End-of-life care in patients with lung cancer

Survivorship in Advanced Lung Cancer: Understanding a New Landscape and Opportunities

People with advanced lung cancer represent a distinct group whose needs remain understudied, especially compared with people diagnosed with limited-stage disease. Fortunately, novel treatments such as tyrosine kinase inhibitors and immune checkpoint inhibitors are leading to significant advances in prognosis and survival, even among those with advanced disease at the time of diagnosis. However, there are known gaps in symptom management, psychosocial and nutritional support, complex care coordination, health behavior coaching, and health care delivery efforts among patients living with advanced lung cancer. Many of these patients would benefit from survivorship and palliative care approaches. In particular, survivorship care may include health care maintenance, treatment of immune-related adverse events and late- or long-term effects, frailty assessment and rehabilitation, and care coordination. Palliative care may be best suited to discuss ongoing symptom management, advanced care planning, and end-of-life considerations, as well as psychosocial well-being. To this end, we share a review of the current status of the palliative and survivorship care infrastructure for patients with advanced lung cancer and provide suggestions across the care continuum for this diverse group of patients and families.

Patient Perspectives on Value Dimensions of Lung Cancer Care: Cross-sectional Web-Based Survey

BACKGROUND

While the lung cancer (LC) treatment landscape has rapidly evolved in recent years, easing symptom burden and treatment side effects remain central considerations in disease control.

OBJECTIVE

The aim of this study was to assess the relative importance of dimensions of LC care to patients, and to explore the disease burden, including socioeconomic aspects not commonly covered in patient-reported outcomes instruments.

METHODS

A questionnaire was sent to patients with LC and their caregivers to rate the value of a diverse set of quality of life dimensions in care, to evaluate communication between health care professionals (HCPs) and patients, and to explore the economic impact on respondents. The survey included questions on the dimensions of care covered by patient-reported outcomes instruments for quality-of-life evaluation (Functional Assessment of Cancer Therapy-Lung scale, EQ-5D, the European Organization for Research and Treatment of Cancer's Core Quality of Life questionnaire, and the European Organization for Research and Treatment of Cancer's Core Quality of Life in lung cancer 13-item questionnaire), as well as the International Consortium for Health Outcomes Measurement (ICHOM) standard set of patient-centered outcomes for LC. The survey respondents were participants on Carenity's patient community platform, living either in France, the United Kingdom, Germany, Italy, or Spain.

RESULTS

The survey included 150 respondents (115 patients and 35 caregivers). "Physical well-being" and "end-of-life care" (median scores of 9.6, IQR 7.7-10, and 9.7, IQR 8.0-10, on a 10-point scale) were rated highest among the different value dimensions assessed. "Physical well-being and functioning" was the dimension most frequently discussed with health care professionals (82/150, 55%), while only (17/100, 17%) reported discussing "end-of-life care." After diagnosis, 43% (49/112) of patients younger than 65 years stopped working. Among respondents who indicated their monthly household income before and after diagnosis, 55% (38/69) reported a loss of income.

CONCLUSIONS

Our results showed the relevance of a broad range of aspects of care for the quality of life of patients with LC. End-of-life care was the dimension of care rated highest by patients with LC, irrespective of stage at diagnosis; however, this aspect is least frequently discussed with HCPs. The results also highlight the considerable socioeconomic impact of the disease, despite insurance coverage of direct costs.

Medical costs of Japanese lung cancer patients during end-of-life care

OBJECTIVE

The medical costs associated with cancer treatment have increased rapidly in Japan; however, little data exist on actual costs, especially for end-of-life care. Therefore, this study aimed to examine the medical costs of lung cancer patients during the last 3 months before death and to compare the costs with those of initial anticancer treatment.

METHODS

We retrospectively evaluated all patients who died from lung cancer at the Japanese Red Cross Medical Center between 1 January 2008 and 31 August 2019. Patients were classified into three cohorts (2008-2011, 2012-2015 and 2016-2019) according to the year of death; the medical costs were evaluated for each cohort. Costs were then divided into outpatient and inpatient costs and calculated per month.

