Communication along Milestones in Lung Cancer Patients with Advanced Disease

Internationally, early integration of palliative care in pediatric oncology has been widely recognized. However, little is known about the perspective of Chinese providers in this regard. The aim of this study was to explore the perspective of Chinese providers on the early integration of palliative care in pediatric oncology. This was a convergent mixed-methods study with a survey among 141 Chinese providers (101 nurses, 38 oncologists, and 2 social workers) and 12 individual interviews (5 oncologists, 5 nurses, and 2 social workers). Three categories existed by comparison and merging of quantitative and qualitative findings: (1) attitudes toward early integration of pediatric palliative care: 75% of the participants endorsed early integration because it would bring benefits to patients and their families-participants had concerns about misunderstandings of palliative care among other stakeholders; (2) patient-provider interactions relating to early integration: participants held contradictory views toward the impact on and influencers of early integration regarding patient-provider interactions; and (3) participants suggested a system to support early integration by addressing parents' misconceptions and providers' training, and institutional facilitation. Chinese pediatric oncology providers generally exhibit a reserved willingness toward the early integration of palliative care. They agree that palliative care would be beneficial but have concerns about providing structural support and addressing cultural influencers. Findings of this study emphasize the significance of convening stakeholders and establishing a pediatric palliative care-friendly system in a developing country, particularly by addressing structural support, resource allocation, clarified responsibilities, and capacity building.

Guidelines recommend early palliative care (PC) integration in advanced cancers. This remains a challenge in countries with high cancer burden and limited PC access. We report the quality improvement (QI) journey aimed at improving timely PC integration in patients with advanced gastric, colorectal and lung cancers at two centres in India. Centre A, an academic institution, and Centre B, a standalone cancer centre, used the A3 methodology for the QI process. An audit was conducted prior to August 2023 to establish the baseline PC referral rate. Process mapping, root cause analysis and Pareto chart were done, and key drivers were identified and interventions were planned. The common interventions were to increase oncologists' awareness, ensure holistic symptom assessment and establish a referral process. The proportion of patients with advanced cancer referred timely to PC was measured and recorded. Sustainability of the QI projects was assessed until September 2024. There was an increase in the timely PC referral from 37% to 66% in Centre A, and from 30% to 60% in Centre B, from before August 2023 to April 2024. QI projects are feasible and effective when supported by good stakeholder collaboration to achieve the target of early and timely PC referral within oncology settings.

Early integration of palliative care in hematology: an urgency for patients, a challenge for physicians

Care management trajectories of infants with life-limiting conditions who died before 12 months of age; a retrospective patient health record review

Cancer survival rates for adolescents and young adults (AYA) have not improved over time relative to children or adults older than 39 years of age. Palliative care is specialized medical care focused on the control of symptoms and relief of suffering with the goal of improving quality of life for the patient and his or her family. To date, the integration of palliative care in AYA patients with cancer remains suboptimal. We explore the role of palliative care in the continuum of clinical care for AYA patients with cancer. Clinical practice guidelines highlight the need for integrating palliative care for all patients with cancer, including the AYA population. Despite this, a paucity of evidence exists regarding the use of palliative care with AYA patients with cancer. Graduate clinical education represents an opportunity to promote the full inclusion and early integration of palliative care in the care of AYA patients with cancer. Advance care planning is one area where some agreement exists on the unique needs of AYA patients and their families. In general, palliative care is seen as being synonymous with end-of-life care for patients with cancer. However, the emerging trend toward standardizing oncology care to meet the unique medical, psychosocial, and supportive care needs of AYA patients with cancer and their families represents an opportunity for health care professionals to collaborate early with palliative care specialists to control symptoms and relieve suffering in this vulnerable population.

BackgroundDespite improvements in diagnostics and therapy, the majority of lung tumours are diagnosed at advanced stage IV with a poor prognosis. Due to the nature of an incurable disease, patients need to engage in shared decision making on advance care planning. To implement this in clinical practice, effective communication between patients, caregivers and healthcare professionals is essential. The Heidelberg Milestones Communication Approach (MCA) is delivered by a specifically trained interprofessional tandem and consists of four milestone conversations (MCs) at pivotal times in the disease trajectory. MC 1 (Diagnosis): i.e. prognosis; MC 2 (Stable disease): i.e. prognostic awareness; MC 3 (Progression): i.e. reassessment; MC 4 (Best supportive care): i.e. end of treatment. In between MCs, follow-up calls are carried out to sustain communication. This study aimed to assess to what extent the MCA was implemented as planned and consolidated in specialized oncology practice.MethodsA prospective observational process evaluation study was conducted, which focused on the implementation fidelity of the MCA. All MCs during two assessment periods were included. We analysed all written records of the conversations, which are part of the routine documentation during MCs and follow-up calls. Adherence to key aspects of the manual was documented on structured checklists at the beginning of the implementation of the MCA and after 6 months. The analysis was descriptive. Differences between the two assessment periods are analysed with chi-square tests.ResultsA total of 133 MCs and 54 follow-up-calls (t1) and of 172 MCs and 92 follow-up calls (t2) were analysed. MC 2 were the most frequently completed conversations (n = 51 and n = 47). Advance care planning was discussed in 26 and 13% of MC 2 in the respective assessment periods; in 31 and 47% of MC 2, prognostic awareness was recorded. The most frequently documented topic in the follow-up calls was the physical condition in patients (82 and 83%).ConclusionThe implementation of a trajectory-specific communication concept was largely successful. Additional studies are needed to understand how fidelity could be further improved.Trial registrationDRKS00013469 / Date of registration: 22.12.2017.

