Integration of medical oncology and palliative care to improve the appropriateness of antitumor therapy near the end of life in advanced cancer patients: first evidences of the prospective sequential MIRTO study. (Supported by “Programma di Ricerca Regione Emilia-Romagna-Università 2007-2009 Area 2 - Ricerca per il Governo clinico”)

Abstract Background: Patients suffering from advanced cancer often loose contact with their primary care physician (PCP) during oncologic treatment and palliative care is introduced very late.The aim of this pilot study was to test the feasibility and procedures for a randomized trial of an intervention to teach PCPs a palliative care approach and communication skills to improve advanced cancer patients’ quality of life. Methods: Observational pilot study in 5 steps. 1) Recruitment of PCPs. 2) Intervention: training on palliative care competencies and communication skills addressing end-of-life issues.3) Recruitment of advanced cancer patients by PCPs. 4) Patients follow-up by PCPs, and assessment of their quality of life by a research assistant 5) Feedback from PCPs using a semi-structured focus group and three individual interviews with qualitative deductive theme analysis.Results: 8 PCPs were trained. PCPs failed to recruit patients for fear of imposing additional loads on their patients. PCPs changed their approach of advanced cancer patients. They became more conscious of their role and responsibility during oncologic treatments and felt empowered to take a more active role picking up patient’s cues and addressing advance directives. They developed interprofessional collaborations for advance care planning. Overall, they discovered the role to help patients to make decisions for a better end-of-life.Conclusions: PCPs failed to recruit advanced cancer patients, but reported a change in paradigm about palliative care. They moved from a focus on helping patients to die better, to a new role helping patients to define the conditions for a better end-of-life.Trial registration : The ethics committee of the canton of Geneva approved the study (2018-00077 Pilot Study) in accordance with the Declaration of Helsinki

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An early palliative care intervention can be confronting but reassuring: A qualitative study on the experiences of patients with advanced cancer

Palliative Medicine ◽

10.1177/0269216319847884 ◽

2019 ◽

Vol 33 (7) ◽

pp. 783-792 ◽

Cited By ~ 4

Author(s):

Monica Fliedner ◽

Sofia Zambrano ◽

Jos MGA Schols ◽

Marie Bakitas ◽

Christa Lohrmann ◽

...

Keyword(s):

Palliative Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

Advanced Cancer Patients ◽

End Of Life Decisions ◽

Early Palliative Care ◽

Network Support ◽

Care Intervention ◽

Life Decisions

Background: Intervention trials confirm that patients with advanced cancer receiving early palliative care experience a better quality of life and show improved knowledge about and use of palliative care services. To involve patients in future health-care decisions, health professionals should understand patients’ perspectives. However, little is known about how patients’ experience such interventions. Aim: To explore advanced cancer patients’ experiences with a structured early palliative care intervention, its acceptability and impact on the patients’ life including influencing factors. Design: Qualitative content analysis of in-depth, semi-structured interviews. Setting/participants: Patients with various advanced cancer diagnoses were enrolled in a multicenter randomized controlled trial (NCT01983956), which investigated the impact of “Symptoms, End-of-life decisions, Network, Support,” a structured early palliative care intervention, on distress. Of these, 20 patients who underwent the intervention participated in this study. Results: Participants received the intervention well and gained a better understanding of their personal situation. Patients reported that the intervention can feel “confronting” but with the right timing it can be confirming and facilitate family conversations. Patients’ personal background and the intervention timing within their personal disease trajectory influenced their emotional and cognitive experiences; it also impacted their understanding of palliative care and triggered actions toward future care planning. Conclusion: Early palliative care interventions like “Symptoms, End-of-life decisions, Network, Support” may provoke emotions and feel “confrontational” often because this is the first time when issues about one’s end of life are openly discussed; yet, advanced cancer patients found it beneficial and felt it should be incorporated into routine care.

