastoma is an incurable disease with a poor prognosis. During the disease course, glioblastoma patients may experience progressive neurological deficits, symptoms of increased intracranial pressure such as drowsiness and headache, incontinence, seizures and progressive cognitive dysfunction. These patients not only have cancer, but also a progressive brain disease. This may seriously interfere with their ability to make their own decisions regarding treatment. It is therefore warranted to involve glioblastoma patients early in the disease trajectory in treatment decision-making on their future care, including the end of life (EOL) care, which can be achieved with Advance Care Planning (ACP). Although ACP, by definition, aims at timely involvement of patients and proxies in decision-making on future care, the optimal moment to initiate ACP discussions in the disease trajectory of glioblastoma patients remains controversial. Moreover, the disease-specific content of these ACP discussions needs to be established. In this article, we will first describe the history of patient participation in treatment decision-making, including the shift towards ACP. Secondly, we will describe the possible role of ACP for glioblastoma patients, with the specific aim of treatment of disease-specific symptoms such as somnolence and dysphagia, epileptic seizures, headache, and personality changes, agitation and delirium in the EOL phase, and the importance of timing of ACP discussions in this patient population.

Advance Care Planning in Patients with Primary Malignant Brain Tumors: A Systematic Review

Advance care planning (ACP) is a process of reflection and communication of a person's future health care preferences, and has been shown to improve end-of-life (EOL) care for patients. The aim of this systematic review is to present an evidence-based overview of ACP in patients with primary malignant brain tumors (pmBT). A comprehensive literature search was conducted using medical and health science electronic databases (PubMed, Cochrane, Embase, MEDLINE, ProQuest, Social Care Online, Scopus, and Web of Science) up to July 2016. Manual search of bibliographies of articles and gray literature search were also conducted. Two independent reviewers selected studies, extracted data, and assessed the methodologic quality of the studies using the Critical Appraisal Skills Program's appraisal tools. All studies were included irrespective of the study design. A meta-analysis was not possible due to heterogeneity amongst included studies; therefore, a narrative analysis was performed for best evidence synthesis. Overall, 19 studies were included [1 randomized controlled trial (RCT), 17 cohort studies, 1 qualitative study] with 4686 participants. All studies scored "low to moderate" on the methodological quality assessment, implying high risk of bias. A single RCT evaluating a video decision support tool in facilitating ACP in pmBT patients showed a beneficial effect in promoting comfort care and gaining confidence in decision-making. However, the effect of the intervention on quality of life and care at the EOL were unclear. There was a low rate of use of ACP discussions at the EOL. Advance directive completion rates and place of death varied between different studies. Positive effects of ACP included lower hospital readmission rates, and intensive care unit utilization. None of the studies assessed mortality outcomes associated with ACP. In conclusion, this review found some beneficial effects of ACP in pmBT. The literature still remains limited in this area, with lack of intervention studies, making it difficult to identify superiority of ACP interventions in pmBT. More robust studies, with appropriate study design, outcome measures, and defined interventions are required to inform policy and practice.

Palliative care at the end-of-life in glioma patients

The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course.

The Last 10 Days of Patients With Glioblastoma: Assessment of Clinical Signs and Symptoms as well as Treatment

BACKGROUND

High-grade gliomas are the most frequent primary brain tumors. Despite improvement in diagnostics and treatment, survival is still poor and quality-of-life issues are of major importance. Little is known regarding the clinical signs and symptoms of dying patients with glioblastoma.

OBJECTIVE

The aim of this study was to investigate signs and symptoms as well as therapeutic strategies in patients with glioblastoma in the end-of-life phase in order to improve end-of-life care.

METHODS

In this prospective single-center study, clinical data were obtained using a standardized protocol. We descriptively analyzed signs, symptoms, and therapeutic strategies on a daily basis.

RESULTS

A total of 57 patients, who died due to glioblastoma in a hospital setting, were included. The most frequent signs and symptoms in the last 10 days before death were decrease in level of consciousness (95%), fever (88%), dysphagia (65%), seizures (65%), and headache (33%). Concerning medication, 95% received opioids. There was a high need for nonsteroidal anti-inflammatory drugs (77%) and anticonvulsants (75%). Steroids were given to 56%.

CONCLUSION

Due to a decrease in level of consciousness and cognitive impairment, assessment of clinical signs and symptoms such as headache at the end of life is difficult. Based on the signs and symptoms in the last days before death in patients with glioblastoma, supportive drug treatment remains challenging. Our study emphasizes the importance of standardized guidelines for end-of-life care in patients with glioblastoma.

International patterns of palliative care in neuro-oncology: a survey of physician members of the Asian Society for Neuro-Oncology, the European Association of Neuro-Oncology, and the Society for Neuro-Oncology

Background

Brain tumor patients have limited survival and suffer from high morbidity requiring specific symptom management. Specialized palliative care (PC) services have been developed to address these symptoms and provide end-of-life treatment. Global utilization patterns of PC in neuro-oncology are unknown.

Methods

In a collaborative effort between the Society for Neuro-Oncology (SNO), the European Association of Neuro-Oncology (EANO), and the Asian Society for Neuro-Oncology (ASNO), a 22-question survey was distributed. Wilcoxon 2-sample and Kruskal-Wallis tests were used to assess differences in responses.

Results

Five hundred fifty-two evaluable responses were received. The most significant differences were found between Asia-Oceania (AO) and Europe as well as AO and United States/Canada (USA-C). USA-C providers had more subspecialty training in neuro-oncology, but most providers had received no or minimal training in palliative care independent of region. Providers in all 3 regions reported referring patients at the onset of symptoms requiring palliation, but USA-C and European responders refer a larger total proportion of patients to PC (P < .001). Physicians in AO and Europe (both 46%) as well as 29% of USA-C providers did not feel comfortable dealing with end-of-life issues. Most USA-C patients (63%) are referred to hospice compared with only 8% and 19% in AO and Europe (P < .001), respectively.

Conclusion

This is the first report describing global differences of PC utilization in neuro-oncology. Significant differences in provider training, culture, access, and utilization were mainly found between AO and USA-C or AO and Europe. PC patterns are more similar in Europe and USA-C.