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J. Klastersky
Moderator of
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ED02 - Palliative Care in Lung Cancer: A Global Challenge (ID 264)
- Event: WCLC 2016
- Type: Education Session
- Track: Palliative Care/Ethics
- Presentations: 5
- Moderators:J. Crawford, J. Klastersky
- Coordinates: 12/05/2016, 11:00 - 12:30, Strauss 3
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ED02.01 - Palliative Care and its Importance for Patients with Lung Cancer (ID 6426)
11:00 - 11:20 | Author(s): H. Watzke
- Abstract
- Presentation
Abstract not provided
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ED02.02 - Palliative Care in South America (ID 6428)
11:20 - 11:40 | Author(s): L.A. Mas Lopez
- Abstract
- Presentation
Abstract not provided
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ED02.03 - Palliative Care in India (ID 6429)
11:40 - 12:00 | Author(s): G.S. Bhattacharyya, K. Govindbabu, H. Malhotra, P.M. Parikh
- Abstract
- Presentation
Abstract:
A cancer diagnosis is one of the most feared events rarely diagnosed before the late 20th century now competes with the Cardio-vascular disease, stroke, respiratory failure. The last half century has produced substantial advances in the treatment and early detection of few types of cancer and atleast modest gain in many other. Yet the reality is that half of the patients diagnosed with cancer will die within the first couple of years. With people living longer, the continued use of tobacco products, infectious disease that transmit cancer causing virus, and epidemic of obesity and arm-chair lifestyle, the cancer burden is projected to increase substantially over the decade. The delivery of high quality cancer care across the care continuum from diagnosis and treatment to maintaining the health of survivors and providing end-of-life care consistent with patients’ needs, values, and preferences. The provision of patient-centered care planning, palliative care, and psychosocial care; the prevention and management of long-term and late effects of cancer treatment; and family caregiver support should span the cancer care continuum from diagnosis through end-of-life care. The full cancer care continuum also includes the domains of prevention and risk reduction and screening. Cancer care for older adults, as noted throughout this report, is especially complex. Age is one of the strongest risk factors for cancer. The majority of cancer diagnoses and cancer deaths occur in individuals 65 years and older, and the majority of cancer survivors are in this age range. There are many important considerations to understanding the prognoses of older adults with cancer and formulating their care plans, such as altered physiology, functional and cognitive impairment, multiple coexisting morbidities, increased side effects of treatment, distinct goals of care, and the increased need for of social support. Their ability to participate in clinical trials has been limited, and thus the evidence base for informing treatment decisions in this population is lacking. The current health care delivery system is poorly prepared to address these concerns comprehensively. Thus, meeting the needs of the aging population will be an integral part of improving the quality of cancer care. Lung cancer is one of the commonest cancer causing death and it presents late. It is an extremely symptomatic disease and majority of the patients succumb to this disease. It is innately human to comfort and provide care to those suffering from cancer particularly who are close to death. Yet what seems evident as an individual’s personal level has by and large no guided policy all over the world. There is no argument that palliative care should be integrated into cancer care from diagnosis to death. Palliative care provides a specialized holistic approach to providing medical care with serious illness and the focus of Palliative Care is on providing relief from symptom and improving the quality of life of patients. Palliative Care is not End-of-Life or hospice but encompasses both. There is a dichotomy in the principle of medical care in cancer which single mindedly focuses on attempts to cure every patient at every stage. Recognition of the importance of symptom control and other aspects of Palliative care from diagnosis through dying process has been growing. Patients should not have to choose between treatment with curative intent or comfort care. There is need for both in varying degrees throughout the course of cancer whether the eventual outcome is survival or death. The goal is to maintain the best possible quality of life allowing the patients to choose whatever treatment they so wish while also meeting the needs of advanced disease through adequate symptom control. This goal is most often not met. For atleast half of those patients dying from cancer - most of whom are elderly and many vulnerable - death entails a spectrum of symptoms including pain, labored breathing, distress, nausea, confusion, and other physical and psychological conditions that go untreated and vastly diminishes the quality of remaining days. The patient is not the only one who suffers; family, care givers undergo unreleaved emotion and financial burden. This cannot be ignored within the context of the patients' who are terminally ill. A major problem in Palliative care is the under recognization, under diagnosis and thus undertreatment of the patients with significant stress ranging from existentional anguish, axiety and depression. Living with and eventually dying from a chronic illness runs substantial cost for patients, family, society and cost of those dying from cancer are 20% higher than average costs. Inadequacy of Palliative and End-of-Life care springs not from a single cause of a sector of society the separation of palliative and hospice care from potentially life prolonging treatment within the health care system, which is both influenced by and affects reimbursement policy; inadequate training of health care personnel in symptom management and other palliative care skills; inadequate standards of care and lack of accountability in caring for dying patients; disparities in care, even when available, for ethnic and socioeconomic segments of the population; lack of information resources for the public dealing with palliative and