Palliative Care

To assess the association between palliative care management, symptoms, and quality of life

Clinical records of patients referred for outpatient palliative care who had follow-up visits within 120 days of initial referral were included. Retrospective analysis of clinical data was done.

• N = 266
• MEAN AGE = 57.2 years (SD = 13.8 years)
• MALES: 46%, FEMALES: 54%
• KEY DISEASE CHARACTERISTICS: 59% had metastatic disease. Multiple cancer sites were included, and 68% were on active treatment. Median time since diagnosis was 17 months. Mean time of follow-up after initial visit was 41 days.

• SITE: Single site 
• SETTING TYPE: Outpatient 
• LOCATION: California

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care

• Retrospective, descriptive

• Edmonton Symptom Assessment Scale

At the time of initial visit, average symptom scores were 2.9–5.8 (10-point scale). At the first follow-up visit, there was an average 0.67-point improvement in pain (p < .001), a 0.67-point improvement in fatigue (p < .001), a 0.94-point improvement in depression (p < .001), and a 0.89-point improvement in anxiety (p < .001). At least 50% of patients reported a greater than one-point improvement in symptoms by the first follow-up visit, and 16%–25% reported a one-point or greater worsening of symptoms. Among 142 patients who had a second follow-up visit, there was continued significant improvement from baseline symptom scores. Patients on active treatment had less improvement in fatigue than others (p = .02).

Most patients who continued follow-up by palliative care demonstrated improvement in pain, fatigue, anxiety, and depression.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (sample characteristics)
• Other limitations/explanation: The study only included those patients referred who had follow-up visits in the palliative care clinic. It is possible that at least some of those who did not come back for another visit did not have symptom improvement, so results may be overestimated. The opposite also is possible. There was a lot of variability in the timing of follow-ups. A single symptom measure was used repeatedly; it is possible that the study had threats to validity because of testing effect and patient expectations. It is not known if oncologic providers made any changes in medications for symptom management, as palliative care follow-up visits were relatively infrequent.

Palliative care, with attention to symptom management, has been shown to be effective in reducing symptom severity for the majority of patients. It is not clear, however, if formal palliative care services result in better outcomes than attention to symptom management in general. It would be expected that, whether provided by oncology or palliative care providers, focused attention on symptom management would result in improvement of symptoms. The optimum frequency of follow-up and timing for optimal symptom control has not been determined.

To assess the impact of palliative care interventions on symptoms and quality of life among patients undergoing HCT

Within 72 hours of transplant admission, patients were randomized to treatment and control groups. Within 72 hours of group assignment, patients in the palliative care group met with the palliative care physician or advanced practice nurse for planning management of symptoms. Palliative interventions were provided according to guidelines in a manual developed for addressing pharmacologic and non-pharmacologic symptom management interventions. Study measures were obtained at baseline and during the second week of hospitalization, day 5 after autologous cell infusion, day 8 after allogeneic HCT, and at 3 and 6 months after HCT.

• N = 157    
• AGE: Mean = 57.05 years
• MALES: 42%  
• FEMALES: 58%
• CURRENT TREATMENT: Combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Most had autologous HCT
• OTHER KEY SAMPLE CHARACTERISTICS: Most had college or more formal education. More than 70% were married.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Massachusetts

• PHASE OF CARE: Transition phase after active treatment
• APPLICATIONS: Palliative care

RCT

• FACT-BMT
• FACT Fatigue score
• PHQ9 for depression
• Hospital Anxiety and Depression Scale
• Edmonton Symptom Assessment Scale (ESAS)

Hospitalization lasted an average of 21 days, ranging from 12-102.  Most commonly addressed symptoms were nausea, pain, diarrhea, and constipation. At two weeks, BMT scores (p = 0.02), fatigue scores (p = 0.04) ESAS symptoms burden scores (p = 0.02), and HADs anxiety and depression subscales (p < 0.008) were all better in the palliative care group. At three months, depression scores were lower in the palliative care group (p = 0.002). HADs scores, however, did not show clinically relevant levels of anxiety or depression. At three months, there was no difference between groups in fatigue, anxiety, or overall symptom burden. During hospitalization, caregivers of intervention patients reported less increase in depression (p = 0.03). Caregivers of those in the intervention group reported improvement in coping compared to those in the control group (p = 0.02).

Palliative care during hospitalization for HCT was associated with lower fatigue and symptoms of anxiety and depression.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Measurement validity/reliability questionable
• Other limitations/explanation: Interventions for symptom control were not described. Anxiety and depression scores were not at a clinically relevant level for HADS, so it is unclear that differences seen were meaningful.

Palliative care service can be beneficial to patients for management of symptoms during hospitalization for HCT.

To determine symptom changes after outpatient palliative care

Patients who were seen in outpatient palliative care and had completed a symptom assessment scale were included in retrospective review of medical records. Only patients who completed the assessment and had at least one follow-up visit were included. The outpatient palliative care service was provided by an interdisciplinary team. Baseline symptom severity was compared to findings on an initial follow-up—usually in 15 days—and compared to a group of patients not eligible for study inclusion.

• N = 1,612 
• MEAN AGE = 59.2 years (SD = 13.2 years)
• MALES: 52%, FEMALES: 48%
• KEY DISEASE CHARACTERISTICS: Multiple disease types; lung, gastrointestinal, and genitourinary cancers were most frequent.
• OTHER KEY SAMPLE CHARACTERISTICS: 73% were Caucasian.

• SITE: Single site 
• SETTING TYPE: Outpatient 
• LOCATION: MD Anderson in Texas

• APPLICATIONS: Palliative care

• Retrospective, descriptive

• Edmonton Symptom Assessment Scale

Of the patients, 52%–74% had improvement in intensity of symptoms of pain, fatigue, depression, anxiety, anorexia, shortness of breath, and sleep disruption. Overall, among patients who had no or mild symptoms at baseline, symptom intensity was worse at follow-up, and among those with moderate or severe symptoms, symptom intensity declined at follow-up. Of patients with moderate or severe symptoms, 48%–80% continued to have clinically significant symptom intensity at follow-up. Median scores for pain, fatigue, depression, anxiety, anorexia, dyspnea, and sleep disturbance improved by at least one point by the first follow-up (p < .001).

Outpatient palliative care services in this setting were associated with reduced symptom intensity among patients who had moderate to severe symptoms. Findings suggest that the timing of initial follow-up might not be sufficient to significantly reduce symptom burden quickly.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Selective outcomes reporting
• Other limitations/explanation: Retrospective design; no information provided regarding disease stage or phase of cancer care involved; only a single follow-up time point

Findings suggest that provision of outpatient palliative care services can be beneficial in reducing symptom burden among patients with cancer. Because 48%–80% still had relatively high intensity of symptoms at follow-up after 15 days—and those with no or mild symptoms had exacerbation of symptoms at follow-up—a shorter initial follow-up period might achieve more rapid improvement and help to prevent exacerbation of symptoms. Findings also suggest that getting more severe symptoms under control may take longer, pointing to the need for nurses to consider involvement of palliative care specialists early in the course of cancer treatment.