RESUMO
BACKGROUND: Studies show that early, integrated palliative care (PC) improves quality of life (QoL) and end-of-life (EoL) care for patients with poor-prognosis cancers. However, the optimal strategy for delivering PC for those with advanced cancers who have longer disease trajectories, such as metastatic breast cancer (MBC), remains unknown. We tested the effect of a PC intervention on the documentation of EoL care discussions, patient-reported outcomes, and hospice utilization in this population. PATIENTS AND METHODS: Patients with MBC and clinical indicators of poor prognosis (n=120) were randomly assigned to receive an outpatient PC intervention (n=61) or usual care (n=59) between May 2, 2016, and December 26, 2018, at an academic cancer center. The intervention entailed 5 structured PC visits focusing on symptom management, coping, prognostic awareness, decision-making, and EoL planning. The primary outcome was documentation of EoL care discussions in the electronic health record (EHR). Secondary outcomes included patient-report of discussions with clinicians about EoL care, QoL, and mood symptoms at 6, 12, 18, and 24 weeks after baseline and hospice utilization. RESULTS: The rate of EoL care discussions documented in the EHR was higher among intervention patients versus those receiving usual care (67.2% vs 40.7%; P=.006), including a higher completion rate of a Medical Orders for Life-Sustaining Treatment form (39.3% vs 13.6%; P=.002). Intervention patients were also more likely to report discussing their EoL care wishes with their doctor (odds ratio [OR], 3.10; 95% CI, 1.21-7.94; P=.019) and to receive hospice services (OR, 4.03; 95% CI, 1.10-14.73; P=.035) compared with usual care patients. Study groups did not differ in patient-reported QoL or mood symptoms. CONCLUSIONS: This PC intervention significantly improved rates of discussion and documentation regarding EoL care and delivery of hospice services among patients with MBC, demonstrating that PC can be tailored to address the supportive care needs of patients with longer disease trajectories. ClinicalTrials.gov identifier: NCT02730858.
Assuntos
Neoplasias da Mama , Cuidados Paliativos na Terminalidade da Vida , Neoplasias , Assistência Terminal , Neoplasias da Mama/terapia , Feminino , Humanos , Neoplasias/terapia , Cuidados Paliativos , Qualidade de VidaRESUMO
INTRODUCTION: Fifteen per cent of women with cervical cancer are diagnosed with advanced disease and carry a 5 year survival rate of only 17%. Cervical cancer may lead to particularly severe symptoms that interfere with quality of life, yet few studies have examined the rate of palliative care referral in this population. This study aims to examine the impact of palliative care referral on women who have died from cervical cancer in two tertiary care centers. METHODS: We conducted a retrospective review of cervical cancer decedents at two tertiary institutions from January 2000 to February 2017. We examined how aggressive measures of care at the end of life, metrics defined by the National Quality Forum, interacted with clinical variables to understand if end-of-life care was affected. Univariate and multivariate parametric and non-parametric testing was used, and linear regression models were generated to determine unadjusted and adjusted associations between aggressive measures of care at the end of life with receipt of palliative care as the main exposure. RESULTS: Of 153 cervical cancer decedents, 73 (47%) received a palliative care referral and the majority (57%) of referrals occurred during an inpatient admission. The median time from palliative care consultation to death was 2.3 months and 34% were referred to palliative care in the last 30 days of life. Palliative care referral was associated with fewer emergency department visits (OR 0.18, 95% CI 0.05 to 0.56), inpatient stays (OR 0.21, 95% CI 0.07 to 0.61), and intensive care unit admissions (OR 0.24, 95% CI 0.06 to 0.93) in the last 30 days of life. Palliative care did not affect chemotherapy or radiation administration within 14 days of death (p=0.36). Women evaluated by palliative care providers were less likely to die in the acute care setting (OR 0.19, 95% CI 0.07 to 0.51). DISCUSSION: In two tertiary care centers, less than half of cervical cancer decedents received palliative care consultations, and those referred to palliative care were often evaluated late in their disease course. Palliative care utilization was also associated with a lower incidence of poor-quality end-of-life care.