BackgroundEarly introduction of palliative care improves outcomes in advanced non-cancer diseases (Davis, Temel, Balboni, et al. Ann Palliat Med. 2015;4(3):99–121). At our tertiary centre patients undergo potentially curative high-risk treatments...

Introduction: The beneficial effect of early integration of palliative care in cancer patients on quality of life and course of disease has been proven in several interventional studies. Despite this knowledge and increasing demand for early integration of palliative care, symptom prevalence studies mainly address symptoms and burdens of patients in the later course of disease. Lack of clarity exists however regarding the symptom burden at the time of diagnosis of the incurable disease. The aim of this systematic review is to identify and evaluate symptom prevalence studies at the time of diagnosis of an incurable cancer disease. Methods: We conducted a systematic review using a search string in the medical database MEDLINE from 1969 to 2020. Two reviewers screened the search results. In a second step all references from included studies were hand-searched. We included studies of patients with an initial diagnosis of an incurable solid or metastatic cancer and early recording of symptoms after the diagnosis. Studies with hematological and pediatric patients or patients already receiving cancer therapy were excluded. Results: A total of 3110 studies were reviewed and just 15 studies matched all criteria for inclusion: six for ovarian cancer, eight for lung cancer and one for pleural mesothelioma. The results show that most patients were symptomatic and burdened already at the time of diagnosis of their incurable cancer disease and there was a variety of relevant symptoms and physical disabilities. Conclusions: Most patients with a newly diagnosed incurable cancer have physical symptoms and psychosocial stress. It can be assumed that there is a need for an interdisciplinary cooperation and palliative care treatment in addition to their primary care and oncological treatment. However, due to the small number of studies, further and more specific clinical research is required in order to determine the needs and treatment approaches for this special patient group.

Lung cancer remains the leading cause of cancer death, and it is known many affected will have significant palliative care needs. Evidence suggests that early involvement of palliative care can translate into improvements in quality of care, quality of life, and survival. However, routine early integration is yet to be embraced as standard of care for the majority of patients, and it is unclear what lung cancer clinicians continue to perceive as the barriers to this model of care. We performed a qualitative exploration of lung cancer clinicians' perceptions, focusing on current experiences of engaging with palliative care, perceptions of palliative care for patients with lung cancer, and views of barriers and benefits of referring to palliative care. Focus group and targeted interviews were conducted with 28 clinicians, with four key emergent themes: 1) Competence/skill--with referrers needing to be confident in the quality and capability of palliative care provision; 2) Care Coordination--the need to ensure integrated care, with defined lines of responsibility and clear team communication; 3) Ease of referral--the need for ready access to a palliative care provider in the lung cancer clinic; and 4) Perceptions--concerns about loss of hope and fears of negative patient reaction. Early and routine involvement of palliative care in patients with incurable lung cancer is acceptable to the majority of treating clinicians. To facilitate early integration of palliative care, palliative care providers need to become front-line team members who provide a high-quality service. Lung cancer clinicians need further education as to the role and benefits of early palliative care, and how best to introduce this.

Globally, there is a growing number of population with noncommunicable and aging diseases that are eligible for palliative care. To analyze when palliative care should be integrated in people with non-oncological chronic diseases and the implications of its implementation. Review of scientific literature in the Web of Science, PubMed and CINAHL databases, using the descriptors palliative care, chronic diseases, and benefits. 28 scientific articles were selected, identifying four categories: palliative care for all; early integration of palliative care; strategies for implementation; benefits of palliative care integration. Palliative care is a strategy of care for all people with complex chronic pathologies, which should be integrated early, in an active, multidimensional and safe way, under the wing of a trained and coordinated health team at different levels of care.

