Annals of palliative medicine最新文献

Background: End-of-life care for persons experiencing severe and persistent mental illness (SPMI) is a complex topic that deserves more attention. Despite growing awareness within international scientific research, topics such as palliative psychiatry, the provision of palliative care, and ethical dilemmas, including medical assistance in dying, remain under-researched. The aim of this study is therefore to qualitatively explore the views of different stakeholders on these issues to inform care providers about current challenges and opportunities in care.

Methods: A qualitative study in Flanders, Belgium, involving 73 participants-including care users, caregivers, managers, and experts-explored experiences, needs, challenges and dilemmas regarding end-of-life care for persons experiencing SPMI. Semi-structured interviews were conducted, transcribed, and thematically analyzed.

Results: Explored themes included advance care planning, suicide risk and prevention, euthanasia, the provision of palliative care, bereavement care, and the use of a palliative care approach. Challenges in standardizing advance care planning were noted. Euthanasia requests were rare but ethically complex. The provision of palliative care within familiar settings was favored but posed challenges related to expertise and staffing. Farewell rituals emphasized strong bonds between caregivers and care users. The study highlights the importance of advance care planning, the relative absence of discussions about suicide and euthanasia, and the challenges in providing palliative care. It underscores the need for education, ethical support, and collaboration with palliative care networks.

Conclusions: End-of-life care for persons experiencing SPMI demands a comprehensive approach that addresses ethical considerations, advance care planning, suicide risk, and the provision of palliative care. Policy recommendations include investing in education, establishing ethical support mechanisms, and fostering collaboration with palliative care networks to ensure dignified and compassionate care for this vulnerable population.

Background and objective: Oligometastatic colorectal cancer (CRC), characterised by limited metastatic disease, has traditionally been managed with surgery and chemotherapy. However, advances in stereotactic ablative radiotherapy (SABR), also known as stereotactic body radiotherapy (SBRT), have introduced the possibility of curative outcomes for selected patients with limited metastatic disease. SABR delivers high-dose, highly precise radiation with minimal toxicity, making it an attractive alternative or complement to surgery and systemic therapy. This narrative review evaluates the role of SABR in the management of oligometastatic CRC, and its application in both palliative and curative settings.

Methods: A systematic search of PubMed and Scopus databases (2014-2024) was conducted using search terms including "colorectal cancer", "oligometastatic", "SABR", "SBRT", "palliative", and "radical". Relevant meta-analyses, systematic reviews, and single- and double-arm studies were included.

Key content and findings: SABR demonstrates promising outcomes in both palliative and curative settings for oligometastatic CRC. Trials like SABR-COMET report significant improvements in overall survival (OS) and progression-free survival (PFS) with SABR, achieving a median OS of 50 months compared to 28 months with standard care. SABR is particularly effective for pulmonary metastases, achieving higher local control (LC) rates than hepatic lesions, likely due to differences in tissue radiosensitivity. Palliative SABR has been shown to delay systemic therapy and improve symptom management, with low toxicity rates, while radical SABR offers durable disease control and potential curative outcomes. Despite these benefits, evidence is limited by small cohort sizes, variable dosing regimens, and a lack of CRC-specific randomised trials.

Conclusions: SABR has emerged as a transformative treatment for oligometastatic CRC, providing significant benefits in both palliative and curative settings, although not yet outperforming traditional treatment modalities such as surgery. Future research, including ongoing phase III trials, aims to refine patient selection, optimise dosing protocols, and integrate SABR with systemic treatments to enhance outcomes. With further validation, SABR has the potential to redefine the therapeutic landscape for oligometastatic CRC, offering hope for improved survival and quality of life.