Assuntos
Cuidados Paliativos/estatística & dados numéricos , Qualidade de Vida , Encaminhamento e Consulta/estatística & dados numéricos , Neoplasias do Colo do Útero/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Estimativa de Kaplan-Meier , Oncologia/métodos , Pessoa de Meia-Idade , Estudos Retrospectivos , Assistência Terminal/métodos , Fatores de Tempo , Neoplasias do Colo do Útero/mortalidadeRESUMO
The cause of drug shortages is a complex issue. This commentary highlights the shortage of intravenous opioid medications for cancer patients, in light of the opioid overdose epidemic.
Assuntos
Administração Intravenosa/métodos , Analgésicos Opioides/toxicidade , HumanosRESUMO
In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.
Assuntos
Dor do Câncer/diagnóstico , Dor do Câncer/terapia , Neoplasias/complicações , Manejo da Dor , Adulto , Fatores Etários , Dor do Câncer/etiologia , Terapia Combinada/efeitos adversos , Terapia Combinada/métodos , HumanosRESUMO
BACKGROUND: The American Society of Clinical Oncology recommends that patients with advanced cancer receive dedicated palliative care services early in their disease course. This investigation serves to understand how palliative care services are utilized for ovarian cancer patients in a tertiary referral center. METHODS: We conducted a retrospective review of women treated for ovarian cancer at our institution from 2010 through 2015. Clinical variables included presence and timing of palliative care referral. Data were correlated utilizing univariable and multivariable parametric and non-parametric testing, and survivals were analyzed using the Kaplan-Meier method and cox-proportional hazard models. RESULTS: We identified 391 women treated for ovarian cancer, of whom 68% were diagnosed with stage III or IV disease. Palliative care referral was utilized in 28% in the outpatient (42%) and inpatient (58%) settings. Earlier use of referral was observed in those who never underwent surgical cytoreduction or had interval cytoreductive surgery (pâ¯<â¯0.001). Palliative care referral was independently associated with advanced stage (OR 1.7, pâ¯=â¯0.02), recurrence (OR 2.0, pâ¯=â¯0.002) and hospice referral (OR 6.0, pâ¯<â¯0.001). In 38% of women referral occurred within 30â¯days of death, and 17% within one week of death. Outpatient initial consultation was associated with an unadjusted 1â¯year overall survival benefit (pâ¯<â¯0.01) compared to inpatient consultation. CONCLUSIONS: The outcomes in this study suggest a late use of palliative care that is reactionary to patient needs and not a routine component of ovarian cancer care as national guidelines recommend.
Assuntos
Adenocarcinoma/terapia , Carcinossarcoma/terapia , Neoplasias Císticas, Mucinosas e Serosas/terapia , Neoplasias Embrionárias de Células Germinativas/terapia , Neoplasias Ovarianas/terapia , Cuidados Paliativos , Encaminhamento e Consulta/estatística & dados numéricos , Tumores do Estroma Gonadal e dos Cordões Sexuais/terapia , Adenocarcinoma/patologia , Adenocarcinoma de Células Claras/patologia , Adenocarcinoma de Células Claras/terapia , Adenocarcinoma Mucinoso/patologia , Adenocarcinoma Mucinoso/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Carcinoma Endometrioide/patologia , Carcinoma Endometrioide/terapia , Carcinossarcoma/patologia , Procedimentos Cirúrgicos de Citorredução/estatística & dados numéricos , Feminino , Humanos , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Neoplasias Císticas, Mucinosas e Serosas/patologia , Neoplasias Embrionárias de Células Germinativas/patologia , Razão de Chances , Neoplasias Ovarianas/patologia , Prognóstico , Modelos de Riscos Proporcionais , Qualidade de Vida , Estudos Retrospectivos , Tumores do Estroma Gonadal e dos Cordões Sexuais/patologia , Taxa de Sobrevida , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: The family and friends (caregivers) of patients with advanced cancer often experience tremendous distress. Although early integrated palliative care (PC) has been shown to improve patient-reported quality of life (QOL) and mood, its effects on caregivers' outcomes is currently unknown. MATERIALS AND METHODS: We conducted a randomized trial of early PC integrated with oncology care versus oncology care alone for patients who were newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers and their caregivers. The early PC intervention focused on addressing the needs of both patients and their caregivers. Eligible caregivers were family or friends who would likely accompany patients to clinic visits. The intervention entailed at least monthly patient visits with PC from the time of diagnosis. Caregivers were encouraged, but not required, to attend the palliative care visits. We used the Hospital Anxiety and Depression Scale (HADS) and Medical Health Outcomes Survey Short-Form to assess caregiver mood and QOL. RESULTS: Two hundred seventy-five caregivers (intervention n = 137; control n = 138) of the 350 patients participated. The intervention led to improvement in caregivers' total distress (HADS-total adjusted mean difference = -1.45, 95% confidence interval [CI] -2.76 to -0.15, p = .029), depression subscale (HADS-depression adjusted mean difference = -0.71, 95% CI -1.38 to -0.05, p = .036), but not anxiety subscale or QOL at week 12. There were no differences in caregivers' outcomes at week 24. A terminal decline analysis showed significant intervention effects on caregivers' total distress (HADS-total), with effects on both the anxiety and depression subscales at 3 and 6 months before patient death. CONCLUSION: Early involvement of PC for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. This work demonstrates that the benefits of early, integrated PC models in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. IMPLICATIONS FOR PRACTICE: Early involvement of palliative care for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. The findings of this trial demonstrate that the benefits of the early, integrated palliative care model in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. These findings contribute novel data to the growing evidence base supporting the benefits of integrating palliative care earlier in the course of disease for patients with advanced cancer and their caregivers.
Assuntos
Cuidadores/psicologia , Neoplasias Gastrointestinais/psicologia , Neoplasias Pulmonares/psicologia , Pacientes/psicologia , Depressão/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/psicologia , Qualidade de VidaRESUMO
Calciphylaxis is a rare but devastating condition that has continued to challenge the medical community since its early descriptions in the scientific literature many decades ago. It is predominantly seen in patients with chronic kidney failure treated with dialysis (uremic calciphylaxis) but is also described in patients with earlier stages of chronic kidney disease and with normal kidney function. In this review, we discuss the available medical literature regarding risk factors, diagnosis, and treatment of both uremic and nonuremic calciphylaxis. High-quality evidence for the evaluation and management of calciphylaxis is lacking at this time due to its rare incidence and poorly understood pathogenesis and the relative paucity of collaborative research efforts. We hereby provide a summary of recommendations developed by a multidisciplinary team for patients with calciphylaxis.
Assuntos
Calciofilaxia/etiologia , Animais , Arteríolas/patologia , Biópsia , Calciofilaxia/diagnóstico , Calciofilaxia/epidemiologia , Calciofilaxia/patologia , Calciofilaxia/terapia , Estudos de Casos e Controles , Distúrbio Mineral e Ósseo na Doença Renal Crônica/complicações , Terapia Combinada , Comorbidade , Nefropatias Diabéticas/complicações , Modelos Animais de Doenças , Eletrólitos/sangue , Evolução Fatal , Feminino , Humanos , Hiperparatireoidismo Secundário/complicações , Falência Renal Crônica/complicações , Desnutrição/complicações , Desnutrição/dietoterapia , Pessoa de Meia-Idade , Obesidade/complicações , Manejo da Dor , Ratos , Fatores de Risco , Choque Séptico/etiologia , Pele/irrigação sanguínea , Pele/patologia , Tiossulfatos/uso terapêutico , Uremia/complicações , Deficiência de Vitamina D/complicações , CicatrizaçãoRESUMO
CONTEXT: Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists. OBJECTIVES: To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness. METHODS: A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs. RESULTS: The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians. CONCLUSION: This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.
