Abstract
Quill CM, Ratcliffe SJ, Harhay MO, Halpern SD: Variation in decisions to forgo life-sustaining therapies in US ICUs. Chest 2014;146:573–582.
The magnitude and implication of variation in end-of-life decision making among ICUs in the United States is unknown. In this study the authors reviewed data on decisions to forgo life-sustaining therapy (DFLSTs) in 269,002 patients admitted to 153 ICUs in the United States between 2001 and 2009. They used fixed-effects logistic regression to create a multivariable model for DFLST and then calculated adjusted rates of DFLST for each ICU. Results demonstrated that patient factors associated with increased odds of DFLST included advanced age, female sex, white race, and poor baseline functional status (all P<.001). However, associations with several of these factors varied among ICUs. The ICU staffing model was also found to be associated with DFLST, with an open ICU staffing model associated with increased odds of a DFLST. The predicted probability of DFLST varied approximately sixfold among ICUs after adjustment for the fixed patient and ICU effects and was directly correlated with the standardized mortality ratios of ICUs. The authors conclude that although patient factors explain much of the variability in DFLST practices, significant effects of ICU culture and practice influence end-of-life decision making. The observation that an ICU's risk-adjusted propensity to withdraw life support is directly associated with its standardized mortality ratio suggests problems with using the latter as a quality measure.
Laryionava K, Heubner P, Hiddemann W, Winkler EC: Framework for timing of the discussion about forgoing cancer-specific treatment based on a qualitative study with oncologists. Support Care Cancer 2014. (E-pub ahead of print.)
Many patients with advanced cancer receive aggressive chemotherapy close to death and are referred too late to palliative or hospice care. The aim of this study was to investigate oncologists' and oncology nurses' perceptions of the optimal timing for discussions about forgoing cancer-specific therapy at the end of life (EOL) and the reasons that might hinder them. Qualitative in-depth interviews with oncologists and oncology nurses were carried out. The empirical data were evaluated from a normative perspective. Twenty-nine physicians and nurses working at the department of hematology and oncology of a German university hospital were interviewed. Results demonstrated that health care professionals differed considerably in their understanding of when to initiate discussions about forgoing cancer-specific therapy at the EOL. However, their views could be consolidated into three approaches: (1) preparing patients gradually throughout the course of disease (anticipatory approach), which is best suited to empower patient self-determination in decision making; (2) waiting until the patient him or herself starts the discussion about forgoing cancer-specific treatment; and (3) waiting until all tumor-specific therapeutic options are exhausted. The authors conclude that the empirically informed ethical analysis clearly favors an approach that prepares patients for forgoing cancer-specific therapy throughout the course of disease. Since the last two approaches often preclude advance care planning, these approaches may be less ethically acceptable. The proposed framework could serve as a starting point for the development of concrete recommendations on the optimal timing for EOL discussions.
Swanson RS, Pezzi CM, Mallin K, et al.: The 90-day mortality after pancreatectomy for cancer is double the 30-day mortality: More than 20,000 resections from the National Cancer Data Base. Ann Surg Oncol 2014. (E-pub ahead of print.)
Operative mortality traditionally has been defined as the rate within 30 days or during the initial hospitalization, and studies that established the volume-outcome relationship for pancreatectomy used similar definitions. Pancreatectomies reported to the National Cancer Data Base (NCDB) during 2007–2010 were examined for 30- and 90-day mortality. Unadjusted mortality rates were compared by type of resection, stage, comorbidities, and average annual hospital volume. Hierarchical logistic regression models generated risk-adjusted odds ratios for 30- and 90-day mortality. Results demonstrated that after 21,482 pancreatectomies, the unadjusted 30-day mortality rate was 3.7% (95% confidence interval [CI] 3.4%–3.9%), which doubled at 90 days to 7.4% (95% CI 7.0–7.8). The unadjusted and risk-adjusted mortality rates were higher at 30 days with increasing age, increasing stage, male gender, lower income, low hospital volume, resections other than distal pancreatectomy, Medicare or Medicaid insurance coverage, residence in a Southern census division, history of prior cancer, and multiple comorbidities. The lowest-volume hospitals (<5 per year) performed 19% of the pancreatectomies, with risk-adjusted odds ratios for mortality that were 4.2 times higher (95% CI 3.1–5.8) at 30 days and remained 1.9 times higher (95% CI 1.5–2.3) at 30–90 days compared with hospitals that had high volumes (≥40 per year). The authors conclude that mortality rates within 90 days after pancreatic resection are double those at 30 days. The volume-outcome relationship persists in the NCDB. Reporting mortality rates 90 days after pancreatectomy is important. Hospitals should be aware of their annual volume and mortality rates 30 and 90 days after pancreatectomy and should benchmark the use of high-volume hospitals.