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Coping with uncertainty: A qualitative study of 33 palliative care consultations among patients with advanced cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.31_suppl.92 ◽

2014 ◽

Vol 32 (31_suppl) ◽

pp. 92-92

Author(s):

Mohamedtaki Abdulaziz Tejani ◽

Charles Stewart Kamen ◽

Supriya Gupta Mohile ◽

Robert E. Gramling

Keyword(s):

Palliative Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

Descriptive Analysis ◽

Care Providers ◽

Advanced Cancer Patients ◽

Patient Centered ◽

The Future ◽

Research Working Group

92 Background: Despite scientific advances, uncertainty remains an inherent and significant issue in clinical practice. Among patients with advanced cancer, uncertainty about the future can lead to distress, loss of sense of control and lower quality of life. Helping patients manage uncertainty is a core domain of patient-centered care. Little is known about how palliative care providers work with cancer patients to accomplish this goal. Methods: We performed descriptive analysis of transcripts from audio recorded inpatient palliative care consultations among adult cancer patients referred for ‘goals of care’ or ‘end of life decision making.’ Each transcript was read as a whole and then again line by line to code verbal expressions of uncertainty. Excerpted segments dealing with uncertainty about the future were grouped and analyzed by an experienced qualitative research working group. Results: 33 consultations were analyzed: 53% men, median age 62 and median survival 3.6 weeks. Multiple expressions of uncertainty were identified – 106 by patients/families and 56 by providers. A majority (63%) were centered on the inevitable uncertainty in predicting clinical course at the end of life. Palliative care providers managed this type of uncertainty in three main ways: (a) pairing expressions of unpredictability with reiteration of what was certain/known at time of consultation (e.g. ‘we will not let you suffer’); (b) utilizing inherent uncertainty of future to promote hope and faith (e.g. ‘nobody knows how long you are going to live’) and (c) reassurance that multi-disciplinary providers would convene to provide consensus and clarity for next visit (e.g. ‘we will all put our heads together and come up with exactly which options are available.’). Conclusions: Uncertainty is highly prevalent during end of life consultations with advanced cancer patients. Palliative care providers use validating strategies to help patients acknowledge and cope with what is inherently uncertain about their future. These methods can be used to develop communication training and guidelines for use with advanced cancer patients at the end of life.

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Cost Savings Associated With Palliative Care Among Older Adults With Advanced Cancer

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909120986800 ◽

2021 ◽

pp. 104990912098680

Author(s):

Paige E. Sheridan ◽

Wendi G. LeBrett ◽

Daniel P. Triplett ◽

Eric J. Roeland ◽

Andrew R. Bruggeman ◽

...

Keyword(s):

Palliative Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

Healthcare Costs ◽

Healthcare Expenditure ◽

Advanced Cancer Patients ◽

Palliative Care Consultation ◽

Care Consultation ◽

The Impact

Background: There is inconsistent evidence that palliative care intervention decreases total healthcare expenditure at end-of-life for oncology patients. This inconsistent evidence may result from small sample sizes at single institution studies and disparate characterization of costs across studies. Comprehensive studies in population-based datasets are needed to fully understand the impact of palliative care on total healthcare costs. This study analyzed the impact of palliative care on total healthcare costs in a nationally representative sample of advanced cancer patients. Methods: We conducted a matched cohort study among Medicare patients with metastatic lung, colorectal, breast and prostate cancers. We matched patients who received a palliative care consultation to similar patients who did not receive a palliative care consultation on factors related to both the receipt of palliative care and end of life costs. We compared direct costs between matched patients to determine the per-patient economic impact of a palliative care consultation. Results: Patients who received a palliative care consultation experienced an average per patient cost of $5,834 compared to $7,784 for usual care patients (25% decrease; p < 0.0001). Palliative care consultation within 7 days of death decreased healthcare costs by $451, while palliative care consultation more than 4 weeks from death decreased costs by $4,643. Conclusion: This study demonstrates that palliative care has the capacity to substantially reduce healthcare expenditure among advanced cancer patients. Earlier palliative care consultation results in greater cost reductions than consultation in the last week of life.

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End-of-life discussions with advanced cancer patients and their effects on bereaved families’ mental health.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.26_suppl.3 ◽

2016 ◽

Vol 34 (26_suppl) ◽

pp. 3-3

Author(s):

Takashi Yamaguchi ◽

Isseki Maeda ◽

Yutaka Hatano ◽

Masanori Mori ◽

Yasuo Shima ◽

...

