Palliative care referral and associated outcomes among patients with cancer in the last 2†weeks of life.

BACKGROUND: Palliative care (PC) improves the quality of life of patients with advanced cancer. Our aim was to describe PC referral among patients with advanced cancer, and associated outcomes in an academic medical centre. METHODS: We reviewed the medical records of 536 inpatients with cancer who had died in 2010. Our retrospective study compared patients who accessed PC services with those who did not. Statistical analysis was conducted using non-parametric tests due to non-normal distribution. We also conducted a multivariate analysis using a logistic regression model including age, gender, type of cancer and metastatic status. RESULTS: Out of 536 patients, 239 (45%) had PC referral. The most common cancer types were respiratory (22%) and gastrointestinal (19%). Patients with breast cancer (OR 23.76; CI 6.12 to 92.18) and gynaecological cancer (OR 7.64; CI 2.61 to 22.35) had greater PC access than patients with respiratory or haematological cancer. Patients referred to PC had significantly less chemotherapy in the last 2 weeks of life than non-referred patients, with 22 patients (9%) vs 59 (19%; p<0.001). PC-referred patients had significantly fewer admissions to intensive care units in the last month of life than non-referred patients, with 14 (6%) vs 58 (20%; p<0.001). CONCLUSIONS: There was a large variation in access to PC according to the type of cancer. There is a need to improve collaboration between the PC service and the respiratory, cancer and haematology specialists. Further research will be required to determine the modality and the impact of this collaboration.

Cancer Patients Dying in the Intensive Care Units and Access to Palliative Care.

BACKGROUND: In France, cancer has become the leading cause of death. Intensive care units (ICU) focus on survival, which may not be an appropriate setting to provide palliative care (PC) as needed by cancer patients and families. OBJECTIVE: To describe the cancer patients who died in the ICU in 2010 in a French academic medical center. DESIGN: Retrospective study Measurements: We reviewed medical records of all cancer patients who died in the ICU in 2010. The information collected from electronic medical records included patient sociodemographics and clinical characteristics, PC service referral, and the date of first contact with PC. RESULTS: Among the 536 cancer patients who died in 2010, 42 (8%) died in the ICU. The cancers were hematological (21%), gastrointestinal (21%) and head and neck (21%). One patient had a PC referral versus 45% in the total population (p < 0.001) and the referral was the same day as the death. Eight (19%) patients had chemotherapy during their last month of life and 2 during the ICU hospitalization. Seventy-four per cent of patient admissions to the ICU related directly to malignancy. The mean time between diagnosis of cancer and death was 2.3 years (standard deviation, 4.4). CONCLUSIONS: Our work highlights the need for early PC in the illness trajectory of cancer patients to prevent the transfer of dying patients to the ICU. More studies are needed to understand the decision making leading to such transfers.

[Improving the quality of cancer pain management in palliative care unit: Targeted clinical audit]. / Qualité de la prise en charge de la douleur du cancer en unité de soins palliatifs : audit clinique ciblé.

Goal This study aims to assess the quality of the cancer pain management in Palliative care unit. METHOD: The method used was the targeted clinical audit. The audit grid was built according to the recommendations of the pilot Committee, and tested until the final version with 19 items was obtained. In this retrospective study, 60 consecutive patients were studied on 2 periods of time. The first one (T1) shows the gap between the patient's chart and the expected standard, and proposes corrective measures. The second one (T2) re-assesses, using the same items list, the efficacy of these measures. RESULTS: After the corrective measures, the patients' medical record documentation was significantly improved at T2 for: neuropathic pain assessment improved, from 3% (T1) to 67% (T2) (P<0.001), so did pain assessment during the titration, from 6.7% (T1) to 90% (T2) (P<0.001). The overdoses symptoms assessment improved from 17% at T1 to 93% at T2, (P=0.002) and breakthrough pain evaluation improved from 3% at T1 to 73% at T2, (P<0.001). The pain reassessment after the rescue doses improved from 10% at T1 to 73% at T2 (P<0.001). The other points improved but not significantly. CONCLUSION: The quality of the pain cancer management was improved during the audit, but some points (patient education and in patient medical record documentation) can be improved. We need to continue to implement the improvement measures in our unit.

