Treatment options in end-of-life care: the role of palliative chemotherapy

Chemotherapy use at the End of Life. A Retrospective Single Centre Experience Analysis

Aims and background

The aim of the study was to evaluate the attitude at our institution in using chemotherapy at the end of life in oncology patients. We compared our habits with other clinical patterns in medical oncology, calculating the temporal interval between the last chemotherapy administration and death of the patient.

Patients and methods

We selected and analyzed 102 patients who received chemotherapy for metastatic or advanced solid tumors (breast, colon, gastric, pancreatic and lung cancers) and who died either in or out of a hospital or hospice from June 2007 to the end of 2009.

Results

We compared 51 patients enrolled in clinical trials with 51 patients not enrolled in clinical trials. Patients of both groups died with advanced cancer between June 2007 and 2009. The following solid tumor types were represented: 48% colorectal cancer, 22% breast cancer, 30% other solid tumors (pancreatic, lung and gastric cancer). The median age at death was 62 years (range, 39 to 84), the male/female ratio was 52:50, and 69% of the patients were married. Most patients, 54%, received 2–3 lines of chemotherapy, 25% received more than 3 lines, and the remaining 21% one line only of chemotherapy. Of the 102 patients identified, 16 (16%) received chemotherapy in the last month of life, and 6 (6%) of these in the last 2 weeks. We speculated that the presence of palliative care services in the territory of residence of patients could influence the time interval between the last chemotherapy and death. We found that 52 patients (51%) lived in areas where palliative care services were not available, 27 (52%) of them received chemotherapy in the last 3 months, 8 (15%) in the last month, and 5(10%) within the last 2 weeks of life. In contrast, of the 49 patients living in the territory served by palliative care units or a hospice, none received chemotherapy during the last 2 weeks of life and 37% received it during the last 3 months of life (P = 0.003).

Conclusions

Among selected patients who died for advanced cancer in our Operative Unit from 2007 to 2009, 50% received chemotherapy in the last 3 months of life. The availability of palliative care services in the territory of residence of patients can influence the interval between the last chemotherapy administration and death. Free full text available at www.tumorionline.it

Palliative Chemotherapy: The Perspectives and Experiences of South African Nurses

OBJECTIVE

The objective of this study was to describe the perspectives and experiences of South African nurses caring for patients receiving palliative chemotherapy.

METHODS

A qualitative descriptive design was used and purposive sampling allowed us to select 11 nurses practising in a private ambulatory cancer care center in Port Elizabeth. In-depth interviews, guided by three broad themes were conducted and analyzed using qualitative content analyses. Data saturation determined the sample size.

RESULTS

Two themes emerged from the data - the patients cling to hope and the positive influence of palliative chemotherapy. The participants believed that patients consenting to palliative chemotherapy were clinging to false hope. They were also of the opinion that family members pressurize patients to consent to treatment. The participants experienced palliative chemotherapy positively, especially when an improvement in the patients' quality of life or pain relief was evident. Fatigue was highlighted as the major side effect, but it did not temper the participants' positive attitudes toward the treatment.

CONCLUSIONS

Although the participants believed that patients cling to hope and consent to palliative chemotherapy because they hope to be cured, they experienced the treatment as positive. For them, the improvement in pain and quality of life outweighed the side effects the patients experienced. The positive attitude patients upheld while receiving this treatment encouraged them. Nurses should gain more knowledge about the meaning, people living with advanced cancer, attach to hope to prevent them from interpreting patients' hope as denial and false.

The role of palliative chemotherapy in hospitalized patients

BACKGROUND

Hospitalized patients with advanced cancer often have a poor performance status, which is considered a relative contraindication to cytotoxic chemotherapy. We investigated outcomes in hospitalized solid tumour oncology patients who received palliative chemotherapy (pct).

METHODS

With ethics approval, we performed a single-institution chart review of all patients hospitalized on our oncology unit who received pct between April 2008 and January 2010. Patient demographics, reasons for admission, cancer type, prior therapy, and administered chemotherapy were recorded. The primary endpoint was median survival from date of inpatient chemotherapy until death or last known follow up. We also investigated place of discharge and whether patients received additional therapy.

RESULTS

During the study period, 199 inpatients received pct. Median age was 61 years; 59% of the patients were women. Most had been admitted with dyspnea (31%) or pain (29%) as the dominant symptom. Common cancers represented were breast (23%), small-cell lung cancer (sclc, 22%), non-small-cell lung cancer (nsclc, 16%), and colorectal cancer (9%). Most patients (67%) were receiving first-line chemotherapy. Median overall survival duration was 4.5 months, and the 6-month survival rate was 41%. The longest and shortest survivals were seen in the sclc and nsclc groups (7.3 and 2.5 months respectively). Factors significantly associated with shorter survival were baseline hypoalbuminemia and therapy beyond the first line. In this cohort, 77% of patients were discharged home, and 72% received further chemotherapy.

CONCLUSIONS

Despite a short median survival, many patients are well enough to be discharged home and to receive further chemotherapy. The development of risk models to predict a higher chance of efficacy will have practical clinical utility.

Cultural and Ethical Considerations for Cardiopulmonary Resuscitation in Chinese Patients With Cancer at the End of Life

End-of-life (EOL) decision making is based on the values and wishes of terminally ill patients. However, little is known on the extent to which cultural factors affect personal attitudes toward life-sustaining treatments (LSTs) such as cardiopulmonary resuscitation (CPR) in China. This study evaluated the cultural and ethical considerations during EOL decisions and assessed the factors that affect pursuing LSTs in China. We used a case–control study design and compared their baseline characteristics with the provided EOL care and treatments. The CPR treatment among patients with cancer at EOL was affected by Chinese family traditions and Western influences. Our results reflect the need to improve EOL care and treatment in China.

