Palliative care and end-of-life measure outcomes: Experience of a tertiary care institute from South India

Praveen Adusumilli; Lingaraj Nayak; Vidya Viswanath; Leela Digumarti; Raghunadha Rao Digumarti

doi:10.4103/sajc.sajc_257_17

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ORIGINAL ARTICLE: Palliative Care

07 (

); 210-213

doi:

10.4103/sajc.sajc_257_17

Palliative care and end-of-life measure outcomes: Experience of a tertiary care institute from South India

Praveen Adusumilli^1,, Lingaraj Nayak¹, Vidya Viswanath², Leela Digumarti³, Raghunadha Rao Digumarti¹

1 Department of Medical Oncology, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Andhra Pradesh

2 Department of Palliative Medicine, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Andhra Pradesh

3 Department of Gynaec Oncology, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Andhra Pradesh

*Corresponding author: Dr. Praveen Adusumilli. praveen.adusumilli@yahoo.com

Published: 2020-12-22

MedIntel Services Pvt Ltd. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/.)

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Abstract

Introduction: Desisting from disease directed treatment in the past weeks of life is a quality criterion in oncology service. Patients with advanced cancer have unrealistic expectations from chemotherapy and hold on to it as a great source of hope. Many oncologists continue futile and unnecessary treatments, instead of conveying to the patients the lack of benefit, resulting in delayed referral for palliative care (PC). Materials and Methods: This is a retrospective analysis of case records from June 2014 to December 2015. The primary objective was to study, how far back in time terminally ill cancer patients received definitive cancer directed therapy (DCDT). Apart from patient demographics, the diagnosis, stage, and details of DCDT, and death were captured. PC referral data were recorded. DCDT to death was taken as treatment-free interval (TFI). Analysis was performed using IBM SPSS Statistics for Windows, Version 20. Results: A total of 292 case records were evaluated. Seventy-three had inadequate treatment details. Hence, 219 records were analyzed. PC referral was done in 78.5% of patients. Only best supportive care (BSC) without any DCDT was given in 27 patients. The most common reason for BSC was a poor performance status in 92.5%. The median time from PC referral till death was 43.5 days (range: 1–518 days). Chemotherapy was the most common DCDT in 52.9% of patients. The median time from DCDT and death was 49 days (range: 0–359 days). Cervical and ovarian cancers patients had the longest TFI ; shortest in unknown primary. Most patients died at home (70.4%). Patients receiving PC preferred home or hospice as place of death. Of the 80 patients given hospice care, 39 (36.5%) died in the hospice. Conclusion: While DCDT needs to be started at the right time, it should also be discontinued when futile. Early involvement of the PC team, even while patients are on DCDT makes the transition smoother and more meaningful.