Background: Managing pleural effusion and symptomatic ascites in palliative care is crucial for alleviating symptoms and significantly enhancing the quality of life (QoL) for affected patients. Choosing the appropriate treatment modality requires careful consideration of potential risks and benefits, as well as the patient's life expectancy. Tunnelled catheters offer a distinct advantage by allowing insertion in an outpatient setting, thereby reducing or avoiding hospitalization, maximizing time spent at home given the limited life expectancy, and necessitating fewer subsequent pleural procedures for symptom relief. This study protocol outlines a prospective, multicentre study aimed at gaining insights into QoL based on patients' palliative care outcomes. Additionally, it will evaluate the clinical use, safety, and performance of tunnelled catheters and drainage kits in the home environment.

Methods: The multicentre prospective study will be conducted across five sites specialized in thoracic surgery and palliative care in Germany and will include a total of 150 patients. Participants will be patients with pleural effusion or ascites requiring a tunnelled catheter. Each patient will be followed postoperatively for at least 6 months. The primary focus will be on patient-reported palliative care outcomes using the validated Palliative Care Outcome Scale (POS) questionnaire. The POS, designed to assess palliative care needs, consists of 10 questions that evaluate physical, emotional, psychological, and spiritual needs. Additionally, the study will record and evaluate the implantation of the tunnelled catheter, the use of the drainage kit, and monitor short- and long-term complications.

Discussion: The findings from this study will expand our understanding of patients' palliative care outcomes when using tunnelled catheters. Moreover, the results will provide deeper insights into the safety and clinical use of tunnelled catheters.

Trial registration: The study was registered at the German Clinical Trial Register (DRKS): DRKS00031242, at 23 March, 2023.

Background: Tracheal stenosis and fistula are critical conditions with severe symptoms necessitating prompt intervention, making tracheal stent insertion a suitable treatment option. This study aimed to describe the efficacy of tracheal stenting using a less invasive flexible bronchoscope for malignant tumors.

Methods: Medical records at Chiba University Hospital from January 2008 to December 2021 were retrospectively examined. During this period, 76 stents were placed in 63 patients. Thirteen patients who underwent tracheal self-expanding metallic stent (SEMS) via flexible bronchoscopy to alleviate palliative symptoms due to malignancy were investigated for clinical outcomes.

Results: The cohort comprised 11 men and two women, and the mean age was 68.7 (range, 60-82) years. Pathologic diagnosis was esophageal cancer in 10 patients, lung cancer in two, and colon cancer in one. Indications for stent insertion were stenosis in six patients, fistulas to neighboring structures in five, and both in two. All patients exhibited airway symptoms, including cough, dyspnea, or pneumonia, and 7 (53.8%) had >50% stenosis on the computed tomography (CT) image. Ultraflex/AERO stents were used in 11/2 patients; the location of insertion was the trachea in 11 patients and both the trachea and bronchus in two. The mean time from stent indication to insertion was 3.6 (range, 0-11) days. Severe complications included membranous tracheal injury, hemoptysis, pneumonia, mediastinitis, and restenosis. Oxygen demand or symptoms improved within 1 week after the procedure in 10 (76.9%) patients. Overall, 10 (76.9%) patients were discharged or transferred to another hospital, while the other 3 (23.1%) died in the hospital without discharge or transfer. Additional chemotherapy was administered to 6 (46.2%) patients. The overall median survival time was 75 days, with a significantly better prognosis observed in 10 patients with symptomatic improvement (107 vs. 3 days, P=0.02) and six eligible for chemotherapy (204 vs. 22 days, P=0.01).

Conclusions: Minimally invasive tracheal stenting using flexible bronchoscopy for malignancy is effective in patients who have undergone tracheal SEMS placement. The prognosis was notably better in patients with symptomatic improvement, particularly when chemotherapy was administered after stenting.

Background: Patients with chronic kidney disease (CKD) have many special needs in the areas of symptom management, advanced care planning, and end-of-life care. We aimed to evaluate the palliative care (PC) provided to patients with CKD admitted with severe coronavirus disease 2019 (COVID-19) at the Clinics Hospital of the University of Sao Paulo Faculty of Medicine during the first wave of the pandemic.