Patient and family experiences of palliative care in hospital: what do we know? An integrative review

BACKGROUND

In most developed countries, acute hospitals play a significant role in palliative care provision and are the setting in which most people die. They are often the setting where a life-limiting diagnosis is made and where patients present when symptoms develop or when they are not well managed. Understanding the experiences of hospital admissions for people with a life-limiting illness and their families is essential in understanding the role acute hospitals play in providing palliative care.

AIM

The aim of this review is to synthesise current evidence regarding the experience of palliative care in an acute hospital setting from the perspectives of patient and family.

DESIGN

An integrative review was completed using standard processes followed by a process of data extraction and synthesis.

DATA SOURCES

Using predefined search terms, literature was sourced from five electronic databases including MEDLINE (EBSCO), CINAHL, EMBASE, Cochrane and PsycINFO between January 1990 and November 2011. Reference lists from relevant articles were cross-checked and pertinent journals hand searched for articles.

RESULTS

In total, 32 articles were included in the review. Five recurring themes were identified from the synthesised data: symptom control and burden, communication with health professionals, decision-making related to patient care and management, inadequate hospital environment and interpersonal relationships with health professionals.

CONCLUSION

This review has identified that, largely as a result of study design, our knowledge of patient and family experiences of palliative care in an acute hospital remains limited to discrete aspects of care. Further research is required to explore the total patient and family experience taking into account all aspects of care including the potential benefits of hospital admissions in the last year of life.

Canadian rural-urban differences in end-of-life care setting transitions

Few studies have focused on the care setting transitions that occur in the last year of life. A three part mixed-methods study was conducted to gain an understanding of the number and implications or impact of care setting transitions in the last year of life for rural Canadians. Provincial health services utilization data, national online survey data, and local qualitative interview data were analyzed to gain general and specific information for consideration. Rural Albertans had significantly more healthcare setting transitions than urbanites in the last year of life (M=4.2 vs 3.3). Online family respondents reported 8 moves on average occurred for family members in the last year of life. These moves were most often identified (65%) on a likert-type scale as “very difficult,” with the free text information revealing these trips were often emotionally painful for themselves and physically painful for their ill family member. Eleven informants were then interviewed until data saturation, with constant-comparative data analysis conducted for a more in-depth understanding of rural transitions. Moving from place to place for needed care in the last year of life was identified as common and concerning for rural people and their families, with three data themes developing: (a) needed care in the last year of life is scattered across many places, (b) travelling is very difficult for terminally-ill persons and their caregivers, and (c) local rural services are minimal. These findings indicate planning is needed to avoid unnecessary end-of-life care setting transitions and to make needed moves for essential services in the last year of life less costly, stressful, and socially disruptive for rural people and their families.

A clinical decision support tool to predict survival in cancer patients beyond 120 days after palliative chemotherapy

BACKGROUND

Palliative chemotherapy is often administered to terminally ill cancer patients to relieve symptoms. Yet, unnecessary use of chemotherapy can worsen patients' quality of life due to treatment-related toxicities. Thus, accurate prediction of survival in terminally ill patients can help clinicians decide on the most appropriate palliative care for these patients. However, studies have shown that clinicians often make imprecise predictions of survival in cancer patients. Hence, the purpose of this study was to create a clinical decision support tool to predict survival in cancer patients beyond 120 days after palliative chemotherapy.

MATERIALS AND METHODS

Data were obtained from a retrospective study of 400 randomly selected terminally ill cancer patients in the National Cancer Centre Singapore (NCCS) from 2008 to 2009. After removing patients with missing data, there were 325 patients remaining for model development. Three classification algorithms, naive Bayes (NB), neural network (NN), and support vector machine (SVM) were used to create the models. A final model with the best prediction performance was then selected to develop the tool.

RESULTS

The NN model had the best prediction performance. The accuracy, specificity, sensitivity, and area under the curve (AUC) of this model were 78%, 82%, 74%, and 0.857, respectively. Five patient attributes (albumin level, alanine transaminase level (ATL), absolute neutrophil count, Eastern Cooperative Oncology Group (ECOG) status, and number of metastatic sites) were included in the model.

CONCLUSIONS

A decision support tool to predict survival in cancer patients beyond 120 days after palliative chemotherapy was created. With further validation, this tool coupled with the professional judgment of clinicians can help improve patient care.

Oncology nurses' personal understandings about palliative care

PURPOSE/OBJECTIVES

To examine how oncology nurses define palliative care, views about who should and should not receive palliative care, and beliefs about palliative care decision making, including who should be involved and how decisions should be managed.

DESIGN

Qualitative interviews and analysis.

SETTING

Preferred location of each respondent.

SAMPLE

12 nurses representing different aspects of oncology nursing.

METHODS

An interview guide was employed to ensure that specific topics were covered. Interviews were transcribed verbatim. Qualitative analysis consisted of independent, multiple reviews of the transcripts to share initial findings and identify, refine, and reach consensus on major themes and subthemes.

MAIN RESEARCH VARIABLES

Nurses' definitions of palliative care, views about who should and should not receive palliative care, and beliefs about palliative care decision making.

FINDINGS

Nurses' perceptions of palliative care focused on symptom management. Most did not distinguish between palliative care and hospice and believed that only patients who were near the end of life should receive palliative care. They viewed their role in decisions regarding palliative care to be limited and indirect.

CONCLUSIONS

Although oncology nurses should be at the cutting edge with regard to palliative care, these nurses' personal understandings could serve to limit care for many patients with cancer who could benefit from it.

IMPLICATIONS FOR NURSING

Education and clinical experience embedded in a continuous quality-improvement model are needed to ensure sustained change that will overcome the multiple, interwoven barriers to providing appropriate palliative care.