RESULTS

Seventy-nine small cell lung cancer and 213 non-small cell lung cancer patients were included. For small cell lung cancer and non-small cell lung cancer patients, most end-of-life medical costs were inpatient costs across all cohorts. The median monthly medical costs for the last 3 months among both small cell lung cancer and non-small cell lung cancer patients did not differ significantly among the cohorts, but the mean monthly costs for non-small cell lung cancer tended to increase. The monthly medical costs for the last 3 months were significantly higher than those for the first year in SCLC (P = 0.013) and non-small cell lung cancer (P < 0.001) patients and those for the first 3 months in non-small cell lung cancer patients (P = 0.005).

CONCLUSIONS

The medical costs during the end-of-life period for lung cancer were high and surpassed those for initial treatment.

Risk Factors for Short-Term Lung Cancer Survival

Background: Lung cancer is typically diagnosed in an advanced phase of its natural history. Explanatory models based on epidemiological and clinical variables provide an approximation of patient survival less than one year using information extracted from the case history only, whereas models involving therapeutic variables must confirm that any treatment applied is worse than surgery in survival terms. Models for classifying less than one year survival for patients diagnosed with lung cancer which are able to identify risk factors and quantify their effect for prognosis are analyzed. Method: Two stepwise binary logistic regression models, based on a retrospective study of 521 cases of patients diagnosed with lung cancer in the Interventional Pneumology Unit at the Hospital “Virgen de las Nieves”, Granada, Spain. Results: The first model included variables age, history of pulmonary neoplasm, tumor location, dyspnea, dysphonia, and chest pain. The independent risk factors age greater than 70 years, a peripheral location, dyspnea and dysphonia were significant. For the second model, treatments were also significant. Conclusions: Age, history of pulmonary neoplasm, tumor location, dyspnea, dysphonia, and chest pain are predictors for survival in patients diagnosed with lung cancer at the time of diagnosis. The treatment applied is significant for classifying less than one year survival time which confirms that any treatment is markedly inferior to surgery in terms of survival. This allows to consider applications of more or less aggressive treatments, anticipation of palliative cares or comfort measures, inclusion in clinical trials, etc.

Assessing Quality of Life of Patients with Advanced Chronic Obstructive Pulmonary Disease in the End of Life

Given the limitations of existing health-related quality-of-life (QOL) measures in capturing the end-of-life experience of patients with advanced chronic diseases, an empirically grounded instrument, the quality-of-life concerns in the end of life questionnaire (QOLC-E), was developed. Though it was built on the McGill quality of life questionnaire (MQOL), its sphere is more holistic and culturally specific for the Chinese patients in Hong Kong. One hundred and forty-nine patients with advanced chronic obstructive pulmonary disease (COPD) or metastatic cancer completed the questionnaire. Seven factors (28 items) which emerged from the factor analysis were grouped into four positive (support, value of life, food-related concerns, and healthcare concerns) and four negative (physical discomfort, negative emotions, sense of alienation, and existential distress) subscales. Good internal consistency and concurrent validity were shown. The results also revealed that these two groups of patients had similar QOL concerns. The validity of applying QOLC-E as an outcome measure to evaluate the effectiveness of palliative and psychoexistential interventions has yet to be tested.

Twenty-eight-day mortality in lung cancer patients with metastasis who initiated mechanical ventilation in the emergency department

Few data are available regarding treatment outcomes in lung cancer patients with metastasis who initiated mechanical ventilation in the emergency department (ED). We aimed to evaluate 28-day mortality in lung cancer patients with metastasis who initiated mechanical ventilation in the ED. Patients with solid malignancy who initiated mechanical ventilation in the ED of a tertiary hospital were retrospectively identified and stratified into four groups according to the presence of lung cancer and metastasis. Among 212 included patients, the mortality rates by the 28^th hospital day were as follows: 44.2% (19/43) in non-lung cancer patients without metastasis, 63.2% (43/68) in non-lung cancer patients with metastasis, 52.4% (11/21) in lung cancer patients without metastasis, and 66.2% (53/80) in lung cancer patients with metastasis. In multivariable analysis, lung cancer patients with metastasis had significantly higher odds ratio for 28-day mortality than non-lung cancer patients without metastasis (adjusted odds ratio [OR] = 7.17, 95% confidence interval [CI] = 2.14-24.01). Sepsis-related respiratory failure (adjusted OR = 2.60, 95% CI = 1.16-5.84) and cardiopulmonary resuscitation (adjusted OR = 13.34, 95% CI = 4.45-39.95) over respiratory failure without sepsis and acute organ dysfunction process measured by sequential organ failure assessment (SOFA) score (adjusted OR = 1.15, 95% CI = 1.05-12.6) were independently associated with an increase in mortality rate. In conclusion, the treatment outcomes in lung cancer patients with metastasis who initiated mechanical ventilation in the ED were poor. Aggressive resuscitation versus end-of-life care in advance of an unexpected medical crisis should be considered in lung cancer patients with metastasis via a multidisciplinary approach with a consideration of underlying comorbid illnesses in the acute organ dysfunction processes.