Assuntos
Atitude do Pessoal de Saúde , Cuidados Paliativos , Medicina Paliativa , Humanos , Masculino , Feminino , Medicina Paliativa/educação , Médicos/psicologia , Encaminhamento e Consulta , Pessoa de Meia-Idade , Manejo da Dor , Estados Unidos , Adulto , Pesquisas sobre Atenção à Saúde , Padrões de Prática Médica , Inquéritos e Questionários , DorRESUMO
BACKGROUND: Patients with advanced cancer often experience immense cancer pain that negatively impacts their quality of life. Interventions to address cancer-related pain are limited. METHODS: We conducted a randomized trial of a digital therapeutic app (ePAL) for patients with advanced cancer receiving care in a specialty palliative care clinic at a tertiary care hospital. Patients were randomized to ePAL or usual care. ePAL included 1) active pain monitoring; 2) artificial intelligence algorithm to triage patient symptoms; and 3) patient education to address barriers to pain management. Participants were instructed to use ePAL over eight weeks. Patient-reported pain symptoms were assessed at baseline, Week-4, and Week-8 (primary endpoint) using the Brief Pain Inventory. Secondary outcomes include pain-related hospitalizations by Week-8. RESULTS: We enrolled 112 patients who were randomly assigned to ePAL (N = 56) or usual care (N = 56). Patients utilized ePAL on average 2.1 times per week to report pain symptoms, and 47.6% reported their pain at least once per week over eight weeks. Patients randomized to ePAL reported lower pain scores at Week-4 (mean: 3.16 vs. 4.28, P = 0.010) and week-8 (mean:2.99 vs. 4.05, P = 0.017), compared to those receiving usual care. Participants randomized to ePAL were less likely to experience a pain-related hospitalization compared to those in the usual care group (7.1% vs. 23.2% P = 0.018) CONCLUSIONS: ePAL was associated with lower patient-reported pain and fewer pain-related hospitalizations compared to usual care in patients with advanced cancer. This study demonstrates the promise of digital therapeutics for improving patients' symptoms while reducing burdensome hospitalizations.
Assuntos
Dor do Câncer , Manejo da Dor , Cuidados Paliativos , Humanos , Masculino , Feminino , Dor do Câncer/terapia , Pessoa de Meia-Idade , Manejo da Dor/métodos , Idoso , Cuidados Paliativos/métodos , Aplicativos Móveis , Neoplasias/complicações , Medição da Dor , Resultado do Tratamento , Hospitalização , Educação de Pacientes como Assunto , Inteligência Artificial , AlgoritmosAssuntos
Analgésicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/complicações , Sedação Consciente , Neoplasias Pulmonares/complicações , Manejo da Dor/métodos , Dor Intratável/terapia , Cuidados Paliativos , Adulto , Antineoplásicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Carcinoma Pulmonar de Células não Pequenas/secundário , Sedação Consciente/ética , Receptores ErbB/antagonistas & inibidores , Cloridrato de Erlotinib , Evolução Fatal , Feminino , Mutação da Fase de Leitura , Genes erbB-1 , Humanos , Pulmão/diagnóstico por imagem , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/patologia , Metástase Linfática , Manejo da Dor/ética , Dor Intratável/etiologia , Cuidados Paliativos/ética , Quinazolinas/uso terapêutico , RadiografiaRESUMO
Pain is a common symptom associated with cancer and its treatment. Pain management is an important aspect of oncologic care, and unrelieved pain significantly comprises overall quality of life. These NCCN Guidelines list the principles of management and acknowledge the range of complex decisions faced in the management oncologic pain. In addition to pain assessment techniques, these guidelines provide principles of use, dosing, management of adverse effects, and safe handling procedures of pharmacologic therapies and discuss a multidisciplinary approach for the management of cancer pain.
Assuntos
Neoplasias/terapia , Manejo da Dor/métodos , Dor/complicações , Acetaminofen/uso terapêutico , Analgésicos Opioides/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Humanos , Dor/tratamento farmacológico , Medição da Dor , Apoio SocialAssuntos
Linfoma de Células B/diagnóstico por imagem , Neurolinfomatose/diagnóstico por imagem , Radiculopatia/diagnóstico , Neuropatia Ciática/diagnóstico por imagem , Diagnóstico Diferencial , Feminino , Humanos , Vértebras Lombares , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons combinada à Tomografia ComputadorizadaRESUMO
With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life-limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.
