Full integration of oncology and palliative care relies on the specific knowledge and skills of two modes of care: the tumour-directed approach, the main focus of which is on treating the disease; and the host-directed approach, which focuses on the patient with the disease. This Commission addresses how to combine these two paradigms to achieve the best outcome of patient care. Randomised clinical trials on integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Early delivery of patient-directed care by specialist palliative care teams alongside tumour-directed treatment promotes patient-centred care. Systematic assessment and use of patient-reported outcomes and active patient involvement in the decisions about cancer care result in better symptom control, improved physical and mental health, and better use of health-care resources. The absence of international agreements on the content and standards of the organisation, education, and research of palliative care in oncology are major barriers to successful integration. Other barriers include the common misconception that palliative care is end-of-life care only, stigmatisation of death and dying, and insufficient infrastructure and funding. The absence of established priorities might also hinder integration more widely. This Commission proposes the use of standardised care pathways and multidisciplinary teams to promote integration of oncology and palliative care, and calls for changes at the system level to coordinate the activities of professionals, and for the development and implementation of new and improved education programmes, with the overall goal of improving patient care. Integration raises new research questions, all of which contribute to improved clinical care. When and how should palliative care be delivered? What is the optimal model for integrated care? What is the biological and clinical effect of living with advanced cancer for years after diagnosis? Successful integration must challenge the dualistic perspective of either the tumour or the host, and instead focus on a merged approach that places the patient's perspective at the centre. To succeed, integration must be anchored by management and policy makers at all levels of health care, followed by adequate resource allocation, a willingness to prioritise goals and needs, and sustained enthusiasm to help generate support for better integration. This integrated model must be reflected in international and national cancer plans, and be followed by developments of new care models, education and research programmes, all of which should be adapted to the specific cultural contexts within which they are situated. Patient-centred care should be an integrated part of oncology care independent of patient prognosis and treatment intention. To achieve this goal it must be based on changes in professional cultures and priorities in health care.
BACKGROUND: Radiation therapy (RT) results in pain relief for about 6 of 10 patients with cancer induced bone pain (CIBP) caused by bone metastases. The high number of non-responders, the long median time from RT to pain response and the risk of adverse effects, makes it important to determine predictors of treatment response. Clinical features such as cancer type, performance status and pain intensity, and biomarkers for osteoclast activity are proposed as predictors of response to RT. However, results are inconsistent and there is a need for better predictors of RT response. A similar argument can be stated for the development of cachexia; there are currently no predictors that can identify patients who will develop cachexia later in the cancer disease trajectory. Experimental and preclinical studies show that pain, depression and cachexia are related to inflammation. However, it is not known if inflammatory biomarkers can predict CIBP, depression or development of cachexia.
METHODS: This multicenter, multinational longitudinal observational study will include 600 adult patients receiving RT for CIBP. Demographic data, clinical variables, osteoclast and inflammatory biomarkers will be assessed before start of RT, and 3, 8, 16, 24 and 52 weeks after last course of RT. The primary aim of the study is to identify potential predictors for pain relief from RT. Secondary aims are to explore potential predictors for development of cachexia, the longitudinal relationship between pain intensity and depression, and if inflammatory biomarkers are associated with changes in pain intensity, cachexia and depression during one-year follow up.
DISCUSSION: The immediate clinical implication of the PRAIS study is to identify potential predictive factors for a RT response on CIBP, and thereby reduce non-efficacious RT. Patient benefits are fewer hospital visits, reduced risk of adverse effects and more individualized pain treatment. The long-term clinical implication of the PRAIS study is to improve the knowledge about inflammation in relation to CIBP, cachexia and depression and potentially identify associations and mechanisms that can be targeted for treatment.
TRIAL REGISTRATION: ClinicalTrials.gov NCT02107664 , date of registration April 8, 2014 (retrospectively registered).
TRIAL SPONSOR: The European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, NTNU, Faculty of medicine and Health Sciences, Trondheim, N-7491, Norway.
CONTEXT: Few studies regarding palliative sedation (PS) have been carried out in home care (HC) setting. A comparison of PS rate and practices between hospice (HS) and HC is also lacking.
OBJECTIVES: Comparing HC and HS settings for PS rate, patient clinical characteristics before and during PS, decision-making process and clinical aspects of PS.
METHODS: 38 HC/HS services in Italy participated in a multicenter observational longitudinal study. Consecutive adult cancer patients followed till death during a four-month period and undergoing PS were eligible. Symptom control and level of consciousness, , were registered every 8h to death.
RESULTS: 4276 patients were screened, 2894 followed till death and 531 (18%) underwent PS. PS rate was 15% in HC, 21% in HS (p<0.001). Principal refractory symptoms were delirium (54%) and dyspnea (48%), respectively more common in HC (p<0.001) and HS (p=0.03). Informed consent was not obtained in 72% of patients but achieved by 96% of families. Midazolam was the most used drug, (94% HS vs 75% HC, p<0.001) mainly by continuous infusion (74% HC vs 89% HS, p<0.001). PS duration was <48h in 67% of patients. Hydration during PS was less frequent in HC (27% vs 49%, p<0.001). In the 8h before death, consciousness level was "unrousable to mild physical stimulation" in 81% and symptom control "complete" in 89% of cases.