Discrepancies in the Viewpoints of Different German Health Care Providers on Palliative Care

In many countries with highly developed health care systems, significant improvements in end-of-life care are strongly recommended. Up to the present, the assessment of perceived deficits predominantly reflects the point of view of experts in the palliative and hospice movement, with very little being known about the perspective of other professionals. The aim of this study was to assess the points of view of a wide range of different health care providers who treated or interacted with palliative care patients. The authors subsequently performed 597 semistructured telephone interviews with a wide range of German health care professionals. Overall, the assessment of the current situation was better than expected, although statistically significant differences existed among the groups surveyed. However, there is an unquestionable need for improvement, although opinions regarding the extent of these deficits depend significantly on the individual respondents’ roles and professional orientation.

Effects of multidisciplinary team care on the survival of patients with different stages of non-small cell lung cancer: a national cohort study

In Taiwan, cancer is the top cause of death, and the mortality rate of lung cancer is the highest of all cancers. Some studies have demonstrated that multidisciplinary team (MDT) care can improve survival rates of non-small cell lung cancer (NSCLC) patients. However, no study has discussed the effect of MDT care on different stages of NSCLC. The target population for this study consisted of patients with NSCLC newly diagnosed in the 2005–2010 Cancer Registry. The data was linked with the 2002–2011 National Health Insurance Research Database and the 2005–2011 Cause of Death Statistics Database. The multivariate Cox proportional hazards model was used to explore whether the involvement of MDT care had an effect on survival. This study applied the propensity score as a control variable to reduce selection bias between patients with and without involvement of MDT care. The adjusted hazard ratio (HR) of death of MDT participants with stage III & IV NSCLC was significantly lower than that of MDT non-participants (adjusted HR = 0.87, 95% confidence interval = 0.84-0.90). This study revealed that MDT care are significantly associated with higher survival rate of patients with stage III and IV NSCLC, and thus MDT care should be used in the treatment of these patients.

The impact of rescue or maintenance therapy with EGFR TKIs for Stage IIIb-IV non-squamous non-small-cell lung cancer patients requiring mechanical ventilation

Background

The toxicity of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) is less than that of cytotoxic agents. The reports of dramatic response and improvement in performance status with the use of EGFR TKIs may influence a physician’s decision-making for patients with non-squamous non-small cell lung cancer (NSCLC) and life-threatening respiratory distress. The aim of this study was to evaluate the outcome of rescue or maintenance therapy with EGFR TKI for stage IIIb-IV non-squamous NSCLC patients requiring mechanical ventilation.

Methods

Eighty-three Asian patients with stage IIIb-IV non-squamous NSCLC and who required mechanical ventilation between June 2005 and January 2010 were evaluated.

Results

Of the 83 patients, 16 (19%) were successfully weaned from the ventilator. The use of EGFR TKI as rescue or maintenance therapy during respiratory failure did not improve the rate of successful weaning (standard care 18% vs. with EGFR TKI, 22%; p = 0.81) in univariate and multivariate analyses.

Conclusions

Rescue or maintenance therapy with EGFR TKI for stage IIIb-IV non-squamous NSCLC patients requiring mechanical ventilation was not associated with better outcome. An end-of-life discussion should be an important aspect in the care of this group of patients, since only 19% were successfully weaned from mechanical ventilation.

Complicated grief symptoms in caregivers of persons with lung cancer: the role of family conflict, intrapsychic strains, and hospice utilization

Guided by a stress process conceptual model, this study examines social and psychological determinants of complicated grief symptoms focusing on family conflict, intrapsychic strains, and the potential moderating effect of care quality and hospice utilization. Relying on data from 152 spouse and adult child lung cancer caregiver survey respondents, drawn from an ancillary study of the Assessment of Cancer CarE and SatiSfaction (ACCESS) in Wisconsin, hierarchical multiple regression analysis was used to examine determinants of complicated grief. After controlling for contextual factors and time since death, complicated grief symptoms were higher among caregivers with less education, among families with lower prior conflict but higher conflict at the end-of-life, who had family members who had difficulty accepting the illness, and who were caring for patients with greater fear of death. Additionally, hospice utilization moderated the effect of fear of death on complicated grief. Findings suggest that family conflict, intrapsychic strains, and hospice utilization may help to explain the variability found in complicated grief symptoms among bereaved caregivers. Implications for enhancing complicated grief assessment tools and preventative interventions across the continuum of cancer care are highlighted.

