![Mean Change in Quality-of-Life Scores from Baseline to 12 Weeks in the Two Study Groups. Quality of life was assessed with the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale, on which scores range from 0 to 136, with higher scores indicating a better quality of life; the lung-cancer subscale (LCS) of the FACT-L scale, on which scores range from 0 to 28, with higher scores indicating fewer symptoms; and the Trial Outcome Index (TOI), which is the sum of the scores on the LCS and the physical well-being and functional well-being subscales of the FACT-L scale (scores range from 0 to 84, with higher scores indicating a better quality of life). With study group as the independent variable, two-sided independent-samples Student's t-tests showed a trend toward a significant between-group difference in the mean (±SD) change in scores from baseline to week 12 on the FACT-L scale (−0.4±13.8 in the standard care group vs. 4.2±13.8 in the palliative care group; difference between groups, 4.6; 95% confidence interval [CI], −0.8 to 9.9; P = 0.09) (Panel A), no significant betweengroup difference in the mean change in scores on the LCS (0.3±4.0 and 0.8±3.6 in the two groups, respectively; difference between groups, 0.5; 95% CI, −1.0 to 2.0; P = 0.50) (Panel B), and a significant between-group difference in the mean change in scores on the TOI (−2.3±11.4 vs. 2.3±11.2; difference between groups, 4.6; 95% CI, 0.2 to 8.9; P = 0.04) (Panel C). Data are from the 47 patients in the standard care group and the 60 patients in the palliative care group who completed the 12-week assessments. I bars indicate 95% confidence intervals.](https://www.researchgate.net/profile/Vicki-Jackson/publication/46157351/figure/fig3/AS:667650539651080@1536191701197/Mean-Change-in-Quality-of-Life-Scores-from-Baseline-to-12-Weeks-in-the-Two-Study-Groups_Q320.jpg)
![Kaplan–Meier Estimates of Survival According to Study Group. Survival was calculated from the time of enrollment to the time of death, if it occurred during the study period, or to the time of censoring of data on December 1, 2009. Median estimates of survival were as follows: 9.8 months (95% confidence interval [CI], 7.9 to 11.7) in the entire sample (151 patients), 11.6 months (95% CI, 6.4 to 16.9) in the group assigned to early palliative care (77 patients), and 8.9 months (95% CI, 6.3 to 11.4) in the standard care group (74 patients) (P = 0.02 with the use of the log-rank test). After adjustment for age, sex, and baseline Eastern Cooperative Oncology Group performance status, the group assignment remained a significant predictor of survival (hazard ratio for death in the standard care group, 1.70; 95% CI, 1.14 to 2.54; P = 0.01). Tick marks indicate censoring of data.](https://www.researchgate.net/profile/Vicki-Jackson/publication/46157351/figure/fig2/AS:339490318110723@1457952207282/Kaplan-Meier-Estimates-of-Survival-According-to-Study-Group-Survival-was-calculated-from_Q320.jpg)
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Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer
Abstract and Figures
Patients with metastatic non-small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease.
We randomly assigned patients with newly diagnosed metastatic non-small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records.
Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02).
Among patients with metastatic non-small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)
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... Based on a growing body of literature, both the American Society of Clinical Oncology and the European Society of Medical Oncology have recommended early palliative care interventions alongside treatment for all patients with advanced cancer [1,2]. Early palliative care has been shown to improve quality of life and reduce intensive care in the last months of life, without shortening duration of survival [3][4][5][6]. The aim is not only to enable better assessment and management of physical and psychological symptoms, but also to provide regular information, with particular emphasis on the patient's understanding of their prognosis. ...
Background
Early palliative care interventions in oncology, as recommended by international oncology societies, promote patient understanding and support decision-making. At the same time, shared decision-making models are being developed to enhance patient participation as part of a new model of patient-physician relationship. For patients with palliative needs, this participation is essential and helps to avoid futile and aggressive treatments at the end of life. The aim of this study is to observe decision making during meetings between oncology and palliative care professionals, focusing particularly on the components of shared decision-making models, but also on the role played by palliative care professionals.
Methods
We conducted a non-participant observation of multidisciplinary meetings and outpatient clinic activities in two Comprehensive Cancer Centres in France. Field notes were then coded using thematic content analysis. Deductive analysis was conducted using the observation grid developed from Elwyn's three-talk model.
Results
Only a few elements of the different models of shared decision-making are apparent in the multidisciplinary meetings. Palliative care professionals emphasise the importance of involving patients and providing them with information about the advantages and disadvantages of different treatment options.
