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.

To evaluate quality of life, anxiety, depression, and provider-patient communication in patients with breast and gynecologic cancers with advanced disease stopping active treatment based on the care model used (integrated [ICM] compared to traditional [TCM])

Patients who had received anticancer treatment that was discontinued and were followed up only in the palliative care unit were recruited. Consented patients were evaluated by a treating physician using the Communication Assessment Protocol (CAP). The patients then completed the CAP. The CAP was aimed at determining the degree to which patients had been informed about the reality of their diseases. Patients were categorized for group placement for study comparisons. Those who had been evaluated at least once for palliative care were placed in the ICM model (included PC commitment team and active cancer treatment). Those with no prior consult were placed in the TCM model. Patients in both groups completed study assessments.

• N = 87
• MEDIAN AGE = 56 years (range = 24–83 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Advanced breast and gynecologic cancers with monastic disease or inoperable recurrences; patients with uncomfortable and uncontrolled symptoms were excluded from study participation
• OTHER KEY SAMPLE CHARACTERISTICS: Gynecologic diseases included cancers of the endometrium, ovary, uterine cervix, and vulva/vagina. Subjects were told that once they enrolled in the study, they would not receive additional anticancer treatment. There were no neuropsychiatric problems, major cognitive impairments, or uncomfortable symptoms impairing questionnaire completion.

• SITE: Single-site
• SETTING TYPE: Not specified
• LOCATION: Sao Paulo, Brazil

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

Prospective, descriptive, two-group comparison

• Hospital Anxiety and Depression Scale (HADS)
• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• Karnofsky Performance Status
• Communication assessment protocol

KPS scores ranged from 30–90 (median = 50). Previous treatment included up to eight different lines of systemic palliative treatment (mean = 2.7). There were no group differences between the two care models. The ICM care group had higher global health (p = 0.022), emotional functioning (p = 0.034), and social functioning (p = 0.018), and it had lower insomnia scores (p = 0.027) compared to the TCM group. A smaller proportion of those in the ICM group demonstrated HADS scores at a level indicating clinically relevant anxiety (HADS ≥ 11, p = 0.018). There was no correlation with the number of consultations with the palliative care team. The ICM group experienced significantly fewer communication problems (p = 0.004). The ICM group received less chemotherapy in the last six weeks compared to the TCM (p = 0.001). There was no significant difference between groups in fatigue, anorexia, constipation, pain, or diarrhea. Multivariate analyses showed increased prognostic factors for survival in the ICM group.

Early palliative care may improve quality of life and reduce insomnia and symptoms of anxiety in patients at the end-of-life phase of care.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Other limitations/explanation: Patients with significant symptoms were excluded from the study, so the sample was biased from the beginning toward individuals with less symptom distress. This factor could be expected to bias study results.

This study sought to show that offering appropriate and timely palliative care using the ICM model can reduce symptom burden during the transition into advanced disease and death. This study provided little support because of study design flaws. There was limited research on the effects of early palliative care. Additional research is needed to test this model in the United States and focus on integration into practice.