Advancing performance measurement in oncology: quality oncology practice initiative participation and quality outcomes

The American health care system, including the cancer care system, is under pressure to improve patient outcomes and lower the cost of care. Government payers have articulated an interest in partnering with the private sector to create learning communities to measure quality and improve the value of health care. In 2006, the American Society for Clinical Oncology (ASCO) unveiled the Quality Oncology Practice Initiative (QOPI), which has become a key component of the measurement system to promote quality cancer care. QOPI is a physician-led, voluntary, practice-based, quality-improvement program, using performance measurement and benchmarking among oncology practices across the United States. Since its inception, ASCO's QOPI has grown steadily to include 973 practices as of November 2010. One key area that QOPI has addressed is end-of-life care. During the most recent data collection cycle in the Fall of 2010, those practices completing multiple data collection cycles had better performance on care of pain compared with sites participating for the first time (62.61% v 46.89%). Similarly, repeat QOPI participants demonstrated meaningfully better performance than their peers in the rate of documenting discussions of hospice and palliative care (62.42% v 54.65%) and higher rates of hospice enrollment. QOPI demonstrates how a strong performance measurement program can lead to improved quality and value of care for patients.

Prognosis and Resuscitation Status of Critically Ill Patients with Lung Cancer Admitted to the Intensive Care Unit

The aims of the study were to assess the intensive care unit (ICU) outcome for critically ill patients with lung cancer, to determine the risk factors for mortality and to examine the resuscitation status on admission and during their ICU course. Data was collected from May 1999 to March 2009 for patients with lung cancer admitted to the ICU. During the study period, 51 patients with lung cancer were admitted to our ICU. The ICU and hospital mortality rates were 49 and 60%, respectively. The majority of patients were full resuscitation on admission to ICU. The resuscitation status was changed in 56% of patients during the ICU course. It is suggested that end-of-life decisions should be addressed earlier in these patients’ illnesses.

Hospice Disease Types Which Indicate a Greater Need for Bereavement Counseling

This article attempts to find a correlation between certain disease types and increased needs for bereavement services for survivors. Data were examined from those requesting increased bereavement services from a hospice provider in Kentucky, over a 2-year span. The survivors were then matched with the disease type of their loved one to see whether there was a connection between the two. Although limited in its scope and focus, the study revealed that patients surviving Alzheimer disease, lung cancer, and renal failure consistently (at least 50% of the time) required increased bereavement services after the death of their loved one. Other disease types indicated more erratic patterns for increased grief services.

[Assessment of the quality of life of patients with lung cancer using the Medical Outcomes Study 36-item Short-Form Health Survey]

OBJECTIVE

To assess the quality of life of patients with lung cancer and to compare it with that of individuals without cancer.

METHODS

The Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) was administered to 57 patients diagnosed with lung cancer, treated at the Lung Cancer Outpatient Clinic of the Hospital São Paulo, and to a control group of 57 individuals recruited from the Extra Penha workout group. The Mann-Whitney test was used to compare the groups, domain by domain. The first model of logistic regression was adjusted for male gender, nonsurgical treatment, Karnofsky performance status and smoking, which were included as predictors. The second model was adjusted for each SF-36 domain in order to identify increases in the proportions of patients in stage IIIB or IV.

RESULTS

The lung cancer group and the control group presented the following mean scores, respectively, for the SF-36 domains: role limitations due to physical health problems, 29.39 +/- 36.94 and 82.89 +/- 28.80; role limitations due to emotional problems, 42.78 +/- 44.78 and 86.55 +/- 28.77; physical function, 56.49 +/- 28.39 and 89.00 +/- 13.80; vitality, 61.61 +/- 23.82 and 79.12 +/- 17.68; bodily pain, 62.72 +/- 28.72 and 81.54 +/- 19.07; general health, 62.51 +/- 25.57 and 84.47 +/- 13.47; emotional well-being, 68.28 +/- 23.46 and 82.63 +/- 17.44; and social functioning, 72.87 +/- 29.20 and 91.67 +/- 17.44. The logistic regression model showed that role limitations due to physical health problems, physical function and emotional well-being were predictors of stages IIIB and IV.

