Good death and bereavement in a lung cancer patient following meaning-centered couples psychotherapy by a cancer nursing specialist

Objective There are many terminally ill cancer patients who are struggling with the meaning of life, but it cannot be said that their concerns are being adequately addressed. Method From a series of cancer patients undergoing end-of-life care, the case of a patient, who developed incurable lung cancer and, together with his wife, lost the meaning of life and underwent meaning-centered couples psychotherapy once every two weeks to have them consider the meaning of life together, is presented. Results The patient was a 70-year-old man who had been diagnosed with lung cancer and pleural dissemination 14 months earlier. The meaning-centered psychotherapy (MCP) sessions were conducted with the patient and his 70-year-old wife by a cancer nursing specialist who had received extensive training in MCP and had also received 7-year on-going supervision from a Japanese MCP-enlightened psychologist. At the same time, palliative treatment of physical distress was performed. The patient was able to discover the meaning of life as a result of MCP performed by a cancer nursing specialist for him and his spouse who had lost any notion of the meaning of life after being informed that he had terminal cancer at the time of the initial diagnosis. Significance of results Meaning-centered psychotherapy provided to terminal cancer patients by cancer nurses can help patients and their families express their gratitude, thereby achieving a good death for the bereaved family. Nurses are likely to increasingly perform MCP in the future.

Association of the RASS Score With Intensity of Symptoms, Discomfort, and Communication Capacity in Terminally Ill Cancer Patients Receiving Palliative Sedation: Is RASS an Appropriate Outcome Measure?

BackgroundPalliative sedation is sometimes needed for refractory symptoms, and the Richmond Agitation-Sedation Scale (RASS) is one of the key measures. The primary aim of this study was to explore the association between the RASS score and degree of distress quantified by other measures: Support Team Assessment Schedule, item 2 (STAS), Discomfort Scale for Dementia of Alzheimer Type (Discomfort Scale), and Non-communicative Patient’s Pain Assessment Instrument (NOPPAIN), as well as a communication capacity measured by the Communication Capacity Scale, item 4 (CCS).MethodsThis was a prospective observational study on terminally ill cancer patients who received continuous infusion of midazolam to relieve refractory symptoms in a palliative care unit of a designated cancer hospital. Primarily responsible palliative care physicians rated RASS, Discomfort Scale, NOPPAIN, and CCS just before starting infusion, and 1 hour, 4 hours, 24 hours, and 48 hours after midazolam infusion, and ward nurses rated STAS at the same time. Since the ward nurses regularly evaluated STAS to titrate midazolam during palliative sedation as routine work, we regarded STAS rated by ward nurses as a standard of distress measure.ResultsA total of 249 assessments were performed for 55 patients. The RASS score was moderately to highly associated with symptom intensity measured by STAS, discomfort measured by the Discomfort Scale, and pain measured by NOPPAIN (r = 0.63 to 0.73). On the other hand, communication capacity measured by CCS is not parallel with the RASS score, and demonstrated a valley-shape. In 82 assessments with RASS of -1 to -3, 11 patients (13%) were regarded as having physical symptoms of STAS of 2 or more.ConclusionsRASS can roughly estimate physical distress in patients receiving palliative sedation, but a measure to more precisely quantify the symptom experience is needed.

Inpatient Hospice Palliative Care Unit and Palliative Consultation Service Enhance Comprehensive Quality of Life Outcomes in Terminally Ill Cancer Patients: A Prospective Longitudinal Study

This study aimed to explore the effectiveness of an inpatient hospice palliative care unit (PCU) and palliative consultation service (PCS) on comprehensive quality of life outcome (CoQoLo) among terminally ill cancer patients. This was a prospective longitudinal study. Terminally ill cancer patients who met the inclusion criteria and received PCU or PCS in a northern Taiwanese medical center were recruited. The CoQoLo Inventory was used to measure CoQoLo level pre- and seven days following hospice care between August 2018 and October 2019. A total of 90 patients completed the study. No significant differences were found in CoQoLo levels between the PCU and PCS groups pre- and seven days following care. However, the CoQoLo level of patients significantly improved seven days following care in both PCU and PCS groups, compared with pre-hospice care. Patients’ age, religious belief, marital status, closeness with family, palliative prognostic index (PPI), and symptom severity were significant concerning CoQoLo levels after adjusting for patients’ baseline characteristics. PCU and PCS showed no difference in CoQoLo levels, but both of them can improve CoQoLo among terminally ill cancer patients. These patients could receive PCU or PCS to achieve a good CoQoLo at the end-of-life stage.