end-of-life care; lack of reliable data on the quality of life and the quality of care of patients dying from cancer (as well as other chronic diseases); and low level of public sector investment in palliative and end-of-life care research and training. This is not to suggest that there is no relevant ongoing research or relevant question or training program - there are - but the efforts are not coordinated and there is no focus for these activities in the Government agencies. What has resulted is under funding, lack of training and lack of research, leadership, with no sustained program for developing and disseminating Palliative treatment. Care for those approaching death is an integral and important part of health care. Everyone dies, and those at this stage of life deserve attention that is as thorough, active, and conscientious as that granted to those for whom cure or longer life is a realistic goal. Care for those approaching death should involve and respect both patients and those close to them. Particularly for patients with a grim prognosis, clinicians need to consider patients in the context of their families and close relationships and to be sensitive to their culture, values, resources, and other characteristics. Good care at the end of life depends on strong interpersonal skills, clinical knowledge, and technical proficiency , and it is informed by scientific evidence, values, and personal and professional experience. Clinical excellence is important because the frail condition of dying patients leaves little margin to rectify errors. Changing individual behavior is difficult, but changing an organization or a culture is potentially a greater challenge—and often is a precondition for individual change. Deficiencies in care often reflect flaws in how the health care system functions, which means that correcting problems will require change at the system level. The health care community has special responsibility for educating itself and others about the identification, management, and discussion of the last phase of fatal medical problems. Although health care professionals may not have a central presence in the lives of some people who are dying, many others draw heavily on physicians, nurses, social workers, and others for care—and caring. Thus, health care professionals are inescapably responsible for educating themselves and helping to educate the broader community about good care for dying patients and their families. More and better research is needed to increase our understanding of the clinical, cultural, organizational, and other practices or perspectives that can improve care for those approaching death. The knowledge base for good end-of-life care has enormous gaps and is neglected in the design and funding of biomedical, clinical, psychosocial, and health services research. Time is now to integrate Palliative care with mainstream care in cancer.
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ED02.04 - Palliative Care in South-East Asia (ID 6430)
12:00 - 12:20 | Author(s): R.B.L. Lim
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Southeast Asia comprises of 10 main countries including Malaysia, Indonesia, Thailand, Philippines, Singapore, Brunei, Cambodia, Laos, Myanmar and Vietnam. The concept of palliative care first developed around the mid-1980s in Singapore and the Philippines and later in the 1990s in Malaysia, Thailand and Indonesia. In other countries such as Brunei, Cambodia, Myanmar, Vietnam and Laos palliative care has only been developing more rapidly over the past 10 years. Levels of development of palliative care in Southeast Asia are highly variable depending very much upon factors such as availability of medical resources, funding, geography, demographics and the priorities of the country’s leadership. In 2011, the Worldwide Palliative Care Alliance(WPCA) mapped out the global development of palliative care dividing countries into 4 categories. Category 1 where there is no known development of palliative care, category 2 where development is at the level of capacity building, category 3 where there is isolated provision of palliative care services and category 4 where services are approximating integration into mainstream medicine. Among these countries, only Singapore and Malaysia have achieved category 4 status while majority are in category 3 (Indonesia, Thailand, Philippines, Myanmar, Cambodia, Brunei and Vietnam). Regardless of the level of development, challenges faced in developing palliative care in Southeast Asia are common throughout and include first and foremost barriers of drug availability and fear of using opioids amongst public as well medical practitioners. Apart from this is the challenge of public perceptions towards death and dying which have made development of this discipline difficult. Even till today there are many misconceptions regarding the role and concept of palliative care amongst healthcare professionals. For countries that are more advanced in their development, the key challenge now is how to continue development in a sustainable manner and how to improve and maintain standards of care. In Malaysia, palliative care began in the early 1990s with the development of voluntary organisations providing homecare services for patients with terminal cancer. In 1995 the concept was introduced into government hospitals and soon received nationwide support by the Ministry of Health in Malaysia. In 2005, the subspecialty of palliative medicine was established and a formalised training programme for medical specialists was developed. At present there are a total of 18 trained palliative medicine specialists in Malaysia with 2 more in training. In 2014, an advanced diploma programme for nurses, physiotherapists and occupational therapists was developed in the Ministry of Health which has now trained 38 nurses and paramedics who have now become permanent stakeholders in palliative care service provision and development. Apart from this, non-governmental organisations also serve as a backbone to community palliative care services in Malaysia and there are currently 25 services throughout the country providing homecare. It is with such initiatives that Malaysia hopes to create a sustainable and credible workforce to continue the development and growth of palliative care throughout the nation and possibly the region.