CONCLUSIONS

The patients with lung cancer had a poorer quality of life, especially regarding physical aspects, than did the control subjects.

Clinician-patient communication: a systematic review

GOAL OF WORK

The goal of this work was to identify methods of clinician-patient cancer-related communication that may impact patient outcomes associated with distress at critical points in the course of cancer care.

MATERIALS AND METHODS

A systematic review of practice guidelines, systematic reviews, or randomized trials on this topic was conducted. Guidelines for quality was evaluated using the Appraisal of Guidelines for Research and Evaluation Instrument, and the contributive value for recommendations was assessed. Systematic reviews and randomized trials were also evaluated for methodological rigor.

RESULTS

Four existing guidelines, eight systematic reviews and nine randomized trials were identified. Two of the guidelines were of high quality, and all systematic reviews reported clear search criteria and support for their conclusions; the randomized trials were of modest or low quality. For all situations and disease stages, guidelines consistently identified open, honest, and timely communication as important; specifically, there was evidence for a reduction in anxiety when discussions of life expectancy and prognosis were included in consultations. Techniques to increase patient participation in decision-making were associated with greater satisfaction but did not necessarily decrease distress. Few studies took cultural and religious diversity into account.

CONCLUSIONS

There is little definitive evidence supporting the superiority of one specific method for communicating information compared to another. Evidence regarding the benefit of decision aids or other strategies to facilitate better communication is inconsistent. Since patients vary in their communication preferences and desire for active participation in decision making, there is a need to individualize communication style.

Cancer patient assessment and reports of excellence: reliability and validity of advanced cancer patient perceptions of the quality of care

PURPOSE

Consumer perceptions are important measures of the quality of cancer care. This article describes the validation of new measures of the quality of cancer care at the time of diagnosis and treatment for advanced cancer with life-limiting prognosis.

METHODS

Focus groups, review of guidelines, and an expert panel were used to construct two surveys of the quality of cancer care. A prospective cohort study examined the reliability and validity of three problem scores (ie, counts of the opportunities to improve the quality of care) that examine care at the time of diagnosis and initial treatment.

RESULTS

At the first interview, 58% of 206 cancer patients (54.9% females; 27.5% with lung cancer; 5.4% with pancreatic cancer; 30.4% with colorectal cancer; 18.6% with breast cancer; mean age, 66.6 years) identified one or more concerns with communication about being diagnosed with advanced cancer. At the second interview, 57.0% of the respondents voiced one or more concerns about treatment communication, and 30.2% expressed one or more concerns about the experience of treatment. Each of the problem scores demonstrated both internal consistency with Cronbach's alpha > .75 and short-term stability of responses in a subsample that had the survey administered twice in 72 hours. Factor analysis largely confirmed the proposed scale structure. All three measures demonstrated moderate correlations suggesting evidence of construct validity.

CONCLUSION

The three proposed problem scores demonstrate evidence of reliability and validity that warrants further testing to examine their responsiveness and discriminate validity in larger, more generalizable samples.

Respiratory support in oncology ward setting: a prospective descriptive study

BACKGROUND

Mechanical ventilation in cancer patients is a critical issue The present prospective descriptive study was designed (1) to assess the patient population needing respirator support in ward setting at a premier state-run oncology institute in India, (2) to observe and analyze the course of their disease while on respirator, and (3) to coordinate better quality of life measures in cancer patients at the institute based on the present study's outcomes.

METHODS

Beginning from March 2005 to March 2006, all cancer patients who were connected to respirator in the wards were enrolled in the current study. Our anesthesiology department at the cancer institute also has primary responsibility for airway management and mechanical ventilation in high dependency units of oncology wards. Preventilation variables in cancer patients were assessed to judge the futility of mechanical ventilation in ward setting. Subsequently, patients were observed for disease course while on respirator. Final outcome with its etio-pathogenesis was correlated with predicted futility of mechanical ventilation.

RESULTS

Over a period of 1 year, 132 (46 men and 86 women) cancer patients with median age 40 years (range 1-75 years) were connected to respirator in oncology wards. Based on the preventilation variables and indications for respirator support, right prediction of medical futility and hospital discharge was made in 77% of patients. Underestimation and overestimation of survival to hospital discharge was made in 10% cases and 13% cases, respectively.