Lutz ST, Jones J, Chow E: Role of radiation therapy in palliative care of the patient with cancer. J Clin Oncol 2014. (E-pub ahead of print.)
Radiotherapy is a successful, time-efficient, well-tolerated, and cost-effective intervention that is crucial for the appropriate delivery of palliative oncology care. The distinction between curative and palliative goals is blurred in many patients with cancer, requiring that treatments be chosen on the basis of factors related to the patient (i.e., poor performance status, advanced age, significant weight loss, severe comorbid disease); the cancer (i.e., metastatic disease, aggressive histology); or the treatment (i.e., poor response to systemic therapy, previous radiotherapy). Goals may include symptom relief at the site of primary tumor or from metastatic lesions. Attention to a patient's discomfort and transportation limitations requires hypofractionated courses, when feasible. Innovative approaches include rapid response palliative care clinics as well as the formation of palliative radiotherapy specialty services in academic centers. Guidelines are providing better definitions of appropriate palliative radiotherapy interventions, and bone metastases fractionation has become the first radiotherapy quality measure accepted by the National Quality Forum. Further advances in the palliative radiation oncology subspecialty will require integration of education and training between the radiotherapy and palliative care specialties.
Lukas RV, Gabikian P, Garza M, Chmura SJ: Treatment of brain metastases. Oncology 2014;87:321–329.
Brain metastases are associated with substantial morbidity and mortality. Key prognostic classification systems for brain metastases are reviewed. The role of surgery, particularly for single brain metastases, is discussed. This is followed by an overview of radiation, both whole brain and focal, in the treatment of brain metastases. Finally, we review examples of important concepts regarding the role of systemic therapy in the treatment of brain metastases.
Andreyev J, Ross P, Donnellan C, et al.: Guidance on the management of diarrhoea during cancer chemotherapy. Lancet Oncol 2014;15:e447–e460.
Diarrhea induced by chemotherapy in cancer patients is common, can cause significant morbidity and mortality, and is managed inconsistently. Previous management guidelines were based on poor evidence and neglect physiological causes of chemotherapy-induced diarrhea. In the absence of level 1 evidence from randomized controlled trials, we developed practical guidance for clinicians based on a literature review by a multidisciplinary team of clinical oncologists, dietitians, gastroenterologists, medical oncologists, nurses, a pharmacist, and a surgeon. Education of patients and their carers about the risks associated with and management of chemotherapy-induced diarrhea is the foundation for optimum treatment of toxic effects. Adequate—and, if necessary, repeated—assessment; appropriate use of loperamide; and knowledge of fluid resuscitation requirements of affected patients is the second crucial step. Use of octreotide and seeking specialist advice early for patients who do not respond to treatment will reduce morbidity and mortality. In view of the burden of chemotherapy-induced diarrhea, appropriate multidisciplinary research to assess meaningful endpoints is urgently required.
Brown AJ, Sun CC, Prescott LS, et al.: Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients. 2014. (E-pub ahead of print.)
The purpose of this study was to assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final 30 days of life. Ovarian, fallopian tube, or primary peritoneal cancer patients registered at the authors' institution during 2007–2011 were identified. Inclusion criteria were met by 183 patients. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer. Fifty percent had experienced at least one form of aggressive care during the last 30 days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (p≤0.001), with a median hospice stay of 18 days before death. Seventy-five percent had an in-hospital DNR order and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12 days prior to death, respectively. Twenty-eight percent had a medical power of attorney and 20% had a living will. These documents were created a median of 381 and 378 days prior to death, respectively. The authors conclude that many ovarian cancer patients underwent some form of aggressive medical care in the last 30 days of life. The time between hospice enrollment and death was short. Patients created medical power of attorney and living will documents far in advance of death, while DNR orders were initiated close to death.