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Evidence-Based Communication in the Palliative Conversation
Published in Kathleen Benton, Renzo Pegoraro, Finding Dignity at the End of Life, 2020
Kimberson Tanco, Eduardo Bruera
Another factor in knowledge that affects communication is prognostication. Prognostication plays a key role in end-of-life choices. Having appropriate knowledge of prognostication is crucial in these discussions. However, physicians have been found to have a tendency to overestimate a patient’s survival and may be able to predict better for patients who have a more immediate risk of dying (Glare et al., 2003). One process to curtail the challenge of prognosticating accurately is to have early advanced-care planning discussions. By individually adapting these discussions to the patient’s hopes and goals and conducting them progressively through the patient’s course of care, patients and families are empowered to express their personal preferences and goals; receive care concordant with their wishes; and have the opportunity to prepare physically, psychosocially, mentally, and financially for what awaits in their disease process (Agarwal & Epstein, 2018).
Refractory Cancer Cachexia
Published in Victor R. Preedy, Handbook of Nutrition and Diet in Palliative Care, 2019
Refractory cachexia is diagnosed clinically. Cachexia becomes refractory if the underlying disease is far advanced, rapidly progressive, and unresponsive to treatment, and the catabolism increased so that weight loss management is not possible or indicated. Refractory cachexia can often only be diagnosed after a defined treatment attempt. Diagnosing refractory cachexia is close to diagnosing dying. However, the symptoms associated with cachexia (i.e., anorexia, weight loss) are often used to diagnose approaching death even when cachexia is potentially still treatable. In general, the dying patient becomes bedbound, does not swallow food or drugs, and is comatose or semi-comatose. But all of these symptoms are ambiguous and can occur in non-dying patients as well. Many different prognostication tools have been developed and validated (Simmons et al. 2017). However, the clinical judgement is still the most important factor (Fairchild et al. 2014).
Communication, counselling and breaking bad news
Published in T. Justin Clark, Arri Coomarasamy, Justin Chu, Paul Smith, Get Through MRCOG Part 3, 2019
T. Justin Clark, Arri Coomarasamy, Justin Chu, Paul Smith
Even in the bleakest situations, there are reasons for hope. For example, someone with a terminal cancer may find hope in the possibility of a period of remission or the prospect of a pain-free peaceful death. Never get into the game of giving precise prognostications about survival – whatever you say is likely to be wrong! An approach to handling a survival question is illustrated in the box nearby.
Sarcopenia in Lung Cancer: A Narrative Review
Published in Nutrition and Cancer, 2023
Uzair Jogiat, Zaharadeen Jimoh, Simon R. Turner, Vickie Baracos, Dean Eurich, Eric L. R. Bédard
In 2010, Baracos et al. published an innovative study reporting a significant association between lung cancer and sarcopenia, independent of body mass index (12). To our knowledge, 10 systematic reviews have currently been published specifically on sarcopenia in lung cancer, excluding reviews which have combined lung cancer with other tumor types (Table 1) (14–19,22–26). Of the reviews which conducted meta-analyses, sarcopenia was consistently associated with worse overall survival (OS), with a pooled hazard ratio (HR) ranging from 2.23 to 3.13 (15,17–19,23). Two meta-analyses were conducted on disease-free survival (DFS), both reporting a significant association with a pooled HR ranging from 1.28 to 1.66 (19,23). Despite the substantial evidence on these long term outcomes, there exist under explored areas of research. Specifically, the impact of sarcopenia on OS and DFS in small cell lung cancer (SCLC), with only a single meta-analysis, including two retrospective studies, reporting on this outcome (19). This raises the question, does the prognostic effect of sarcopenia change with variations in therapeutic decision-making and more aggressive disease? The management of lung cancer is multi-faceted, taking into consideration resectability, stage, histology, and performance status, among other factors. How does sarcopenia impact the prognosis of patients with unresectable lung cancer undergoing medical therapy? Prognostication for patients with incurable disease is of significant importance, providing patients with essential information to make timely decisions about their care.
Prognostic information and care plans for patients dying of cancer
Published in Acta Oncologica, 2023
Our finding that the number of patients given time-prognostic information was quite low overall (n = 148, 49%) aligns with previous studies presenting somewhat higher and lower percentages [2,16,17]. A more startling finding is how late these conversations took place prior to death. A timing of 11 days (SPHC group) or 6 days (regular group) gives patients hardly any time to plan and prioritize. Moreover, a patient in such a late stage of illness will not have much energy left and therefore will not have as much use for the information as she or he would have had if it were given earlier. The question is, why are patients being given prognostic information with such short timing? Several studies indicate that insecurity among physicians and other health care specialists may be one reason for late timing or lack of prognostic information [14,18–20]. Fear of hurting the patient by providing information of approaching or even impending death is common. However, information on time prognosis has not been associated with a higher level of anxiety, depression or pain among patients [2,21,22]. Rather, patients who receive this information may express a sense of redirected hope and new goals, such as being pain free or having good quality of life during the remaining time [21]. Another common fear among physicians is giving an incorrect estimation of a patient’s remaining life span. However, it has been shown that most patients prefer some kind of time prognostication – even knowing that it may be faulty – rather than none at all [23].
Overtreatment in end-of-life care: how can we do better?
Published in Acta Oncologica, 2022
Although prognostication is difficult it is perhaps even more difficult for healthcare professionals to accept the consequences of prognostication, i.e., to inform the patient and relatives about limited survival time. This means that the goal of the care has to be changed into a palliative care approach where symptom relief and maintained QoL is the overall aim. This is preferably performed by making a care plan together with the patients and his/her relatives. An important part of the care plan is to decide which actions that should and should not be taken when the patients deteriorate. Importantly, the patient should be able to choose how and in which way the time left should be spent. Should the time be spent by unnecessary investigations or distressing treatments and endless hours in the hospital – or should it be spent with the loved ones, in a peaceful surrounding with adequate access to palliative care? Still, for some patients the most prioritized thing to do is to have ‘tried everything possible’ when it comes to treatments and interventions – but at least it should be the patient’s choice and they should be well informed about the prognosis.