CONCLUSION

Based on preventilation variables, prediction of outcome in cancer patients needing respirator support can be made in 77% cases. This high probability of prediction can be used to educate patients, and their families and primary physicians, for well-informed and documented advance directives, formulated and regularly revised DNAR policies, and judicious use of respirator support for better quality-of-life outcomes.

Symptom concerns and resource utilization in patients with lung cancer

OBJECTIVE

Lung cancer remains a major source of death in the United States. With the aging of the population, health policy makers are challenged to develop systems of care for the complex needs of these patients. This study sought to determine quality of life and symptom concerns in lung cancer patients. The study also sought to determine how supportive care resources were being used to address these concerns.

METHODS

One hundred consecutive patients with newly diagnosed lung cancer presenting over a 12-month period were selected from the tumor registry. Charts were reviewed for demographic data, treatment history, treatment received, number and type of practitioner encounters, readmissions, and complications for a 6-month period.

RESULTS

Of the 100 charts retrospectively reviewed, 4 patients had small cell and 96 patients had non-small cell lung cancer. The median age was 67 years. Fifty-three patients were men. The most common symptoms were pain, cough, dyspnea, and fatigue. A total of 114 referrals in 57 patients were made. Nutrition consultation was the most common.

CONCLUSIONS

This study serves to guide the institution in the development of more effective support services for patients with lung cancer to address quality of life concerns through collaboration between clinicians and researchers.

Trends in end-of-life ICU use among older adults with advanced lung cancer

BACKGROUND

There is increasing concern about the appropriateness of intensive medical care near the end of life in ICUs throughout the United States. As a result of hospice expansion in the 1990s, we hypothesized that ICU use decreased over time in older adults with advanced lung cancer.

METHODS

Retrospective analysis using the linked Surveillance, Epidemiology and End Results Medicare database. There were 45,627 Medicare beneficiaries > or = 66 years of age with confirmed stage IIIB or IV lung cancer between January 1, 1992, and December 31, 2002, who died within a year of their cancer diagnosis from 1993 through 2002.

RESULTS

ICU use in the last 6 months of life increased from 17.5% in 1993 to 24.7% in 2002 (p < 0.001). After adjusting for patient characteristics, there was a 6.6% annual increase in ICU use from 1993 to 2002. During the same period, hospice use had risen from 28.8 to 49.9% (p < 0.001). A total of 6.2% of patients received both end-of-life ICU care and hospice care, a percentage that increased over time. The total health-care cost for Medicare fee-for-service patients during last 6 months was $40,929 for ICU users and $27,160 for non-ICU users (p < 0.001).

CONCLUSION

Despite increasing hospice use, ICU utilization among older adults dying with advanced lung cancer continued to rise in the United States during the 1990s.

Palliative Care Consultation, Quality-of-Life Measurements, and Bereavement for End-of-Life Care in Patients With Lung Cancer

OBJECTIVE

To develop clinical practice guidelines for application of palliative care consultation, quality-of-life measurements, and appropriate bereavement activities for patients with lung cancer.

METHODS

To review the pertinent medical literature on palliative care consultation, quality-of-life measurements, and bereavement for patients with lung cancer, developing multidisciplinary discussions with authorities in these areas, and evolving written guidelines for end-of-life care of these patients.

RESULTS

Palliative care consultation has developed into a new specialty with credentialing of experts in this field based on extensive experience with patients in end-of-life circumstances including those with lung cancer. Bereavement studies of the physical and emotional morbidity of family members and caregivers before, during, and after the death of a cancer patient have supported truthful communication, consideration of psychological problems, effective palliative care, understanding of the patient's spiritual and cultural background, and sufficient forewarning of impending death.

CONCLUSION

Multidisciplinary investigations and experiences, with emphasis on consultation and delivery of palliative care, timely use of quality-of-life measurements for morbidities of treatment modalities and prognosis, and an understanding of the multifaceted complexities of the bereavement process, have clarified additional responsibilities of the attending physician.

Systematic review of educational interventions in palliative care for primary care physicians

BACKGROUND

A literature review of educational interventions in palliative care (PC) for primary care physicians (PCP) was performed, to evaluate its impact in changing professional practice.