RESUMO
CONTEXT: Palliative care (PC) clinicians faced many challenges delivering outpatient care during the coronavirus-19 (COVID-19) pandemic. OBJECTIVES: We described trends for in-person and video visit PC delivery challenges before and during the COVID-19 pandemic in the U.S. METHODS: We performed a secondary data analysis of patient characteristics and PC clinician surveys from a multisite randomized controlled trial at 20 academic cancer centers. Patients newly diagnosed with advanced lung cancer (N = 653) were randomly assigned to receive either early in-person or telehealth PC and had at least monthly PC clinician visits. PC clinicians completed surveys documenting PC delivery challenges after each encounter. We categorized patients into 3 subgroups according to their PC visit dates relative to the onset of the COVID-19 pandemic in the U.S.-pre-COVID-19 (all visits before March 1, 2020), pre/post-COVID-19 (≥1 visit before and after March 1, 2020), and post-COVID-19 (all visits after March 1, 2020). We performed Pearson's chi-squared, Fisher's exact, and Kruskal-Wallis tests to examine associations. RESULTS: We analyzed 2329 surveys for video visits and 2176 surveys for in-person visits. For video visits, the pre-COVID-19 subgroup (25.8% [46/178]) had the most technical difficulties followed by the pre/post-COVID-19 subgroup (17.2% [307/1784]) and then the post-COVID-19 subgroup (11.4% [42/367]) (P = 0.0001). For in-person visits, challenges related to absent patients' family members occurred most often in the post-COVID-19 subgroup (6.2% [16/259]) followed by the pre/post-COVID-19 subgroup (3.6% [50/1374]) and then the pre-COVID-19 subgroup (2.2% [12/543]) (P = 0.02). CONCLUSION: Technical difficulties related to PC video visits improved, whereas in-person visit challenges related to absent patients' family members worsened during the pandemic.
Assuntos
COVID-19 , Telemedicina , Humanos , Pandemias , Cuidados Paliativos , Assistência AmbulatorialRESUMO
COVID-19 strained our nation's hospitals and exposed gaps in care. As COVID-19 surged in Boston in March 2020, we worked to rapidly create a Palliative Care Compassion Unit (PCCU) to care for those dying of COVID-19 or non-COVID-19-related illnesses. The PCCU provided interdisciplinary end-of-life care, supported families, and enabled surge teams to focus on patients needing life-sustaining treatments. In this study, we describe the creation of the PCCU, including opportunities and challenges, in hopes of lending insight to other palliative care teams who may need to rapidly craft new care models during a crisis.
Assuntos
COVID-19 , Assistência Terminal , Morte , Humanos , Cuidados Paliativos , Pandemias , SARS-CoV-2RESUMO
CONTEXT: Individuals caring for patients with advanced cancer (caregivers) experience psychological distress during the patient's illness course. However, data on the prevalence of bereaved caregivers' psychological distress and its relationship with the quality of patient's end of life (EOL) care are limited. OBJECTIVES: To describe rates of depression and anxiety symptoms in bereaved caregivers of patients with advanced cancer and to understand the relationship between these outcomes and patient distress at the EOL. METHODS: We conducted a secondary analysis of 168 caregivers enrolled in a supportive care trial for patients with incurable lung and gastrointestinal cancers and their caregivers. We used the Hospital Anxiety and Depression Scale to assess caregivers' depression and anxiety symptoms at three months after the patient's death. Caregivers also rated the patient's physical and psychological distress in the last week of life on a 10-point scale three months after the patient death. We used linear regression adjusting for caregiver age, sex, randomization, and cancer type to explore the relationship between bereaved caregivers' depression and anxiety symptoms and their ratings of physical and psychological distress in patients at the EOL. RESULTS: Of the 168 bereaved caregivers, 30.4% (n = 51) and 43.4% (n = 73) reported clinically significant depression and anxiety symptoms, respectively. Caregiver ratings of worse physical (B = 0.32; P = 0.009) and psychological (B = 0.50; P < 0.001) distress experienced by the patient at the EOL were associated with worse depression symptoms in bereaved caregivers. Only caregiver rating of worse psychological distress experienced by the patient at the EOL (B = 0.42; P < 0.001) was associated with worse bereaved caregivers' anxiety symptoms. CONCLUSION: Many bereaved caregivers of patients with advanced cancer experience symptoms of depression and anxiety, which are associated with their perceptions of distress in their loved ones at the EOL.