Routine early integration of palliative care with advanced cancer management is not yet a part of standard practice in many countries, including mainland China. Whether patients in China suffering from advanced cancer are referred to palliative care services in a timely manner remains unclear. We sought to investigate the timing of palliative care referral of Chinese cancer patients at our center and its predictors. Retrospective medical data including demographic characteristics and referral information were collected for analysis. A total of 759 patients referred to our palliative care unit (PCU) from January of 2007 to December of 2013 were included in the final analysis. The mean age of the 759 patients included in the study was 62.89 years (range 61.95-63.82). Some 369 patients (48.6%) were male and 559 (73.6%) Shanghainese (indigenous). Lung cancer (17.9%) was the most common diagnosis. The time interval since enrollment into the PCU until a patient's death (length of stay, LOS) was calculated. A longer LOS indicated earlier referral to inpatient PC services. The median LOS was 21 days (CI 95% = 19.79-22.21). Multivariate analysis showed that whether or not the patient was indigenous (p = 0.002) and younger than 65 (p = 0.031) were independent factors for a longer LOS. Such other characteristics as gender and primary cancer type bore no relationship to LOS. Our findings demonstrate that Chinese cancer patients are referred relatively late in the course of their disease to inpatient palliative care services. To overcome the barriers to early integration of palliative care into a patient's treatment plan, accurate information about palliative care must be provided to both oncologists and patients via comprehensive and systematic educational programs.

Palliative Care Practice Patterns among Patients with Lung Cancer Metastatic to the Brain

The National Cancer Plan emphasises the importance of medical communication and calls for its integration into medical education and training. In this context, the Milestone Communication Approach meets the communicative challenges in dealing with lung cancer patients. Interprofessional tandems, consisting of doctors and nurses, conduct structured conversations at defined moments with patients and their relatives. The concept aims at shared decision making, continuity in the care of lung cancer patients and the early integration of palliative care. During the symposium on the Heidelberg Milestone Communication in January 2020, recommendations on the care situation of lung cancer patients in advanced stages were developed. In addition, the further adaptability of HeiMeKOM to other settings and hospitals and to other diseases was discussed as well as the possibility of implementing such a concept in standard care. This article presents the experiences, best practice examples and recommendations discussed during the symposium in order to enable their extrapolation to other similarly oriented projects. The long-term goal is to transfer the milestone concept to other hospital, primarily certified lung cancer centers, and to ensure permanent funding. For further dissemination of the concept and, above all, to have it established in standard care, health policy awareness and support are required in addition to the integration of the concept in competence catalogues of continuing medical and nursing education.

BACKGROUND The disease course of glioblastoma (GB) patients is usually characterized by high symptom burden and short median survival (approx. 14 months). Nevertheless, they rarely receive specialized palliative care, especially in the early stage of the disease (early integration of palliative care, EIPC). The “Early Palliative Care for Patients with Glioblastoma” (EPCOG) study therefore aimed at investigating the impact of EIPC on quality of life (QoL) in this cohort of patients. MATERIAL AND METHODS Confirmatory, multicenter, single blinded, randomized, controlled clinical study. Patients with newly diagnosed/recurrent GB were randomly assigned to the control or interventional group. Patients in the interventional arm received proactive specialized palliative care (PC physician and PC social worker) on a monthly basis for 12 months. The control group received standard care. Data were collected by a blinded researcher every three months for 24 months. The primary outcome was QoL assessed by the sum of three subscales (trial outcome index, TOI) of the Functional Assessment of Cancer Therapy for brain tumor (FACT-Br) from baseline to six months of treatment. RESULTS 556 patients were screened for eligibility, 231 patients were included in the study. 109 patients were treated in the intervention and 108 patients in the control group. Groups did not differ significantly in terms of age, gender or first/recurrent diagnosis. 34 patients were still alive after 24 months (intervention group: n=15, control group: n=19). 131 patients died during the study (intervention group: n=71, control group: n=60); without a statistically significant difference between groups. Within the intervention period, the TOI relative to the baseline tended to be better in the intervention group than in the control group, especially after three months. However, the difference was not statistically significant. CONCLUSION This is the first multicenter, randomized, confirmatory clinical trial to investigate the impact of EIPC on GB patients with an observation period long enough to realistically reflect the course of the disease. Despite the very vulnerable patient group, the study was even feasible with a higher number of patients than originally planned. The selected primary outcome parameter (TOI) included physical and functional, but not emotional and social factors, which may play a more important role in assessing QoL of GB patients.

Commentary on : Hoek PD, Schers HJ, Bronkhorst EM, et al . The effect of weekly specialist palliative care teleconsultations in patients with advanced cancer—a randomized clinical trial. BMC Med...