However, patient involvement in decision-making remains difficult in daily practice. Decisions to discontinue oncological treatment are often driven by clinical and biological signs of terminal evolution rather than shared decision-making.
Conclusions
There are still cultural and organisational barriers to actual implementation of early integrated onco-palliative care. Promotion of shared decision making can be a strong lever of change which is frequently mobilised by palliative care teams.
End-of-life (EOL) care is a critical part of sickle cell disease (SCD) management. However, barriers to high-quality EOL care remain, including (1) disease-related barriers (prior opioid exposure, risk of vaso-occlusive crises, chronic conditions with conflicting needs, and limitations of receiving disease-directed therapy on hospice); (2) communication-related barriers (challenges of identifying and responding to religious and spiritual concerns, limited health literacy, and previous health care system experience); (3) systemic issues (social determinants of health, structural racism, and mistrust of the medical system). However, palliative care and interdisciplinary collaboration can overcome many of these barriers. In addition, we can improve EOL care by accounting for opioid exposures, multimodal symptom management, and exploring (1) who people want involved in decision-making, (2) the role of religion and spirituality in decision-making, and (3) previous experiences with EOL. Systemic barriers can be addressed through the social determinants of health screening, minimizing financial burdens of care, and building longitudinal relationships with people with SCD. This requires the continued education of SCD providers about primary palliative care and palliative care providers about SCD. With such strategies, high-quality EOL care is possible for this vulnerable population.
For over a decade, “early integration” has become a slogan in the palliative care (PC) community. The care of cancer patients requires improvement, and the studies on the early integration of PC reveal its deficits in the oncological practice. Unmet needs in physical, psychological, spiritual, or social care need to be addressed. A “collusion of hope” in cancer treatment delays appropriate end-of-life care and complicates bereavement. Communicating prognosis and comprehending survival and discussion on measures to enhance the quality of life frequently do not occur simultaneously. Early collaboration between an oncologist and a PC specialist for those with advanced cancer improves symptoms and reduces aggressive cancer care at the end of life without shortening survival. Within the changing care environment and increasing time limitations, the multidimensional needs of a patient on therapy for advanced cancer will increase. A holistic approach to the patient and the family hence requires a multi-professional team. Consensus around palliative quality indicators is in its infancy and is often governed by cost-effectiveness. This is a real crunch for already resource-poor settings.
The historical controversy surrounding the hospice movement, pioneered by Dame Cicely Saunders in 1967, has contributed to stigmas that persist today. These include:
Associating palliative care with surrender or failure.
Cultural or personal resistance to discussing death and dying.
Financial and systemic barriers, such as lack of insurance coverage for early palliative interventions.
Palliative care is a multidisciplinary approach aimed at improving the quality of life for patients facing serious, chronic, or life-limiting illnesses. Unlike hospice care, palliative care is not confined to end-of-life scenarios and can be integrated alongside curative treatments. This article explores the core functions, challenges, and clinical significance of palliative care, including symptom management, psychosocial support, advanced care planning, and interprofessional collaboration. Emphasis is placed on dispelling misconceptions surrounding palliative care, addressing systemic and logistical barriers, and highlighting its impact on healthcare outcomes. With a focus on both the patient and their family, palliative care fosters a holistic and compassionate approach to treatment, ensuring dignity and comfort across diverse care settings.
Misunderstandings about palliative care are rooted in historical and cultural factors. Common myths include:
Palliative Care is Only for the Dying: Many people erroneously believe palliative care is limited to the final stages of life, leading to delayed referrals and underutilization of its benefits.
Palliative Care Means "Giving Up": Patients and families may perceive the involvement of palliative care as a sign that the healthcare team has abandoned hope, which can create resistance to its services.
Palliative care is a multidisciplinary approach aimed at improving the quality of life for patients facing serious, chronic, or life-limiting illnesses. Unlike hospice care, palliative care is not confined to end-of-life scenarios and can be integrated alongside curative treatments. This article explores the core functions, challenges, and clinical significance of palliative care, including symptom management, psychosocial support, advanced care planning, and interprofessional collaboration. Emphasis is placed on dispelling misconceptions surrounding palliative care, addressing systemic and logistical barriers, and highlighting its impact on healthcare outcomes. With a focus on both the patient and their family, palliative care fosters a holistic and compassionate approach to treatment, ensuring dignity and comfort across diverse care settings.