Art therapy among palliative cancer patients: Aesthetic dimensions and impacts on symptoms.

OBJECTIVE: This study aimed to explore whether aesthetic beauty and the pleasure that results from artistic activity can contribute to a reduction in the symptoms experienced by palliative care patients, and to improve the effectiveness of art therapy sessions. METHOD: A self-assessment of six symptoms (pain, anxiety, ill-being, tiredness, sadness, and depression) adapted from the Edmonton Symptom Assessment System (ESAS) was completed by patients before and after a one-hour art therapy session. This assessment was completed after the session with a self-assessment of aesthetic feeling. A correlation analysis was then performed. RESULTS: From July of 2012 to December of 2013, 28 patients took part in 63 art therapy sessions. On the whole, these sessions reduced the global distress of patients by 47% (p < 0.0001). There was a significant reduction in all the symptoms studied; pain (p = 0.003), anxiety (p < 0.0001), ill-being (p < 0.0001), tiredness (p < 0.0001), sadness (p < 0.0001), and depression (p < 0.0001). A study of the significant correlations (0.35 < rs < 0.52, p < 0.05) indicated that technical satisfaction, aesthetic beauty, and pleasure are all involved to varying degrees in reduction of symptoms. SIGNIFICANCE OF RESULTS: Our findings confirm the benefits of art therapy in reducing distress within the palliative context. We also make suggestions for the future direction and improvement of these sessions.

Burnout among physicians in palliative care: Impact of clinical settings.

OBJECTIVE: Burnout syndrome is a work-related professional distress. Palliative care physicians often have to deal with complex end-of-life situations and are at risk of presenting with burnout syndrome, which has been little studied in this population. Our study aims to identify the impact of clinical settings (in a palliative care unit (PCU) or on a palliative care mobile team (PCMT)) on palliative care physicians. METHOD: We undertook a cross-sectional study using a questionnaire that included the Maslach Burnout Inventory (MBI), and we gathered sociodemographic and professional data. The questionnaire was sent to all 590 physicians working in palliative care in France between July of 2012 and February of 2013. RESULTS: The response rate was 61, 8% after three reminders. Some 27 (9%) participants showed high emotional exhaustion, 12 (4%) suffered from a high degree of depersonalization, and 71 (18%) had feelings of low personal accomplishment. Physicians working on a PCMT tended (p = 0.051) to be more likely to suffer from emotional exhaustion than their colleagues. Physicians working on a PCMT worked on smaller teams (fewer physicians, p < 0.001; fewer nonphysicians, p < 0.001). They spent less time doing research (p = 0.019), had fewer resources (p = 0.004), and their expertise seemed to be underrecognized by their colleagues (p = 0.023). SIGNIFICANCE OF RESULTS: The prevalence of burnout in palliative care physicians was low and in fact lower than that reported in other populations (e.g., oncologists). Working on a palliative care mobile team can be a more risky situation, associated with a lack of medical and paramedical staff.

Barriers to research in palliative care in France.

PURPOSE: Palliative care (PC) needs expansion of its research capacity to improve the quality of care. This is particularly true for France that contributed less than 2% of all European PC research publications. We conducted a survey to assess the barriers French healthcare professionals (HCPs) involved in PC research had to face. METHODS: We surveyed all 420 PC departments registered in the French National Association for Palliative Care (SFAP) database using a previously used questionnaire. We documented the ethical limitations, time constraints, financial resources, patient issues and methodological issues related to PC research. RESULTS: We obtained 382 responses. Ninety-two (24.1%) HCPs were involved in a research project during the last 5 years. In univariate results, predictors of being involved in PC research were men (p=0.004), physician (p=0.022), working at a university hospital (p<0.001). There was a trend towards working in a PC unit (p=0.052). The main barriers to participating in PC research were lack of time (80.1%) and patient issues (47.4%). Lack of methodological support (33.0%) and financial limitations (30.4%) were also reported as major barriers. CONCLUSIONS: There is a consensus that PC research and publication in the English language for peer-reviewed journals must be expanded in France but at this stage, clinical teams still lack specific funding and appropriate support. More research is needed to confirm our results and to determine the best ways to develop PC research capacity in France.