METHODS

Studies undertaking any educational intervention in PC by PCP, published between 1966 and February 2005, identified through Medline, EMBASE, Cochrane Database of Systematic Reviews and Clinical Trials, Educational Resources Information Centre, Research and Development Resource Base in Continuing Medical Education, Spanish Medical Index, using a combined text word and MESH heading search strategy.

RESULTS

Eighteen articles were included with 1653 physicians. Educative methods were: role model training, small group discussions, and distribution of guidelines. Quality of the studies was low. Opioids prescription improved in two studies. Discrepancies were shown between the perception of PCP in symptom management, determined through questionnaires, and the data concerning opioids prescription. Knowledge improved in all studies. Some benefit of multifaceted approach was stated. Carers were satisfied, in general, with the PCP care, but dissatisfied with patients' pain control.

CONCLUSION

PC education for PCP is poorly studied. Adequate research designs are necessary in future studies with objective outcomes and patient opinion.

Outcome and Code Status of Lung Cancer Patients Admitted to the Medical ICU

OBJECTIVES

To determine the outcome of lung cancer patients admitted to the medical ICU (MICU), to examine their code status at MICU admission and prior to death, and to determine which subspecialty physician was responsible for the change in code status.

DESIGN

Retrospective chart review study.

SETTING

A 19-bed MICU in a tertiary-care university hospital.

PATIENTS

Consecutive patients with a diagnosis of lung cancer admitted to the MICU from July 2002 to June 2004.

MEASUREMENTS AND MAIN RESULTS

Forty-seven patients with a diagnosis of lung cancer accounted for 53 MICU admissions. Mean (+/- SD) age at MICU admission was 65 +/- 10 years. Sixty-six percent were male. Eighty-three percent had non-small cell lung cancer (NSCLC); 64% of these were stage IV NSCLC. The most common organ system implicated on MICU admission was pulmonary, with 38% of patients presenting with pneumonia. Overall MICU mortality was 43%, and in-hospital mortality was 60%. Patients who required mechanical ventilation or had more advanced lung cancer stage had the worst prognosis, with mortality rates of 74% and 68%, respectively. Seventy-four percent of patients were "full code" at MICU admission. Subsequently, the code status was changed to "do not resuscitate" in 49% of these cases. The pulmonary/critical care physician was involved in this change 96% of the time and was the sole physician in 65% of cases.

CONCLUSIONS

This study confirms that patients with lung cancer admitted to the MICU have a high mortality. Despite this, the majority of patients are full code on MICU admission. Pulmonary/critical care physicians play an important role in the end-of-life decision making of lung cancer patients admitted to the MICU, perhaps because of their availability in the MICU and also because of their sense of responsibility in maintaining and withdrawing life support.

An interdisciplinary workshop to improve palliative care: Advanced heart failure— Clinical guidelines and healing words

Objective: Effective communication is recognized as an essential process to providing quality care, including palliative and end-of-life care. Discussion of prognosis and support needs of patients with heart failure is particularly challenging given the nature of the condition and care across several settings. The objective was to design, implement, and evaluate an interdisciplinary workshop aimed at improving attitudes and skills related to communication with patients and family, health team communication and documentation, and assessment of physical and emotional symptoms.

Methods: A pretest, delayed posttest evaluation design was used to evaluate two 4-h workshops offered to nurses, social workers, and other nonphysician clinicians.

Results: Although baseline reports of skills were high for the participants, significant improvement was noted for objectives emphasized in the workshop.

Significance of results: This project demonstrated the feasibility of designing, marketing a brief workshop, and positively impacting communication and documentation skills.

Ethical aspects of palliative care in lung cancer and end stage lung disease

Over 50 000 people die per year in England and Wales from lung cancer and chronic obstructive pulmonary disease (COPD). Current National Institute for Clinical Evidence guidelines for lung cancer and COPD recommend provision of palliative care for those that need it. Palliative care historically has accepted patients with cancer, but access to patients with non-malignant disease has been more sporadic. This paper aims to highlight the many ethical dilemmas faced when treating both these groups of patients. These include issues surrounding the form of treatment or treatment withdrawal, the burden on the patient or on the health service; or conducting research in terminally ill patients.

