The Oncologist's Role in Care of the Dying Cancer Patient

Factors influencing terminal cancer patients' autonomous DNR decision: a longitudinal statutory document and clinical database study

Objective

Much of our knowledge of patient autonomy of DNR (do-not-resuscitate) is derived from the cross-sectional questionnaire surveys. Using signatures on statutory documents and medical records, we analyzed longitudinal data to understand the fact of terminal cancer patients’ autonomous DNR decision-making in Taiwan.

Methods

Using the medical information system database of one public medical center in Taiwan, we identified hospitalized cancer patients who died between Jan. 2017 and Dec. 2018, collected their demographic and clinical course data and records of their statutory DNR document types, letter of intent (DNR-LOI) signed by the patient personally and the consent form signed by their close relatives.

Results

We identified 1,338 signed DNR documents, 754 (56.35%) being DNR-LOI. Many patients had the first DNR order within their last week of life (40.81%). Signing the DNR-LOI was positively associated with being under the care of a family medicine physician prior to death at last hospitalization and having hospice palliative care and negatively associated with patient age ≥ 65 years, no formal education, having ≥ 3 children, having the first DNR order to death ≤ 29 days, and the last admission in an intensive care unit.

Conclusions

A substantial proportion of terminal cancer patients did not sign DNR documents by themselves. It indicates they may not know their actual terminal conditions and lose the last chance to grasp time to express their life values and wishes. Medical staff involving cancer patient care may need further education on the legal and ethical issues revolving around patient autonomy and training on communicating end-of-life options with the patients. We suggest proactively discussing DNR decision issues with terminal cancer patients no later than when their estimated survival is close to 1 month.

Inadequate cancer pain management in Italian clinical trials

Pain treatment in Italy is far from being optimal. In order to improve this situation, the reporting of a complete assessment of pain in the clinical record became compulsory by law. Pain-related cancer protocols (143) were selected from the National Monitoring Centre of Clinical Trials Database and reviewed. Our data indicate that pain management is not being reported as it should be: treatment has been taken into account in only 36.4% of the protocols, and assessment in 37.1%. Furthermore, breakthrough cancer pain has never been reported. The main aim of cancer therapy is obviously control the disease, however Ethics Committees should pay close attention to pain therapy when evaluating clinical protocols.

Facilitating advance care planning in community palliative care: conversation starters across the client journey

This paper describes the development of a tool for palliative care nurses to initiate and facilitate advance care planning (ACP) conversations in community palliative care practice. Seven community palliative care services located across Australia participated in a multi-site action research project. Data included participant observation, individual and focus group interviews with palliative care health professionals, and medical record audit. A directed content analysis used a pre-established palliative care practice framework of referral, admission, ongoing management, and terminal/discharge care. From this framework a Conversation Starter Tool for ACP was developed. The Tool was then used in orientation and continuing nurse education programmes. It provided palliative care nurses the opportunity to introduce and progress ACP conversations.

Developing effective cancer pain education programs

Pain is prevalent, burdensome, and undertreated in individuals with cancer across the disease trajectory. Providing patients and family caregivers with psychosocial support and education to manage cancer pain is a core component of quality care that can result in significant clinical benefit. In this review, we: (1) outline an approach for developing and assessing the effectiveness of education programs for adults with cancer pain; (2) discuss considerations for tailoring programs to the needs of diverse populations and those with limited health literacy skills; (3) describe the resource needs and costs of developing a program; (4) highlight innovative approaches to cancer pain education. We conclude with recommendations for future research and the next generation of educational interventions.