Methadone rotation for cancer patients with refractory pain in a palliative care unit: an observational study.

BACKGROUND: Methadone has been reported to be as effective as morphine for cancer pain management. It is commonly used as an alternative opioid in case of insufficient relief. OBJECTIVE: Our aim was to assess efficacy and tolerance of opioid rotation to methadone for refractory cancer pain management in palliative care unit (PCU) inpatients. METHODS: All the patients undergoing opioid rotation to methadone from 2008 to 2011 in two PCUs (Lyon and Nice, France) were included. Pain assessments were undertaken on day 0 (D0), day 3 (D3), day 7 (D7), and day 14 (D14) using a visual analogue scale (VAS; 0-10) and the Douleur Neuropathique 4 (DN4) scale for neuropathic pain. Patients reported pain relief using a 4-point Likert scale (1=no relief; 4=important relief ). RESULTS: Nineteen patients (7 females) with a median age of 55 (Q1-Q3; 44-58) underwent methadone rotation. The most common type of cancer was gastrointestinal. Seventeen patients had a diagnosis of mixed pain syndromes. Morphine equivalent daily dose (MEDD) prior to switching was 480 mg (Q1-Q3; 100-1021), and at least two nonmethadone opioid rotations had already been done for 13 patients. Between D0 and D7, the VAS score decreased by 4 points (p<0.001). The DN4 score became negative on D7 for 11 of 17 patients (65%). On D7, 16 of 18 patients (89%) expressed moderate to greater than moderate pain relief. Methadone was discontinued in one patient on D7 because it was deemed ineffective and for 8 patients, who were unable to take oral drugs, it was discontinued after D14. CONCLUSION: Our results suggest that methadone is effective and well tolerated for refractory cancer pain.

[Advanced directives: nurses' and physicians' representations in 2012]. / Directives anticipées : représentations d'infirmiers et de médecins en 2012.

In cancer patients, decision-making process is crucial and patient's involvement is described as a central component. In 2005, a new tool appears to convey patient's opinion even if he is not able to communicate anymore: advanced directives (AD). Unfortunately, their documentation is marginal. The objective of this study was to investigate nurses' and physicians' representations towards AD. A questionnaire had been sent to hospitals, public health facilities and liberal practitioners during February 2012. We collected responses from 42/251 physicians (17 %) and 80/198 nurses (40 %). Sixty percent of participants reported that they were not familiar with the legislative framework for AD. For physicians, main barriers were patient cognitive impairment (P = 0.004) and lack of information on the clinical situation (P = 0.004). For nurses, difficulties were toward end of life and prognosis discussion (P = 0.002), clinical situation evolution since AD documentation (P = 0.008), time frame for AD application (P < 0.001) and the fact that final decision is made by physician alone (P = 0.015). AD should be part of a good medical practice and literature has highlighted the benefit of AD on patient's quality of life. End of life discussion therefore requires dedicated time and specific training for physicians and nurses to improve the rate of patients with AD.

[Management of psychiatric inpatients with advanced cancer: a pilot study]. / Prise en charge de pathologie cancéreuse avancée chez des patients institutionnalisés en psychiatrie : une étude pilote.

The prevalence of cancer is not well established and probably underestimated in long-stay psychiatric inpatients. Psychiatric patients do not have the same access for cancer screening and care. Therapeutic decision-making is a real ethical problem. In this context, access to medical care should be provided by the establishment of guidelines and/or recommendations for this specific population. The aim of our study was to assess how cancer was managed among long term psychiatric inpatients. For this pilot study, we used a mixed methodology: a quantitative part with a retrospective chart review of cancer patients in a psychiatric institution and a qualitative part based on semi-structured interviews with psychiatrists with discourse analysis. Delay in cancer diagnosis can be explained by communication and behavior disorders, inadequate screening, and additional tests often refused by patients. Compliance and ethical issues (i.e. obtaining informed consent) are many pitfalls to optimal cancer care that should be explored in further research.