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References

Dahlin C, National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. Pittsburgh, PA: National Consensus Project; 2013.
World Health Organization. Palliative Care; 2015. Available from: http://www.who.int/mediacentre/factsheets/fs402/en/. [Last accessed on 2016 Jul 03].
Rajagopal MR, Venkateswaran C. Palliative care in India: Successes and limitations. J Pain Palliat Care Pharmacother 2003;17:121-8.
Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, Fan L, Li J, Chavarri-Guerra Y, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol 2014;15:489-538.
Central Bureau of Health Intelligence. Projected Cases of Cancer at India Level for Selected Times and Selected Time Periods. Available from: http://www.cbhidghs.nic.in/writereaddata/mainlinkFile/NHP-2015.pdf. [Last accessed on 2017 Aug 07].
Tharappel E, Rajaram P. Barriers and challenges encountered by end-of-life care professionals: An Indian perspective. J Palliat Care 2014;30:200.
Joranson DE, Rajagopal MR, Gilson AM. Improving access to opioid analgesics for palliative care in India. J Pain Symptom Manage 2002;24:152-9.
Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, et al. American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 2012;30:880-7.
Hui D, Bruera E. Integrating palliative care into the trajectory of cancer care. Nat Rev Clin Oncol 2016;13:159-71.
Bouleuc C, Chvetzoff G. End of chemotherapy decision for metastatic breast cancer patients. Bull Cancer 2009;96 Suppl 2:81-9.
Earle CC, Neville BA, Landrum MB, Souza JM, Weeks JC, Block SD, et al. Evaluating claims-based indicators of the intensity of end-of-life cancer care. Int J Qual Health Care 2005;17:505-9.
Braga S, Miranda A, Fonseca R, Passos-Coelho JL, Fernandes A, Costa JD, et al. The aggressiveness of cancer care in the last three months of life: A retrospective single centre analysis. Psychooncology 2007;16:863-8.
Näppä U, Lindqvist O, Rasmussen BH, Axelsson B. Palliative chemotherapy during the last month of life. Ann Oncol 2011;22:2375-80.
Sanz Ortiz J. Chemotherapy at the end of life: Up until when? Clin Transl Oncol 2012;14:667-74.
Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL, et al. Patients' expectations about effects of chemotherapy for advanced cancer. N Engl J Med 2012;367:1616-25.
Chen AB, Cronin A, Weeks JC, Chrischilles EA, Malin J, Hayman JA, et al. Expectations about the effectiveness of radiation therapy among patients with incurable lung cancer. J Clin Oncol 2013;31:2730-5.
Grunfeld EA, Maher EJ, Browne S, Ward P, Young T, Vivat B, et al. Advanced breast cancer patients' perceptions of decision making for palliative chemotherapy. J Clin Oncol 2006;24:1090-8.
Martoni AA, Tanneberger S, Mutri V. Cancer chemotherapy near the end of life: The time has come to set guidelines for its appropriate use. Tumori 2007;93:417-22.
Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: Results of a randomized study of early palliative care. J Clin Oncol 2011;29:2319-26.
Rugno FC, Paiva BS, Paiva CE. Early integration of palliative care facilitates the discontinuation of anticancer treatment in women with advanced breast or gynecologic cancers. Gynecol Oncol 2014;135:249-54.
Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42.
Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC, et al. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 2004;22:315-21.
Yun YH, Kwak M, Park SM, Kim S, Choi JS, Lim HY, et al. Chemotherapy use and associated factors among cancer patients near the end of life. Oncology 2007;72:164-71.
Cheng WW, Willey J, Palmer JL, Zhang T, Bruera E. Interval between palliative care referral and death among patients treated at a comprehensive cancer center. J Palliat Med 2005;8:1025-32.
Kamal AH, Swetz KM, Carey EC, Cheville AL, Liu H, Ruegg SR, et al. Palliative care consultations in patients with cancer: A mayo clinic 5-year review. J Oncol Pract 2011;7:48-53.
Lowery WJ, Lowery AW, Barnett JC, Lopez-Acevedo M, Lee PS, Secord AA, et al. Cost-effectiveness of early palliative care intervention in recurrent platinum-resistant ovarian cancer. Gynecol Oncol 2013;130:426-30.
Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: Results of a randomized study of early palliative care. J Clin Oncol 2011;29:2319-26.
Ghoshal A, Damani A, Salins N, Deodhar J, Muckaden MA. Economics of palliative and end-of-life care in India: A Concept paper. Indian J Palliat Care 2017;23:456-61.
McCaffrey N, Cassel JB, Coast J. An economic view on the current state of the economics of palliative and end-of-life care. Palliat Med 2017;31:291-2.
Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The project ENABLE II randomized controlled trial. JAMA 2009;302:741-9.
Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: Patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol 2015;33:1438-45.
Salins N, Patra L, Usha Rani MR, Lohitashva SO, Rao R, Ramanjulu R, et al. Integration of early specialist palliative care in cancer care: Survey of oncologists, oncology nurses, and patients. Indian J Palliat Care 2016;22:258-65.
Luta X, Maessen M, Egger M, Stuck AE, Goodman D, Clough-Gorr KM, et al. Measuring intensity of end of life care: A systematic review. PLoS One 2015;10:e0123764.
Rochigneux P, Raoul JL, Beaussant Y, Aubry R, Goldwasser F, Tournigand C, et al. Use of chemotherapy near the end of life: What factors matter? Ann Oncol 2017;28:809-17.
Pollockquestions K. Is home always the best and preferred place of death? bmj. 2015;19.
Mack JW, Chen K, Boscoe FP, Gesten FC, Roohan PJ, Schymura MJ, et al. High intensity of end-of-life care among adolescent and young adult cancer patients in the New York state medicaid program. Med Care 2015;53:1018-26.
Paris J, Morrison RS. Evaluating the effects of inpatient palliative care consultations on subsequent hospice use and place of death in patients with advanced GI cancers. J Oncol Pract 2014;10:174-7.

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[1] Dahlin C, National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. Pittsburgh, PA: National Consensus Project; 2013.

[2] World Health Organization. Palliative Care; 2015. Available from: http://www.who.int/mediacentre/factsheets/fs402/en/. [Last accessed on 2016 Jul 03].

[3] Rajagopal MR, Venkateswaran C. Palliative care in India: Successes and limitations. J Pain Palliat Care Pharmacother 2003;17:121-8.

[4] Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, Fan L, Li J, Chavarri-Guerra Y, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol 2014;15:489-538.

[5] Central Bureau of Health Intelligence. Projected Cases of Cancer at India Level for Selected Times and Selected Time Periods. Available from: http://www.cbhidghs.nic.in/writereaddata/mainlinkFile/NHP-2015.pdf. [Last accessed on 2017 Aug 07].

[6] Tharappel E, Rajaram P. Barriers and challenges encountered by end-of-life care professionals: An Indian perspective. J Palliat Care 2014;30:200.

[7] Joranson DE, Rajagopal MR, Gilson AM. Improving access to opioid analgesics for palliative care in India. J Pain Symptom Manage 2002;24:152-9.

[8] Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, et al. American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 2012;30:880-7.

[9] Hui D, Bruera E. Integrating palliative care into the trajectory of cancer care. Nat Rev Clin Oncol 2016;13:159-71.