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ED02.05 - Palliative Care in Iran (ID 6431)
12:20 - 12:40 | Author(s): R. Malayeri
- Abstract
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It is well known that palliative care is a necessity in cancer patients, as early on as the time of diagnosis. In adult oncology, there is evidence to suggest early specialist palliative care improves HRQOL, mood, treatment decision-making, health-care utilization, advanced care planning, patient satisfaction, and end-of-life care (1). Early admission to community-based palliative care also reduces the use of Emergency departments by cancer patients in the 90 days before death (2). Palliative care for cancer patients is rather new in Iran and has a history of less than 7 years. Here we give an overview on the status of palliative care in Iran. We also present the demographics of our patients in the first and largest palliative care ward in Iran over the last two years. Iran has a population of around 80 million people. In Iran, cancer is known as the third cause of death. Adult morbidity rate of cancer in different regions of Iran is estimated 48-112 cases per million people among the females and 51-144 cases per million people among the males (3). Also, mortality rate related to cancer was about 53500 people in 2014 (4). The majority of cancer patients expire in the intensive care units (ICU), whereas bed occupancy of ICUs is in crises, being about 100% in Iran. For each ICU bed, 4 people are applicants (5). We currently have around 8 active palliative care units for cancer patients and one palliative care ward in Iran, all run by charities. In these palliative care units, we have oncologists, palliative care specialists, pain specialists, psychologists, spiritual care specialists, social workers and dieticians. A total number of 3677 patients, ages between 16 and 94 (Median 61), of whom 3277 (89%) with a similar age distribution had a cancer diagnosis were referred to our palliative care unit in Firoozgar Hospital, which is run by the Ala Charity, in Tehran in the last three years. 1770 female (54%) and 1457 male (46%) advanced cancer patients were referred. A number of 388 (12%) patients had breast cancer, 339 (10%) had hematologic malignancies, 312 (10%) had esophageal or gastric cancer, 311 (10%) had colorectal cancer, 105 (3%) had a cancer of the CNS, 101 (3%) had lymphoma, 93 (3%) had renal cancer, 87 patients (3%) had ovarian cancer, 81 (2%) had lung cancer, 54 patients (2%) had prostate cancer and 50 (2%) had pancreatic cancer. The other 40% of the cancer patients had either less frequent cancers or their exact cancer site was not recorded. In most countries, the gap between death and specific therapies is considered as an indicator of the quality of physician services and more length of time will be a better indicator for physician services, while cancer patients in health system of Iran receive specific treatment and chemotherapy even to moment of death. To consider countless benefits of home care and the patients’ desire to receive services at home, if we can provide the conditions that at least 20% of end stage cancer patients receive home based palliative care, 1000 deaths will occur at home yearly, and 1000 ICU beds will be released for use for other patients with better prognosis for survival (5). For this reason, the Ala charity has also started free of charge home care services in Isfahan and Tehran. Iran, like many other countries, needs many more palliative care units as well as an expansion of home based palliative care services to advanced and very advanced cancer patients. As palliative medicine is not financially lucrative, charities play a major role in setting up, maintaining and expanding these units. References: Salins N, Ramanjulu R, Patra L, Deodhar J, Muckaden MA. Integration of Early Specialist Palliative Care in Cancer Care and Patient Related Outcomes: A Critical Review of Evidence. Indian J Palliat Care. (2016) 22:252-7 McNamara BA, Rosenwax LK, Murray K, Currow DC. Early admission to community-based palliative care reduces use of emergency departments in the ninety days before death. J Palliat Med. (2013) ;16:774-9 Mousavi SM, Gouya MM, Ramazani R, et al. Cancer incidence and mortality in Iran. Annals of Oncology. (2009) ;20:556–63. World Health Organization. Cancer country profiles in Iran 2014. Geneva: WHO; 2014. [cited 29 August 2015]. Avilable from: http://www.who.int/cancer/country-profiles/en/ Heydari H. Home-based Palliative Care: A Strategy for Keeping Intensive Care Unit Beds Vacant. Int J Community Based Nurs Midwifery. (2016);4:186-7.