Methods: A retrospective observational study was conducted in a quaternary hospital. Patients assisted by the PC team with CKD in 2020 were selected according to a protocol for identifying patient at an elevated risk of death who require PC support. The clinical and demographic characteristics, as well as the outcomes, were assessed using electronic records.

Results: A total of 217 patients with CKD were included in the study, of whom 44.2% were admitted to the intensive care unit (ICU). Patients with CKD had an increased relative risk (RR) of death [1.31, 95% confidence interval (CI): 1.12-1.53] but were not assisted by the PC team to a higher degree. Eighty patients with CKD (83.3%) died without being assisted by the PC team. Dialysis treatment and CKD grades were not significantly associated with PC assistance.

Conclusions: Although patients with CKD experienced higher mortality rates, they did not receive PC at a significantly greater frequency and many died without receiving adequate end-of-life care during the COVID-19 pandemic in Brazil.

Background: This study aims to clarify how patients with relapsed or refractory (R/R) hematological malignancies prepare for the future and set treatment goals. R/R hematological malignancies often require intensive therapies, including stem cell transplantation and CAR-T cell therapy, which pose high risks of adverse events. Many patients continue aggressive treatment until the end of life for pain relief or even a potential cure, despite the significant symptom burden. Understanding each patient's treatment motivations and preferences is essential to aligning care with their individual values. By examining their experiences, current health status, and treatment goals, this study seeks to provide a basis for holding early discussions on future care, contributing to individualized decision-making support for patients facing limited treatment options and uncertain prognoses.

Methods: A qualitative descriptive study design was used to conduct semi-structured interviews with 16 patients with relapsed/refractory hematopoietic malignancies who were hospitalized for chemotherapy.

Results: The four main themes expressed by the participants were (I) I want to live through the treatment until the end of my life because I know recovery is difficult; (II) my current treatment depends on how much my body can endure; (III) I want to keep trying, but I am at the limit of what I can do now; and (IV) I want to continue even if the treatment is limited because I think it will help someone else.

Conclusions: Patients with hematopoietic malignancies who are undergoing treatment may be motivated by a variety of different factors to continue with treatment. Discussing patients' goals and wishes with respect to treatment is critically important to ensure that such treatment is aligned with patients' preferences.

Background: Despite the plausible role for community health workers (CHWs) in supporting historically disenfranchised patients experiencing cancer-related pain, few survivorship care models currently include CHWs. The purpose of our study was to learn from existing CHWs regarding the feasibility of working with rural dwelling and/or Hispanic/Latino patients and their cancer care teams; as well as assessing their anticipated barriers and facilitators of delivering a proposed collaborative care pain intervention [Achieving Equity through SocioCulturally-informed, Digitally-Enabled Cancer Pain managemeNT (ASCENT)].

Methods: Guided by the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework, we recruited experienced CHWs to a mixed-methods feasibility study, including survey, interview and/or focus group. The survey assessed CHWs' comfort level with proposed intervention-related tasks (e.g., working with patients diagnosed with cancer). Interviews and focus groups explored potential training needs, as well as perceived intervention implementation barriers and facilitators. We summarized results using descriptive statistics and a rapid qualitative analytic approach.

Results: In total, 12 CHWs participated. Data included surveys (n=12), interviews (n=8), and a focus group with 4 participants. Overall, participant-CHWs felt confident they could participate in healthcare teams and remotely engage rural-dwelling and/or Hispanic/Latino patients diagnosed with cancer. Implementation barriers and facilitators included: working remotely in an unfamiliar geographic area, resource availability, technology, implementation-specific challenges, and patient level factors (e.g., loss of motivation).

Conclusions: Participant-CHWs viewed serving on a multidisciplinary healthcare team to support Hispanic/Latino and rural-dwelling cancer patients experiencing pain as feasible but identified training and resourcing needs.