Predictive Factors for the Development of Dyspnea Within 7 Days After Admission Among Terminally Ill Cancer Patients

Background: Predictive factors for the development of dyspnea have not been reported among terminally ill cancer patients. Objective: This current study aimed to identify the predictive factors attributed to the development of dyspnea within 7 days after admission among patients with cancer. Methods: This was a secondary analysis of a multicenter prospective observational study on the dying process among patients admitted in inpatient hospices/palliative care units. Patients were divided into 2 groups: those who developed dyspnea (development group) and those who did not (non-development group). To determine independent predictive factors, univariate and multivariate analyses using the logistic regression model were performed. Results: From January 2017 to December 2017, 1159 patients were included in this analysis. Univariate analysis showed that male participants, those with primary lung cancer, ascites, and Karnofsky Performance Status score (KPS) of ≤40, smokers, and benzodiazepine users were significantly higher in the development group. Multivariate analysis revealed that primary lung cancer (odds ratio [OR]: 2.80, 95% confidence interval [95% CI]: 1.47-5.31; p = 0.002), KPS score (≤40) (OR: 1.84, 95% CI: 1.02-3.31; p = 0.044), and presence of ascites (OR: 2.34, 95% CI: 1.36-4.02; p = 0.002) were independent predictive factors for the development of dyspnea. Conclusions: Lung cancer, poor performance status, and ascites may be predictive factors for the development of dyspnea among terminally ill cancer patients. However, further studies should be performed to validate these findings.

Developing an integrated model of community-based palliative care into the primary health care (PHC) for terminally ill cancer patients in Iran

Background Patients with cancer commonly experience pain and suffering at the end of life days. Community-based palliative care can improve the quality of life of terminally-ill cancer patients and provide them with a merciful death. The purpose of this study was to develop an integrated model of community-based palliative care into PHC for terminally ill cancer patients. Method This study is a health system research (HSR) that was conducted in three phases from October 2016 to July 2020. In the first phase, dimensions of community-based palliative care were explored in patients with cancer using qualitative methods and conventional content analysis. In the second phase, a scoping review was carried out to complete the collected data from the qualitative phase of the study. Based on the collected data in the first and second phases of the study, a preliminary draft of community-based palliative care was developed for patients with cancer based on the framework of the World Health Organization. Finally, the developed model was validated using the Delphi technique in the third phase of the study. Results Data analysis indicated that providing community-based care to patients with cancer is influenced by the context of care. According to the developed model, patients are identified as terminally ill, and then are referred to the local comprehensive health center in a reverse manner. After patients’ referral, they can receive appropriate healthcare until death by the home care team in relation to the comprehensive health center based on the framework of primary healthcare. Conclusions This model was developed based on the current Iranian healthcare structure and the needs of terminally ill cancer patients. According to the model, healthcare is provided in a reverse manner from the subspecialty centers to patients’ homes in order to provide easy access to palliative care. It is suggested to use this model as a pilot at the regional level.

Exploration of optimal paracentesis volume for terminally ill patients with malignant ascites.

12089 Background: Malignant ascites (MA) often causes distressing symptoms especially for terminally ill cancer patients. Control of such symptoms is generally difficult when it becomes refractory to standard antitumor therapies. Paracentesis is the most common treatment modality which provides rapid and temporary symptom relief, while it requires frequently repeated treatment to maintain symptom control. The optimal procedure is often a balance between the potential for symptom improvement and the known risks of adverse events such as hypotension and renal impairment. However, there are limited data regarding the optimal amount of fluid to be removed. The aim of this study was to explore the efficacy (paracentesis interval and symptom relief) and safety (adverse events) of paracentesis by the drainage volume. Methods: This is part of a multicenter prospective observational study (EASED study). Consecutive adult patients with advanced cancer admitted to 23 participating palliative care units were eligible. We analyzed patients with MA who received paracentesis. We compared paracentesis-free survival (PFS) using Cox regression among 3 groups with different paracentesis volumes: minimum: < = 1500 mL, small: 1500-2500 mL, and moderate: > 2500 mL, with adjustment for potential confounders: age, sex, the Karnofsky Performance Status, and variables of which P-values were < 0.1 in univariate analysis. Trend of the difference in abdominal distention numerical rating scale (NRS) before and after paracentesis and adverse events were compared among 3 groups. Under missing at random assumption, missing values were imputed using multiple imputation. Results: A total of 1926 patients were enrolled and 673 patients developed MA at admission. Of these, 586 patients never received paracentesis during their PCU stay. Thus, the population for analysis consisted of 87 patients. Median PFS was 7 days. Compared with a moderate volume, small-volume paracentesis was not a significant risk for shorter PFS (HR: 1.14, 95%CI: 0.69-1.93), while a minimum volume was a significant risk for shorter PFS (HR: 2.34, 95%CI: 1.25-4.39). The spline-based hazard ratio curve indicated that a dose-response of the ascites drainage volume to PFS was not likely when more than 2,000 mL of ascites was removed. Abdominal distension NRS significantly decreased after paracentesis (median: 7.5 to 4.0, p < 0.0001), while the difference did not significantly increase as the volume of paracentesis rose (p = 0.61). No severe adverse event was observed. Conclusions: Even small-volume paracentesis could alleviate abdominal distension of terminally ill cancer patients with MA without shortening the paracentesis interval compared with moderate-volume paracentesis. Small-volume paracentesis was an effective and safe treatment for such patients. Our findings may help physicians estimate an optimal volume of paracentesis for each patient with MA.