Palliative chemotherapy: oxymoron or misunderstanding?

Roeland, E.J. & LeBlanc, T.W. BMC Palliative Care, 2016 (15:33)

Oncologists routinely prescribe chemotherapy for patients with advanced cancer. This practice is sometimes misunderstood by palliative care clinicians, yet data clearly show that chemotherapy can be a powerful palliative intervention when applied appropriately. Clarity regarding the term “palliative chemotherapy” is needed: it is chemotherapy given in the non-curative setting to optimize symptom control, improve quality of life, and sometimes to improve survival. Unfortunately, oncologists lack adequate tools to predict which patients will benefit. In a study recently published in BMC Palliative Care, Creutzfeldt et al. presented an innovative approach to advancing the science in this area: using patient reported outcomes to predict responses to palliative chemotherapy.

With further research, investigators may be able to develop predictive models for use at the bedside to inform clinical decision-making about the risks and benefits of treatment. In the meantime, oncologists and palliative care clinicians must work together to reduce the use of “end-of-life chemotherapy”—chemotherapy given close to death, which does not improve longevity or symptom control—while optimizing the use of chemotherapy that has true palliative benefits for patients.

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Identification of hospital patients in need of palliative care – a predictive score

Meffert, C. et al. BMC Palliative Care. Published online: 22 February 2016

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Background: Palliative care was initially developed for patients with advanced cancer. Over the past years, however, palliative care has broadened its focus from terminal cancer patients to patients with other serious, life-limiting illnesses. Nevertheless, the identification of palliative care needs (PCNs) among hospital patients remains an insufficiently investigated topic of research. The aim of our study was to describe the characteristics of hospital patients with palliative care needs and to develop a score for their identification.

Methods: We conducted an epidemiological study. Data were collected prospectively from inpatients at the University Medical Center Freiburg, Germany. For each patient discharged from a hospital ward, the treating physician had to report whether the patient had PCNs or not. The response rate was 96 %, and data from 39,849 patients could be analyzed. A binary logistic regression analysis was performed in order to identify risk factors for developing PCNs and to develop a predictive score for the identification of patients with PCNs upon their admission to the hospital. In order to validate the risk prediction model, we used a bootstrap analysis.

Results: During the study period, 6.9 % (2757) of all patients had palliative care needs. Only 56 of them (2 %) received palliative treatment. Binary logistic regression analysis showed that older patients without relatives who suffered from metastatic cancer and/or liver cirrhosis had the highest risk of developing palliative care needs (PCN-score; sensitivity: 0.815; specificity: 0.640).

Conclusions: Given the aging population and associated increase in the number of patients requiring palliative care, it is crucial to detect palliative care needs in hospital patients with both cancerous and non-cancerous life-limiting diseases. Our predictive score contributes to the identification of palliative care needs in patients with life-limiting diseases, which allows physicians to take the appropriate therapeutic steps.

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End of life care

Seven major leading cancer charities including McMillian Cancer Care and Marie Curie have jointly published On the brink: The future of end of life care.

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This report finds that too many people approaching death are forced to spend long periods of time in hospital due to a lack of social care or alternative support options in their community. This in turn leads to increased hospital admissions and higher costs for an NHS under financial pressures.

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Helping people to be cared for and die at home

This Housing LIN Practice Briefing looks at the importance of end of life care delivered at home, describing the context, inequalities in end of life care, examples of good or emerging practice, and recommendations for actions. Funded by Public Health England, it is intended to be a practical guide for those working in mainstream and/or specialist housing, care and support and public health to understand their respective roles, and how they may work together, to help people to have their end of life care wishes met.

Full briefing: End of Life Care: Helping people to be cared for and die at home

The impact of a new public health approach to end-of-life care: A systematic review

Sallnow, L. et al. Palliative Medicine. March 2016: vol. 30 no. 3200-211

N0030869 A carer comforting an elderly lady
Image source: Libby Welch

Background: Communities play an increasingly significant role in their own health and social care, and evidence demonstrates the positive impact of this work on a range of health outcomes. Interest is building regarding the application of the principles of the new public health approach to those facing the end of life and their families and communities.

Aim: To review the evidence relating to the impact of a new public health approach to end-of-life care, specifically as this applies to efforts to strengthen community action.

Design: A systematic review employing narrative synthesis. Both meta-ethnography and the use of descriptive statistics supported analysis.

Data sources: Eight databases (AMED, ASSIA, BiblioMap, CINAHL, Cochrane Reviews, EMBASE, MEDLINE and PsycINFO) were searched from the earliest record to March 2015 using set eligibility criteria.

Results: Eight articles were included in the analysis. Three main themes emerged from the meta-ethnography: making a practical difference, individual learning and personal growth and developing community capacity. The quantitative findings mapped to the meta-ethnography and demonstrated that engaging communities can lead to improved outcomes for carers such as decreased fatigue or isolation, increase in size of caring networks and that wider social networks can influence factors such as place of death and involvement of palliative care services.

Conclusion: Evidence exists for the impact of community engagement in end-of-life care. Impact assessment should be an integral part of future initiatives and policy makers should recognise that these approaches can influence complex issues such as carer support, community capacity, wellbeing and social isolation.

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Faith at the end of life: public health approach resource for professionals

Public Health England (PHE)

This resource aims to help frontline professionals and providers working in community settings and commissioners maintain a holistic approach to the people dying, caring or bereaved. It provides information to help ensure that commissioning and delivery of services and practice takes account of spiritual needs of the six largest faith groups in England and remains appropriate to the community setting in which they work.

Progress and divergence in palliative care education for medical students: A comparative survey of UK course structure, content, delivery, contact with patients and assessment of learning

Walker, S. et al. Palliative Medicine. Published online: February 4, 2016

Image source: Sean MacEntee

Background: Effective undergraduate education is required to enable newly qualified doctors to safely care for patients with palliative care and end-of-life needs. The status of palliative care teaching for UK medical students is unknown.

Aim: To investigate palliative care training at UK medical schools and compare with data collected in 2000.

Design: An anonymised, web-based multifactorial questionnaire.

Settings/participants: Results were obtained from palliative care course organisers at all 30 medical schools in 2013 and compared with 23 medical schools (24 programmes) in 2000.

Results: All continue to deliver mandatory teaching on ‘last days of life, death and bereavement’. Time devoted to palliative care teaching time varied (2000: 6–100 h, mean 20 h; 2013: 7–98 h, mean 36 h, median 25 h). Current palliative care teaching is more integrated. There was little change in core topics and teaching methods. New features include ‘involvement in clinical areas’, participation of patient and carers and attendance at multidisciplinary team meetings. Hospice visits are offered (22/24 (92%) vs 27/30 (90%)) although they do not always involve patient contact. There has been an increase in students’ assessments (2000: 6/24, 25% vs 2013: 25/30, 83%) using a mixture of formative and summative methods. Some course organisers lack an overview of what is delivered locally.

Conclusion: Undergraduate palliative care training continues to evolve with greater integration, increased teaching, new delivery methods and wider assessment. There is a trend towards increased patient contact and clinical involvement. A minority of medical schools offer limited teaching and patient contact which could impact on the delivery of safe palliative care by newly qualified doctors.

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