Keyword(s):

Mental Health ◽

Palliative Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

Complicated Grief ◽

Advanced Cancer Patients ◽

Palliative Care Teams ◽

Prevalence Of Depression

3 Background: End-of-life (EOL) discussions are important for providing appropriate care to patients with advanced cancer at the end of their life. To explore the relationship between EOL discussions and bereaved families’ mental health, as well as the quality of the patient’s death and quality of care at the end of life. Methods: This was a nationwide questionnaire survey of bereaved families of deceased cancer patients who died at 75 sites (20 inpatient palliative care teams in acute hospitals, 33 palliative care units/inpatient hospices, and 22 outpatient clinics that provide home palliative care service) in Japan. 13,711 bereaved family members of cancer patients who died before January 2014 in each of the participating institutions were potential participants. We evaluated the prevalence and details of EOL discussions which were defined as “a discussion with physicians about the preferred place of death or resuscitation”. We also evaluated the prevalence of depression (defined as the Patient Health Questionnaire-9 ≥ 10) and complicated grief (defined as the Brief Grief Questionnaire ≥ 8) in bereaved families. Results: 9123 questionnaires returned (response rate 67%). Of those, 80.6% had EOL discussions. After propensity score weighted adjustment, bereaved families with EOL discussion less frequently developed depression (17.3% and 21.6% ; P < 0.001) and complicated grief (13.7% and 15.9% ; P = 0.03) than without. There were significant differences in the trend test among families without and in those with EOL discussions < 1, 1–3, and > 3 months before the patient’s death, for the prevalence of depression (21.6%, 20.6%, 16.8%, and 15.5%, respectively; P trend < 0.001) and complicated grief (15.9%, 16.4%, 12.8%, and 12.9%, respectively; P trend < 0.001). Conclusions: EOL discussions may contribute to decrease depression and complicated grief in bereaved families. EOL discussions should be initiated with advanced cancer patients when physicians expect a patient’s prognosis is limited to several months.

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Questions prompt lists used by palliative care teams help trigger discussions on prognosis and end-of-life issues with advanced cancer patients.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.12110 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 12110-12110

Author(s):

Carole Bouleuc ◽

Alexis Burnod ◽

Paul H. Cottu ◽

Jean-Yves Pierga ◽

Sylvie Dolbeault

Keyword(s):

Palliative Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

P Value ◽

Advanced Cancer Patients ◽

Palliative Care Consultation ◽

Palliative Care Teams ◽

Life Issues ◽

End Of Life Issues

12110 Background: Accuracy of prognosis perception is a key element to allow advanced cancer patients to make informed decisions and to reflect on their end-of-life priorities. This study aims to explore whether a question prompt list can promote discussions on prognosis and end-of-life issues during palliative care consultations for advanced cancer patients. Methods: In this multicentric randomised study, patients assigned in the interventional arm receive a question prompt list during the first palliative care consultation (T1) after referral by oncologists. The primary endpoint is the number of questions asked by patients during the second palliative care consultation (T2) one month later. Secondary objectives are anxiety and depression, quality-of-life, satisfaction with care, coping assessed at baseline (T1) and at two months (T3). Palliative care teams from 3 french comprehensive cancer centers participate in the study. Main inclusion criteria were adult patients with metastatic non-haematological cancer referred to the palliative care team and with an estimated life expectancy less than one year. Results: Patients (n = 71) in the QPL arm asked more questions (mean 21.8 versus 18.2, p-value = 0.03) during the palliative care consultations compared to patients in the control arm (n = 71). These questions addressed palliative care (mean 5.6 versus 3.7, p-value = 0.012) and end-of-life issues (mean 2.2 versus 1, p = 0.018) more frequently than in the control arm. At two months, compared to baseline, there was no change in anxio-depressive symptoms or quality of life. Conclusions: QPL favours discussion on prognosis and end-of-life care during the palliative care consultations for advanced cancer patients. Clinical trial information: NCT02854293 .