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ED06 - Symptom Management in Lung Cancer (ID 269)
- Event: WCLC 2016
- Type: Education Session
- Track: Palliative Care/Ethics
- Presentations: 1
- Moderators:R. Gralla, R. Malayeri
- Coordinates: 12/05/2016, 16:00 - 17:30, Stolz 1
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ED06.06 - Decisions in Case of Intractable Symptoms (ID 6452)
17:15 - 17:30 | Author(s): J. Klastersky
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Case report A 55-year-old lady was diagnosed with small cell lung cancer in late 2008. She had been a long-time cigarette smoker without, any other significant medical history. She was a housewife, deeply religious and dedicated mother to 2 children. As a first treatment for her cancer, she received radiotherapy on the right apex and mediastinum, concomitantly with chemotherapy (cisplatin plus etoposide), early in 2009. Six months later, she presented a very painful right shoulder and chest wall. Chemotherapy was resumed, with some improvement of the pain, but late in 2009, radiotherapy had to be administered to the chest for uncontrolled pain; oral etoposide was given without much benefit. The pain progressively increased and the patient was complaining of increasing shortness of breath. As the tumour was clearly progressing, in 2010, with further lung, bone and liver involvement, a decision was made to discontinue any specific oncological treatment. Both symptoms pain and dyspnea increased in intensity and became uncontrollable late in 2010; the patient and her family requested sedation at any cost. The patient was started on palliative sedation and died peacefully after 2 days; with her family present. Supportive and palliative treatments for pain Table 1 summarizes the time evolution of the patient and the corresponding interventions as far as analgesics and co-analgesics are concerned. Management of dyspnea over the course of her disease, the patient experienced progressive dyspnea which could be managed with oxygen, corticoids, benzodiazepines and bronchodilatating aerosols, as well as physical therapy and hypnosis. Dyspnea became major and beyond control the day prior to the last hospitalization and was a reason for accelerated sedation. Figure 1 Management of depression The patient had multiple reasons for being severely depressed: her mother was experiencing lung cancer at the same time ; the patient was concerned about becoming increasingly a burden for her family; she was aware of her worsening condition and realizing that her life would end soon; she was extremely anxious to have to die in intractable pain. The management of the patient’s depression included the following: monthly consultation with an onco-psychiatrist and weekly visits to a psychologist-social worker ; psychotropic drugs ; several sessions of hypnosis. Palliative sedation That the control of the patient’s pain and/or dyspnea might require palliative sedation has been discussed since 2010 (time of worsening of her symptoms) between the patient, her family and the caregivers. The patient and her family spoke openly about end-of-life issues, always emphasizing not to let the patient die in severe pain. After making the decision to resort to sedation in case of intractable symptoms, the patient and her family expressed a sense of relief that her suffering could and would be alleviated. When the patient expressed unbearable pain and dyspnea, the mobile nursing team started her on midazolam, scopolamine and methadone by sub-cutaneous route, with no clear-cut response; the patient was brought to the hospital, where the same medications were given intravenously, with the addition of haloperidol. No attempt to lift the sedation process (respite sedation) was made, according to the patient’s will. The patient was able to rest comfortably and died peacefully after 2 days, with her family at her side. Discussion In case of dyspnea due to lung cancer progression, corticosteroids, morphine and oxygen are used since many years ; novel options were introduced timidly during the last years. These new options include non-invasive ventilation, high-flow oxygen and rational use of medications usually prohibited in patients with respiratory distress, such as benzodiazepines, antidepressants and synthetic opioids [1]. The World Health Organization (WHO) scale for cancer-related pain proves to be an effective approach to pain management in cancer patients [2], and many variations based on it have been proposed [3]. However, these approaches represent pragmatic and empiric attitudes that are rarely evaluated in prospective studies. There is also a lack of consensus about the use of co-analgesia and other supportive approaches for refractory pain [5]; although pragmatic recommendations exist, a comprehensive algorithm for the management of refractory pain is still lacking. Based on the experience in our supportive care unit, we proposed a comprehensive model for the progressive management of pain in cancer patients (Figure 1). Finally, the approach to pain (or other symptoms) that is beyond medical control, fortunately a relatively rare situation, has not been clearly defined [6;7]. Palliative sedation or euthanasia is always an emotionally and ethically challenging event for all involved and implies to meet the needs of the patient and family but also those of the caregivers [8; 9; 10] and requires repeated and professional counselling with the patient and family as well as regular debriefing sessions with the medical and nursing teams. Although the decision to offer and provide palliative sedation or euthanasia (if requested by the patient and not illegal) is never easy, it should be seen, however, as the medical duty to safeguard the patient’s autonomy, the principle of individual freedom to make choices. Figure 2 References 1. Cabezón-Gutiérrez L, Khosravi-Shahi P, Custodio-Cabello S, Muñiz-González F, del Puerto Cano-Aguirre M, Alonso-Viteri S. Opioids for management of episodic breathlessness or dyspnea in patients with advanced disease. Support Care Cancer 2016;24:4045-55 2. Meuser T, Pietruck C, Radbruch L, Stute P, