Assessment of Changes in Symptoms Is Feasible and Prognostic in the Last Weeks of Life: An International Multicenter Cohort Study

Survival Prediction of Patients Who Were Terminally Ill Using the EORTC QLQ-C15-PAL Scores and Laboratory Test Values

Background

Prognostics for patients with cancer is especially important for the supportive care of those who are terminally ill. We previously found that symptom scores as patient-reported outcomes (PROs)-such as dyspnea and fatigue scores-some biochemical parameters, the palliative performance scale (PPS) scores, and symptom clusters were useful prognostic factors; however, the predictability of a prognosis based on these factors remains unclear.

Objective

To identify appropriate three-week survival predictive factor(s), in terms of performance, in patients who were terminally ill.

Design

We collected symptom scores as PROs using the Japanese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL).

Setting/Subjects

We used data from terminally ill patients with cancer who were hospitalized at the palliative care unit of the Higashisumiyoshi-Morimoto Hospital (Osaka, Japan) from June 2018 to December 2019 (n = 130), as well as additional data obtained from the same clinical study from January to March 2020 (n = 31).

Measurements

To evaluate predictive performance, indices such as sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated.

Results

We found that the presence of a symptom cluster showed high sensitivity but low specificity and that a higher PPS value (>30) showed high specificity but low sensitivity, suggesting that these factors could provide relevant information for survival prognosis (less than or equal to three weeks).

Conclusion

Symptom clusters obtained from patients is important for effective supportive care of those who are terminally ill.

A Consensus Definition of End of Life from an International and Interdisciplinary Perspective: A Delphi Panel Study

Background: Those working in the field of palliative care have recognized that many terms are being used synonymously and that clear definitions (or any definitions) for many of these terms are lacking. The synonymous use of the terms palliative and end of life (EOL) can especially lead to conflicts in clinical practice, such as a tardy referral to palliative care. Such conflicts may then result in poorer treatment of patients, for instance, pain management. In research, the lack of clear definitions or even of any established definition for central concepts, such as EOL, weakens study validity and research outcomes. Objective: The aim of this study was to establish a concise definition for the EOL phase. Design: A modified Delphi study design was chosen. A structured questionnaire based on a previously conducted concept analysis about the EOL was used. Setting: A panel of international and interdisciplinary experts was established. Between 34 (1st round) and 21 (4th round) individuals participated in the anonymous online expert panel. Results: After four panel rounds, we were able to provide a definition which covers physical and psychosocial aspects that should be considered at the beginning of the EOL phase and possible predictions about the remaining time. The definition also covers aspects of EOL care, such as considerations related to the individual's dignity, spirituality, and maintenance of relationships. Conclusion: EOL is a term which is defined by considering multiple aspects that affect the process of identifying the EOL phase, the EOL phase itself and the resulting care options.

Prognostication of the last days of life: Review article

Accurate prediction of impending death (i.e., last few days of life) is essential for terminally-ill cancer patients and their families. International guidelines state that clinicians should identify patients with impending death, communicate the prognosis with patients and families, help them with their end-of-life decision-making, and provide sufficient symptom palliation. Over the past decade, several national and international studies have been conducted that systematically investigated signs and symptoms of impending death as well as how to communicate such a prognosis effectively with patients and families. In this article, we summarize the current evidence on prognostication and communication regarding the last days of life of patients with cancer, and future directions of clinical research.

Prevalence and severity of symptoms and signs in patients with advanced cancer in the last days of life: the East Asian collaborative cross-cultural study to elucidate the dying process (EASED)

PURPOSE

Few large-scale studies have focused on the prevalence of symptoms and signs during the last days of patients diagnosed with advanced cancer. Identifying the patterns of specific symptoms according to cancer type is helpful to provide end-of-life care for patients with advanced cancer. We investigated the prevalence and severity of symptoms and signs associated with impending death in patients with advanced cancer.

METHODS

In this secondary analysis of an international multicenter cohort study conducted in three East Asian countries, we compared the severity of symptoms and signs among dying patients in the last 3 days of life according to the type of primary cancer using one-way analysis of variance (ANOVA). Post hoc analysis was conducted for multiple comparisons of each symptom according to the type of primary cancer.

RESULTS

We analyzed 2131 patients from Japan, Korea, and Taiwan. The prevalence of most symptoms and signs were relatively stable from 1 week after admission to the last 3 days of life. According to cancer type, edema of the lower extremities was the most common symptom and fatigue/ ascites were the most severe symptoms in digestive tract cancer. For lung cancer, respiratory secretion was the most prevalent and dyspnea/respiratory secretion were the most severe symptoms.

CONCLUSION

We demonstrated the prevalence and severity of symptoms and signs associated with the impending death of patients with advanced cancer in East Asia. Our study can enable clinicians to recognize the specific symptoms and signs at the very end of life.