Hospice care eligibility is another significant concern. Criteria for admission often vary by diagnosis, requiring patients to forgo curative treatments and have a prognosis of six months or less. This rigid framework can exclude patients who might otherwise benefit from the comfort-focused approach. Patients who outlive the six-month prognosis may face challenges in renewing services, despite ongoing needs. Hospice care eligibility is another significant concern. Criteria for admission often vary by diagnosis, requiring patients to forgo curative treatments and have a prognosis of six months or less. This rigid framework can exclude patients who might otherwise benefit from the comfort-focused approach. Patients who outlive the six-month prognosis may face challenges in renewing services, despite ongoing needs. Palliative care is a multidisciplinary approach aimed at improving the quality of life for patients facing serious, chronic, or life-limiting illnesses. Unlike hospice care, palliative care is not confined to end-of-life scenarios and can be integrated alongside curative treatments. This article explores the core functions, challenges, and clinical significance of palliative care, including symptom management, psychosocial support, advanced care planning, and interprofessional collaboration. Emphasis is placed on dispelling misconceptions surrounding palliative care, addressing systemic and logistical barriers, and highlighting its impact on healthcare outcomes. With a focus on both the patient and their family, palliative care fosters a holistic and compassionate approach to treatment, ensuring dignity and comfort across diverse care settings.
While palliative care and hospice care share the goal of improving quality of life and alleviating suffering, they differ in scope and patient eligibility:
Palliative Care: Applicable at any stage of illness and alongside curative or life-prolonging treatments. It addresses physical, psychological, spiritual, and social needs.
Palliative care is a multidisciplinary approach aimed at improving the quality of life for patients facing serious, chronic, or life-limiting illnesses. Unlike hospice care, palliative care is not confined to end-of-life scenarios and can be integrated alongside curative treatments. This article explores the core functions, challenges, and clinical significance of palliative care, including symptom management, psychosocial support, advanced care planning, and interprofessional collaboration. Emphasis is placed on dispelling misconceptions surrounding palliative care, addressing systemic and logistical barriers, and highlighting its impact on healthcare outcomes. With a focus on both the patient and their family, palliative care fosters a holistic and compassionate approach to treatment, ensuring dignity and comfort across diverse care settings.
The ten most frequently reported pretreatment symptoms on the Rotterdam Symptom Checklist, which was completed by more than 650 patients entering two MRC Lung Cancer Working Party multicentre randomised trials, included general symptoms (tiredness, lack of appetite) and psychological distress (worry, anxiety) in addition to disease-related chest symptoms (cough, shortness of breath). Although the number and severity of symptoms increased with worsening performance status, the commonest symptoms were found to be virtually the same for patients with small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC), and for different grades of performance status. Women with NSCLC reported more psychological symptoms than males, but this difference was much less evident in patients with SCLC. Thus, in order to assess fully the benefit of palliative treatments in patients with lung cancer, account must be taken of all symptoms at presentation, in addition to the traditionally recognised chest symptoms.
Advanced care planning (ACP) is considered an essential component of medical care in the United States, especially in patients with incurable diseases. However, little is known about clinical practices in outpatient oncology settings related to discussing end-of-life care and documenting code status preferences in ambulatory medical records.
To assess the rate of documentation of code status in the electronic longitudinal medical records (LMR) of patients with metastatic cancer.
Retrospective review of 2,498 patients with metastatic solid tumors at an academic cancer center. An electronic patient database and the LMR were queried to identify demographic information, cancer type, number of clinic visits, and documentation of code status.
The sample consisted of adult patients with metastatic prostate, breast, ovarian, bladder kidney, colorectal, non-colorectal gastrointestinal (GI), and lung cancers.
Primary outcome was the percentage of documented code status in the LMR.
Among the 2,498 patients, 20.3% had a documented code status. Code status was designated most frequently in patients with non-colorectal GI (193/609, 31.7%) and lung (179/583, 30.7%) cancers and least frequently in patients with genitourinary malignancies [bladder/kidney (4/89, 4.5%), ovarian (4/93, 4.3%), and prostate (7/365, 1.9%) cancers]. Independent predictors of having documented code status included religious affiliation, cancer type, and a greater number of visits to the cancer center. Younger patients and black patients were less likely to be designated as DNR/DNI.
Despite the incurable nature of metastatic cancer, only a minority of patients had a code status documented in the electronic medical record.