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One Thousand Lives

Managing Cancer and Living Meaningfully ◽

10.1093/med/9780190236427.003.0004 ◽

2021 ◽

pp. 31-44

Author(s):

Gary Rodin ◽

Sarah Hales

Keyword(s):

Palliative Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

Psychosocial Interventions ◽

Psychosocial Oncology ◽

Advanced Cancer Patients ◽

Will To Live

This chapter provides an overview of the foundational contributions of early leaders in psychosocial oncology and palliative care that informed the development of the Managing Cancer and Living Meaningfully (CALM) intervention. This includes the collective works of such pioneers as Kübler-Ross, Glaser and Strauss, and Pattison, which were instrumental in the development of psychosocial interventions such as CALM. The research conducted by our team with advanced cancer patients and their families over two decades is also described, highlighting the longitudinal Will to Live Study. In that study over 700 patients with advanced cancer were assessed at baseline and over 400 were followed longitudinally until the end of life, deepening our understanding of their experience over the trajectory of this disease. The findings of this research confirmed the need for an intervention such as CALM and helped to shape its nature and form.

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Acute palliative care unit–initiated interventions for advanced cancer patients at the end of life: prediction of impending death based on Glasgow Prognostic Score

Supportive Care in Cancer ◽

10.1007/s00520-020-05638-z ◽

2020 ◽

Author(s):

Yoshihide Nagasako ◽

Masahiro Suzuki ◽

Tetsuji Iriyama ◽

Yoko Nagasawa ◽

Yoshiki Katayama ◽

...

Keyword(s):

Palliative Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

Life Prediction ◽

Prognostic Score ◽

Glasgow Prognostic Score ◽

Palliative Care Unit ◽

Advanced Cancer Patients ◽

Impending Death

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Spiritual care provided by oncology physicians and nurses to advanced cancer patients.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.9116 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 9116-9116

Author(s):

Zachary Epstein-Peterson ◽

Adam Sullivan ◽

Andrea C. Phelps ◽

Michael J. Balboni ◽

Tyler J. Vanderweele ◽

...

Keyword(s):

Palliative Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

Spiritual Care ◽

Cancer Care ◽

End Of Life Care ◽

Life Care ◽

Advanced Cancer Patients ◽

Care Guidelines

9116 Background: For many patients facing a diagnosis of advanced cancer, religion and/or spirituality (R/S) play an important role in coping with illness. Data suggest that cancer patients receiving spiritual care (SC) have better quality of life and receive less futile, aggressive interventions at the end of life. National palliative care guidelines include SC as a key component of end-of-life care. However, current SC practices and the role clinicians should play in SC provision remain unclear. Methods: The Religion and Spirituality in Cancer Care (RSCC) study is a survey-based, cross-sectional study of oncology physicians and nurses and advanced cancer patients from five Boston-area institutions. The survey elicited respondents’ R/S beliefs/practices, their views on the appropriateness of SC in the advanced cancer care setting, and their experiences in giving or receiving SC (e.g., spiritual history, referrals to chaplains). In total, 68 patients, 204 physicians, and 114 nurses responded (response rates: patients = 73%; clinicians = 63%). Multivariable analyses (MVAs) were performed to determine predictors (e.g., clinician demographics, R/S, spiritual care training) of SC provision by clinicians. Results: All respondents reported a low frequency of SC provision, with only 9% of patients receiving SC from physicians, 20% from nurses, and physicians reporting performing SC during only 8% of interactions, nurses during 12% of interactions. In MVAs, prior training in spiritual care was significantly associated with SC provision (OR physicians 5.89, CI 2.14-16.22; OR nurses 10.42, CI 1.30-89.19), as was the provider identifying as being spiritual (OR 3.85 physicians CI, 2.12-6.98; OR 2.92 nurses CI, 1.15-7.42). Conclusions: These data highlight the current inadequacies of SC provision by clinicians, despite national palliative care guidelines, and underscore the central role of SC training for doctors and nurses, as this was the strongest predictor of SC provision. Given the important role that SC has in end-of-life care and the paucity of data guiding its provision, we hope this research will advance the understanding of how to integrate SC into end-of-life care, and ultimately improve patient outcomes at the end-of-life.

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