CONCLUSION: Our results show feasibility of PS in HC and HS, and suggest setting differences in rates, indications and practice of PS, possibly related to patients selection or care organization.
Purpose : Palliative care referral is primarily based on clinician judgment, contributing to highly variable access. Standardized criteria to trigger automatic referral have been proposed, but it remains unclear how best to apply them in practice. The authors conducted a Delphi study of international experts to identify a consensus for the use of standardized criteria to trigger automatic referral.
Methods : Sixty international experts stated their level of agreement for 14 statements regarding the use of clinician-based referral and automatic referral over two Delphi rounds. A consensus was defined as an agreement of =70% a priori.
Results : The response rate was 59/60 (98%) for the first round and 56/60 (93%) for the second round. Twenty-six (43%), 19 (32%), and 11 (18%) respondents were from North America, Asia/Australia, and Europe, respectively. The panel reached consensus that outpatient palliative care referral should be based on both automatic referral and clinician-based referral (agreement = 86%). Only 18% felt that referral should be clinician-based alone, and only 7% agreed that referral should be based on automatic referral only. There was consensus that automatic referral criteria may increase the number of referrals (agreement = 98%), facilitate earlier palliative care access, and help administrators to set benchmarks for quality improvement (agreement = 86%).
Conclusions : Our panelists favored the combination of automatic referral to augment clinician-based referral. This integrated referral framework may inform policy and program development.
Palliative sedation (PS), the medical act of decreasing a patient's awareness to relieve otherwise intractable suffering, is considered by some commentators to be controversial because of its consequences on residual survival and/or quality of life, and to be inappropriate for treating pure existential suffering. The authors will argue that PS must be always proportional, i.e. controlling refractory symptoms while keeping the loss of personal values (communication, affective relationships, care relationship) as low as possible, and that imminence of death is necessary too, from an ethical point of view, if a deep and continuous sedation (DCS) is proposed. Moreover, in case of pure existential suffering DCS should only be considered after repeated trials of respite sedation. The use of progressive consent and advance care planning to share the decision with the patient and to involve the family in the decision process as much as the patient desires is another ethical aspect to be pursued. Producing, implementing and sustaining guidelines at the higher scientific and professional level promise to help in improving both clinical and ethical aspects of the practice of PS.
La taskforce de l'Association européenne pour les soins palliatifs a travaillé avec l'Académie européenne de neurologie pour produire une revue de consensus sur les soins palliatifs dans le cas de troubles neurologiques. Les auteurs en soulignent les principales recommandations.
Un groupe de travail de l'EAPC (Association européenne de soins palliatifs) s'est réuni pour établir un état des lieux des connaissances sur l'accès douloureux paroxystique, selon les preuves théoriques et pratiques. Ils ont convenu que la douleur épisodique ou transitoire pourrait être un terme plus simple et plus adéquat dans la plupart des langues dont l'anglais, le français, l'italien et l'espagnol.
Cet article présente la version mise à jour des lignes directrices de l'Association Européenne de Soins Palliatifs (EAPC) sur l'utilisation d'opioïdes pour le traitement de la douleur cancéreuse. Ces lignes directrices sont présentées comme une liste de 16 recommandations fondées sur les preuves.
Un groupe d'experts, sous l'égide du comité directeur du réseau de recherche de l'Association européenne de soins palliatifs, a travaillé sur la question de la douleur et de ses outils de mesure et de caractérisation. Il donne le soulagement de la douleur en tant que tâche prioritaire. Il définit la spécificité des études cliniques dans le cadre des soins palliatifs et en distingue deux types : descriptives et actives, sur l'effet de thérapeutiques. Il décrit les outils servant à mesurer et décrire la douleur, leurs principes d'application et les recommandations pour leur utilisation. Il analyse des particularités à respecter lorsqu'il s'agit d'enfants. Des tableaux résument le type d'études, les paramètres et variables intervenant lors de ces recherches, et des critères adoptés selon différentes échelles de mesure.
La gabapentine est administrée comme un traitement de "rajout" pour 22 patients souffrant de douleur cancéreuse neuropathique et partiellement sensibles au traitement par les opioïdes. Les épisodes de douleurs globales, brûlantes ou lançantes sont évalués séparément. Il semble que ce médicament donne des résultats très favorables.
Cette étude porte sur une série de 14 patients souffrant d'occlusion intestinale et qui ont été soignés avec des injections sous-cutanées d'octréotide, une substance analogue à la somatostatine et qui réduit le volume des sécrétions gastro-intestinales. Les vomissements ont été contrôlés efficacement chez 12 patients, et aucun effet secondaire important n'a été décelé. L'octréotide apparaît être une substance pharmaceutique utile dans cette situation clinique.