Assuntos
Cuidados Paliativos na Terminalidade da Vida , Neoplasias , Angústia Psicológica , Assistência Terminal , Cuidadores , Depressão/epidemiologia , Humanos , Neoplasias/terapia , Qualidade de Vida , Estresse PsicológicoRESUMO
Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.
Assuntos
Enfermagem de Cuidados Paliativos na Terminalidade da Vida , Neoplasias do Colo do Útero , Atenção à Saúde , Feminino , Humanos , Cuidados Paliativos , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/terapia , Populações VulneráveisRESUMO
The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.
Assuntos
Enfermagem de Cuidados Paliativos na Terminalidade da Vida , Neoplasias do Colo do Útero , Atenção à Saúde , Feminino , Humanos , Cuidados Paliativos , Neoplasias do Colo do Útero/terapiaRESUMO
Background: As the death rate numbers in the United States related to COVID-19 are in the tens of thousands, clinicians are increasingly tasked with having serious illness conversations. However, in the setting of infection control policies, visitor restrictions, social distancing, and a lack of personal protective equipment, many of these important conversations are occurring by virtual visits. Objective: From our experience with a multisite study exploring the effectiveness of virtual palliative care, we have identified key elements of webside manner that are helpful when conducting serious illness conversations by virtual visit. Results: The key elements and components of webside manner skills are proper set up, acquainting the participant, maintaining conversation rhythm, responding to emotion, and closing the visit. Other considerations that may require conversion to phone visits include persistent technical difficulties, lack of prerequisite technology to conduct virtual visits, patients who are too ill to participate, or who find virtual visits too technically challenging. Conclusions: Similar to bedside manner, possessing nuanced verbal and nonverbal webside manner skills is essential to conducting serious illness conversations during virtual visits.
Assuntos
COVID-19/diagnóstico , COVID-19/terapia , Comunicação , Pessoal de Saúde/psicologia , Cuidados Paliativos/psicologia , Relações Médico-Paciente , Telemedicina/métodos , Adulto , Atitude do Pessoal de Saúde , COVID-19/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , SARS-CoV-2 , Estados Unidos/epidemiologiaRESUMO
Background: We conducted a multicenter, randomized trial of early integrated palliative and oncology care in patients with advanced cancer to confirm the benefits of early palliative care (PC) seen in prior single-center studies. Methods: We randomly assigned patients with newly diagnosed incurable cancer to early integrated palliative and oncology care (n = 195) or usual oncology care (n = 196) at sites through the Alliance for Clinical Trials in Oncology. Patients assigned to the intervention were expected to meet with a PC clinician at least monthly until death, whereas usual care patients consulted PC on request. The primary endpoint was the change in quality of life from baseline to week 12 per the Functional Assessment of Cancer Therapy-General (FACT-G). Secondary outcomes included anxiety, depression, and communication about prognosis and end-of-life care. Results: Due to significant morbidity and a high proportion of measures that were not completed within the protocol window or for unknown reasons, the rate of missing data was high. We anticipated that 70% of patients (n = 280) would complete the FACT-G at baseline and week 12, but only 49.3% (n = 193/391) completed the measure. Delivery of the intervention was also suboptimal, as 14.9% (n = 29/195) of intervention patients had no PC visits by week 12. Intervention patients reported a mean 3.35 (standard deviation [SD] = 14.7) increase in FACT-G scores from baseline to week 12 compared with usual care patients who reported a 0.12 (SD = 12.7) increase from baseline (p = 0.10). Conclusion: This study highlights the difficulties of conducting multicenter trials of supportive care interventions in patients with advanced cancer. Clinical Trials Registration: NCT02349412.