[10] Bouleuc C, Chvetzoff G. End of chemotherapy decision for metastatic breast cancer patients. Bull Cancer 2009;96 Suppl 2:81-9.

[11] Earle CC, Neville BA, Landrum MB, Souza JM, Weeks JC, Block SD, et al. Evaluating claims-based indicators of the intensity of end-of-life cancer care. Int J Qual Health Care 2005;17:505-9.

[12] Braga S, Miranda A, Fonseca R, Passos-Coelho JL, Fernandes A, Costa JD, et al. The aggressiveness of cancer care in the last three months of life: A retrospective single centre analysis. Psychooncology 2007;16:863-8.

[13] Näppä U, Lindqvist O, Rasmussen BH, Axelsson B. Palliative chemotherapy during the last month of life. Ann Oncol 2011;22:2375-80.

[14] Sanz Ortiz J. Chemotherapy at the end of life: Up until when? Clin Transl Oncol 2012;14:667-74.

[15] Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL, et al. Patients' expectations about effects of chemotherapy for advanced cancer. N Engl J Med 2012;367:1616-25.

[16] Chen AB, Cronin A, Weeks JC, Chrischilles EA, Malin J, Hayman JA, et al. Expectations about the effectiveness of radiation therapy among patients with incurable lung cancer. J Clin Oncol 2013;31:2730-5.

[17] Grunfeld EA, Maher EJ, Browne S, Ward P, Young T, Vivat B, et al. Advanced breast cancer patients' perceptions of decision making for palliative chemotherapy. J Clin Oncol 2006;24:1090-8.

[18] Martoni AA, Tanneberger S, Mutri V. Cancer chemotherapy near the end of life: The time has come to set guidelines for its appropriate use. Tumori 2007;93:417-22.

[19] Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: Results of a randomized study of early palliative care. J Clin Oncol 2011;29:2319-26.

[20] Rugno FC, Paiva BS, Paiva CE. Early integration of palliative care facilitates the discontinuation of anticancer treatment in women with advanced breast or gynecologic cancers. Gynecol Oncol 2014;135:249-54.

[21] Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42.

[22] Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC, et al. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 2004;22:315-21.

[23] Yun YH, Kwak M, Park SM, Kim S, Choi JS, Lim HY, et al. Chemotherapy use and associated factors among cancer patients near the end of life. Oncology 2007;72:164-71.

[24] Cheng WW, Willey J, Palmer JL, Zhang T, Bruera E. Interval between palliative care referral and death among patients treated at a comprehensive cancer center. J Palliat Med 2005;8:1025-32.

[25] Kamal AH, Swetz KM, Carey EC, Cheville AL, Liu H, Ruegg SR, et al. Palliative care consultations in patients with cancer: A mayo clinic 5-year review. J Oncol Pract 2011;7:48-53.

[26] Lowery WJ, Lowery AW, Barnett JC, Lopez-Acevedo M, Lee PS, Secord AA, et al. Cost-effectiveness of early palliative care intervention in recurrent platinum-resistant ovarian cancer. Gynecol Oncol 2013;130:426-30.

[27] Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: Results of a randomized study of early palliative care. J Clin Oncol 2011;29:2319-26.

[28] Ghoshal A, Damani A, Salins N, Deodhar J, Muckaden MA. Economics of palliative and end-of-life care in India: A Concept paper. Indian J Palliat Care 2017;23:456-61.

[29] McCaffrey N, Cassel JB, Coast J. An economic view on the current state of the economics of palliative and end-of-life care. Palliat Med 2017;31:291-2.

[30] Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The project ENABLE II randomized controlled trial. JAMA 2009;302:741-9.

[31] Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: Patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol 2015;33:1438-45.

[32] Salins N, Patra L, Usha Rani MR, Lohitashva SO, Rao R, Ramanjulu R, et al. Integration of early specialist palliative care in cancer care: Survey of oncologists, oncology nurses, and patients. Indian J Palliat Care 2016;22:258-65.

[33] Luta X, Maessen M, Egger M, Stuck AE, Goodman D, Clough-Gorr KM, et al. Measuring intensity of end of life care: A systematic review. PLoS One 2015;10:e0123764.

[34] Rochigneux P, Raoul JL, Beaussant Y, Aubry R, Goldwasser F, Tournigand C, et al. Use of chemotherapy near the end of life: What factors matter? Ann Oncol 2017;28:809-17.

[35] Pollockquestions K. Is home always the best and preferred place of death? bmj. 2015;19.

[36] Mack JW, Chen K, Boscoe FP, Gesten FC, Roohan PJ, Schymura MJ, et al. High intensity of end-of-life care among adolescent and young adult cancer patients in the New York state medicaid program. Med Care 2015;53:1018-26.

[37] Paris J, Morrison RS. Evaluating the effects of inpatient palliative care consultations on subsequent hospice use and place of death in patients with advanced GI cancers. J Oncol Pract 2014;10:174-7.

Palliative care and end-of-life measure outcomes: Experience of a tertiary care institute from South India

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