Microwave ablation: principles and applications

Microwave ablation is the most recent development in the field of tumor ablation. The technique allows for flexible approaches to treatment, including percutaneous, laparoscopic, and open surgical access. With imaging guidance, the tumor is localized, and a thin (14.5-gauge) microwave antenna is placed directly into the tumor. A microwave generator emits an electromagnetic wave through the exposed, noninsulated portion of the antenna. Electromagnetic microwaves agitate water molecules in the surrounding tissue, producing friction and heat, thus inducing cellular death via coagulation necrosis. The main advantages of microwave technology, when compared with existing thermoablative technologies, include consistently higher intratumoral temperatures, larger tumor ablation volumes, faster ablation times, and an improved convection profile. Microwave ablation has promising potential in the treatment of primary and secondary liver disease, primary and secondary lung malignancies, renal and adrenal tumors, and bone metastases. The technology is still in its infancy, and future developments and clinical implementation will help improve the care of patients with cancer.

Is there a cost to poor communication in cancer care?: a critical review of the literature

In this paper, the authors engage in a critical analysis of the existing empirical literature which addresses the impact of ineffective communication between cancer patients and clinicians. It is increasingly accepted that communication plays a significant role in many aspects of the care experience, and that poor communication can have a significantly negative influence on the patient's psychosocial experience, symptom management, treatment decisions, and quality of life. However, scant attention has been given to the idea that poor communication may also have an economic impact worthy of attention. This area has not been the focus of systematic inquiry or substantive critical consideration. On the basis of critical analysis of the limited empirical evidence that exists across a wide range of studies in related areas, the authors propose that the existential and material costs associated with poor communication in cancer care may well be considerable, and conclude with a call to mobilize a heightened enthusiasm for addressing the research challenges in this field.

Home-based palliative care study: site of death, and costs of medical care for patients with congestive heart failure, chronic obstructive pulmonary disease, and cancer

PURPOSE

To examine differences in site of death and costs of services by primary diagnosis for patients receiving home-based palliative care as compared to usual care at the end of life.

DESIGN AND METHODS

A nonequivalent group design was employed with 298 terminally ill patients diagnosed with cancer, CHF, or COPD enrolled. The treatment group received an interdisciplinary home-based palliative care program and the comparison group received usual Kaiser Permanente services. Data collected included patient demographics, severity of illness, service use, and site of death.

RESULTS

Among all diseases, patients enrolled in palliative care were more likely to die at home. Enrollment in palliative care was significant associated with cost reductions for patients with cancer, COPD, and CHF. No significant difference was found between diagnostic groups in terms of magnitude of cost savings.

IMPLICATIONS

Provision of interdisciplinary home-based palliative care at end of life can effectively increase the likelihood of dying at home for patients with CHF, COPD, and cancer while realizing significant cost savings.

Quality‐of‐Life Considerations in Patients with Advanced Lung Cancer: Effect of Topotecan on Symptom Palliation and Quality of Life

Key goals in the treatment of lung cancer are to improve both survival and quality of life (QOL). While formal techniques are frequently used to evaluate survival and response, such rigor is used less often in assessing the impact of treatment on quality of life. Many patients with lung cancer are elderly and have complex medical histories and a myriad of comorbidities. In these patients, with limited survival expectations, symptom palliation, quality of life, and convenience of therapy are especially important end points. Indeed, clinical trials are now incorporating symptom scores and QOL outcomes in their designs (now combined as "patient reported outcomes" or PROs). Moreover, symptom palliation correlates well with QOL and survival duration, providing further rationale for therapy selection based on these parameters. The potential palliative and QOL benefits of chemotherapy have been investigated for several agents in lung cancer trials. Of these, topotecan (Hycamtin; GlaxoSmithKline; Philadelphia, PA) is the best characterized in relapsed small cell lung cancer (SCLC). In a phase III trial of topotecan versus cyclophosphamide, doxorubicin (Adriamycin; Bedford Laboratories; Bedford, OH), and vincristine (Oncovin; Eli Lilly and Company; Indianapolis, IN) (CAV) in patients with recurrent SCLC, topotecan was associated with statistically significant (p < 0.05) improvements in general symptoms (e.g., fatigue and interference with daily activity) and disease-specific symptoms (e.g., dyspnea and hoarseness). Moreover, the introduction of oral therapies, such as oral topotecan, may increase the convenience of therapy by reducing the time needed for therapy and the need for frequent venipuncture. This review summarizes the role of chemotherapy in symptom palliation, with an emphasis on the impact of topotecan therapy on symptom parameters in patients with relapsed SCLC and the emerging role of oral therapy in this setting.