Routine assessment of unmet needs in individuals with advanced cancer and their caregivers: A qualitative study of the palliative care needs assessment tool (PC-NAT)

Symptom burden and quality of life among patient and family caregiver dyads in advanced cancer

PURPOSE

Symptom management among patients diagnosed with advanced cancer is a high priority in clinical care that often involves the support of a family caregiver. However, limited studies have examined parallel patient and caregiver symptom burden and associations with their own and each other's quality of life (QOL). This study seeks to identify patient and caregiver symptom clusters and investigate associations between identified clusters and demographic, clinical, and psychosocial factors (cognitive appraisals and QOL).

METHODS

This study was a secondary analysis of self-reported baseline survey data collected from a randomized clinical trial of 484 adult advanced cancer patients and their caregivers. Latent class analysis and factor analysis were used to identify symptom clusters. Bivariate statistics tested associations between symptom clusters and demographic, clinical, and psychosocial variables.

RESULTS

The most prevalent symptom for patients was energy loss/fatigue and for caregivers, mental distress. Low, moderate, and high symptom burden subgroups were identified at the patient, caregiver, and dyad level. Age, gender, race, income, chronic conditions, cancer type, and treatment type were associated with symptom burden subgroups. Higher symptom burden was associated with more negative appraisals of the cancer and caregiving experience, and poorer QOL (physical, social, emotional, functional, and overall QOL). Dyads whose caregivers had more chronic conditions were more likely to be in the high symptom burden subgroup.

CONCLUSION

Patient and caregiver symptom burden influence their own and each other's QOL. These findings reinforce the need to approach symptom management from a dyadic perspective.

Outpatient palliative care referral system (PCRS) for patients with advanced cancer: an impact evaluation protocol

INTRODUCTION

Early palliative care (PC) in the clinical pathway of advanced cancer patients improves symptom control, quality of life and has a positive impact on overall quality of care. At present, standardised criteria for appropriate referral for early PC in oncology care are lacking. The aim of this project is to develop a set of standardised referral criteria and procedures to implement appropriate early PC for advanced cancer patients (the palliative care referral system, PCRS) and test its impact on user perception of quality of care received, on patient quality of life and on the use of healthcare resources.

SETTING

Selected oncology clinics and PC outpatient clinic.

METHODS AND ANALYSIS

A scoping literature review and an expert consultation through a nominal group technique will be used to revise existing referral tools and to develop a new one, the PCRS. 25 patients will be enrolled in a pilot study to assess feasibility of the implementation of PCRS; 10 interviews with patients and healthcare professionals will be carried out to evaluate applicability.A pretest-post-test quasiexperimental study involving 150 patients before implementation of the PCRS and 150 patients after implementation will be carried out.Patient satisfaction with care received, quality of life and use of resources, and caregiver satisfaction with care will also be assessed to explore the impact of the intervention.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the Institutional Review board of the Fondazione IRCCS Istituto Nazionale Tumori; approval reference INT201/19.Results will be disseminated through open access publications and through scientific communication presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04936568.

What defines the comprehensive assessment of needs in palliative care? An integrative systematic review

BACKGROUND

The comprehensive assessment of needs in palliative care identifies where patients most want attention to guide clinical decisions that tailor care provision from their first encounters.

AIM

To define how and what needs are identified by the comprehensive assessment of needs in the original peer-reviewed articles in the field of palliative care.

DESIGN

An integrative systematic review as outlined by Whittemore and Knafl. Quality appraisal performed using the Mixed Methods Appraisal Tool.

DATA SOURCES

PubMed, CINAHL, PsycINFO, Web of Science databases searched through May 2019 and updated in July 2020.

RESULTS

Forty-nine articles met inclusion criteria for original articles in English or Spanish reporting comprehensive assessment of needs of adult patients receiving palliative care. The majority (41/49) of studies were moderate to high quality. Two themes were identified: (1) How a comprehensive assessment of needs should be carried out in palliative care, which reflected a preference to develop structured tools for assessment; (2) What needs of patients should be assessed in the comprehensive assessment of needs in palliative care, which conveyed a trend to assess beyond core domains - physical, psychological, social, spiritual - with information and practical most prevalent, but with substantial variation in specifying and classifying needs into domains.

CONCLUSIONS

The assessment of needs in palliative care is comprehensive but lacks consensus on the needs and domains that should be assessed by the palliative care team. Future studies should better define what needs can be standardized into the assessment to improve process of care and patient satisfaction.

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer

BACKGROUND

Integration of specialist palliative care into routine oncologic care improves patients' quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of "palliative care" and "hospice care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.

MATERIALS AND METHODS

We reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of "palliative care" and "hospice care," the definitions for these terms if available, and the recommended timing for these services.

RESULTS

We identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care.

CONCLUSION

"Palliative care" was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

IMPLICATIONS FOR PRACTICE

Integration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

Moving closer to death: understanding psychosocial distress among older veterans with advanced cancers

BACKGROUND

Early identification of psychosocial distress is important to address the needs of vulnerable populations and influence symptom management. Older veterans diagnosed with life-limiting cancers are particularly vulnerable because they often have unmet needs, experiencing psychological or emotional problems and gaps in healthcare communication, which extends suffering. Lack of emotional support, ongoing physical pain, and unresolved symptom control can further increase distress among older veterans, contributing to complexity of decision-making for end of life (EOL) care.

OBJECTIVE

We explored older veterans' experiences and identification of psychosocial distress in cancer care to better understand how they describe distress while facing the end of life.

METHODS

Guiding this study is a conceptual framework from psychosocial oncology with the multifactorial experience of distress indicated by NCCN guidelines for distress screening. We use a phenomenological approach to explore the experience of psychosocial distress among older veterans diagnosed with advanced cancers at risk for dying within a year.

INCLUSION CRITERIA

Provider response of "no" to, "Would you be surprised if your patient died within a year?" and "yes", to the question, "Have you talked with your patient about the severity of their illness as being life-limiting, terminal?"

RESULTS

Five themes emerged: (1) the meaning of distress: "It's hard to explain"; (2) severity of advanced cancer: "There's no stage five"; (3) distressing thoughts about the possibility of dying: "Either way, it's life limiting"; (4) coping: "Deal with it and hope for a better day"; and (5) personal factors: "I don't want to be anything but a man who can handle adversity." Findings suggest older veterans may have unique cancer experiences different from other populations.

CONCLUSION

Older veterans in this study exhibited distressing symptoms which demonstrate they are at risk for declining health and in need of support for their distress. Healthcare providers are urged to understand the complexity of distress to provide the best possible treatment for older veterans.