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Background: Many experts recommend palliative care consultation early in the course of oncology treatment; however little is known about the components of this type of intervention. We sought to better define the components of early palliative care consultation in patients with recently diagnosed incurable cancer. Methods: As part of a larger randomized study of integrated versus standard palliative care in an ambulatory thoracic oncology clinic, we analyzed data from 47 patients who received early palliative care consultation within eight weeks of diagnosis of incurable NSCLC with a performance status of 0–2. Prior to randomization, patients completed questionnaires on quality of life (FACT-L) and mood (HADS) as well as illness understanding. The FACT-L Trial Outcome Index which is a combined score of physical, functional well being, and lung cancer symptoms was calculated and used in correlations to more fully assess quality of life. After the consultation, palliative care clinicians recorded how time was spent during the encounter. Results: Seven palliative care clinicians provided consultation to 47 patients. The mean total time spent with each patient was 59.5 minutes (SD 28.6). The major components of each consultation were symptom management 25.7 minutes (SD 15.8), patient and family coping 19.6 minutes (SD 14.7), and illness understanding and education 10.4 minutes (SD 7.6). Greater total consultation time was correlated with poorer performance status (r=0.30, p=0.04) and lower quality of life scores on the FACT-L TOI which is a combined score of physical, functional wellbeing, and lung cancer symptoms (r=0.36, p=0.01). Symptom management time was also correlated with lower quality of life scores on the FACT-L TOI (r-0.52, p<0.001) and higher depression scores on the HADS (r=0.33, p=0.02). Conclusions: Initial palliative care consultation near the time of diagnosis in patients with incurable NSCLC is lengthy and comprised primarily of symptom management, patient and family coping, and illness understanding and education. Patients with poorer performance status and quality of life received longer total time in consultation and in time devoted to symptom management
No significant financial relationships to disclose.
Objective:
While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.
Measurements:
The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.
Results:
As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.
Conclusion:
In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
Objective-To evaluate the effect of cytotoxic chemotherapy on survival in patients with non-small cell lung cancer. Design-Meta-analysis using updated data on individual patients from all available randomised trials, both published and unpublished. Subjects-9387 patients (7151 deaths) from 52 randomised clinical trials. Main outcome measure-Survival. Results-The results for modern regimens containing cisplatin favoured chemotherapy in all comparisons and reached conventional levels of significance when used with radical radiotherapy and with supportive care. Trials comparing surgery with surgery plus chemotherapy gave a hazard ratio of 0.87 (13% reduction in the risk of death, equivalent to an absolute benefit of 5% at five years). Trials comparing radical radiotherapy with radical radiotherapy plus chemotherapy gave a hazard ratio of 0.87 (13% reduction in the risk of death; absolute benefit of 4% at two years), and trials comparing supportive care with supportive care plus chemotherapy 0.73 (27% reduction in the risk of death; 10% improvement in survival at one year). The essential drugs needed to achieve these effects were not identified. No difference in the size of effect was seen in any subgroup of patients. In all but the radical radiotherapy setting, older trials using long term alkylating agents tended to show a detrimental effect of chemotherapy. This effect reached conventional significance in the adjuvant surgical comparison. Conclusion-At the outset of this meta-analysis there was considerable pessimism about the role of chemotherapy in non-small cell lung cancer. These results offer hope of progress and suggest that chemotherapy may have a role in treating this disease.
STANDARD CRITERIA FOR TOXICITY and for response to treatment are important prerequisites to the conduct of cancer trials. The Eastern Cooperative Oncology Group criteria for toxicity and response are presented to facilitate future reference and to encourage further standardization among those conducting clinical trials.
(C) Lippincott-Raven Publishers.
ABSTRACT– A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
The management of acute postoperative pain poses a significant challenge in surgical specialities. Despite the prevalence and impact of acute postoperative pain, there is a paucity of published data regarding its occurrence and sensory qualities after joint replacement.
That a proportion of patients would experience severe acute postoperative pain at rest after total hip replacement (THR) and total knee replacement (TKR).
Pain was assessed preoperatively, and then five times daily for the first three postoperative days in 105 THR and TKR patients. Pain severity was assessed using a pain Visual Analogue Scale and the sensory qualities of pain were assessed using the pain descriptors from the Short-Form McGill Pain Questionnaire.
Median acute pain scores peaked on the first postoperative day, with 58% of TKR patients and 47% of THR patients reporting moderate-severe pain. Preoperative pain was most frequently described as aching, stabbing and sharp, whereas acute postoperative pain was described as aching, heavy and tender. Night pain disturbed between 44-57% of TKR patients and 21-52% of THR patients on postoperative nights 1-3.
These findings demonstrate that acute postoperative pain at rest after joint replacement, particularly TKR, is poorly managed, although it does not reach the severity of preoperative pain.
Level IV (observational cohort study).
In this Sounding Board article, the authors argue that health care costs can be reduced without a negative effect on quality by reducing spending on interventions that are not cost-effective.