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  MS14 - Interface Between Disease Modifying Treatment and Palliation (ID 31)

  • Event: WCLC 2013
  • Type: Mini Symposia
  • Track: Supportive Care
  • Presentations: 1
  • Moderators:L. Morgan, B. Ivimey
  • Coordinates: 10/29/2013, 14:00 - 15:30, Bayside 105, Level 1

  • 12197

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    MS14.4 - Transition to End of Life Care (ID 524)

    15:05 - 15:25  |  Author(s): C.S. Karapetis
    • Abstract
    • Presentation
    • Slides

    Abstract
    Metastatic lung cancer remains an incurable condition despite recent advances in medical therapy. New treatments can prolong survival and enhance quality of life for patients. Lung cancers can shrink and impressive responses may divert attention from the inevitable reality that the cancer will eventually acquire resistance to therapy. In the current era, patients are guided through multiple lines of therapy; first line, maintenance, second-line and so on. Such ‘lines of therapy’ extend the time on active therapeutic measures designed to alter the biological behavior of advanced lung cancer. Cancer centres that conduct clinical trials may offer potential active intervention beyond the proven ‘lines of therapy’, thereby extending time on active therapy. This may delay the transition to end-of-life care, but the likelihood of benefit with therapies beyond 2[nd] line is low. Whilst oncologists have a greater armamentarium in the fight against lung cancer, there comes a time for every patient when the medical advice will be to stop ‘active therapy’ as there is no prospect of benefit. The focus of care will be on symptom control with acceptance of palliative care. This is the time when patients accept that medical intervention will not prolong survival time, cannot alter the growth and spread of the cancer and will not influence the harmful effect of the cancer on the body. The body will fail, and in the process a functional decline will become obvious. This transition to ‘end-of-life’ care is not a clearly defined time point. Complex decision-making and emotional discussions are usually required. Several issues should be taken into account in determining when anti-cancer therapies should continue to be utilised or when such measures should be abandoned. These issues include: The likelihood of a beneficial response to a proposed therapy The safety and toxicity of the proposed intervention The patient’s ‘performance status’ – an overall measure of functional capacity Comorbidity and organ dysfunction Patient preference There are validated measures of prognosis that may assist in determining when this transition to palliative care should commence, including extent of cancer, weight loss, serum albumin, white cell count, neutrophil to lymphocyte ratio, lactate dehydrogenase and measures of critical organ function (cerebral, pulmonary, liver and renal). The synthesis of all of this information, a global assessment of the patient and knowledge of all the available treatment options is required to determine the timing of transition to ‘end-of-life’ care. The transition is usually handled through a multidisciplinary approach, with potential involvement of multiple health care professionals including the general practitioner, palliative care physician, medical oncologist, radiation oncologist and surgeon. Additional input from health care professionals in the fields of psychology, psychiatry, dietetics, social work and physiotherapy can enhance the quality of care in this transition period, depending on the degrees of distress and disability. Expert counseling is required. Involvement of the primary carers and family in discussions and decision-making is also important. Optimising care for patients during the late stages of cancer should focus on alleviating symptoms, allow planning for death, facilitate arrangements and enable personal commitments before death, dealing with grief and supporting the caregivers. These measures can improve quality of life, reduce anxiety and permit a more peaceful death. Ongoing active cancer therapies may introduce adverse events, require additional hospital visits and expose patients to invasive procedures. This can delay the introduction and implementation of optimal palliative care in the ‘end-of life’ period. The transition to end of life care should also be an opportunity to consider advanced directives. This issue needs to be discussed in a sensitive manner. Decisions around intensive medical intervention and confirmation of ‘not-for-resuscitation’ status will allow for patient wishes to be respected and permit patient autonomy at this difficult stage. An appreciation and acceptance of ‘end’-of-life’ care, when the prognosis is clearly very poor and death from an advancing lung cancer inevitable, will improve the prospect of allowing a comfortable death, a ‘good death’. This should be a goal that every cancer specialist seeks for patients with incurable cancer.

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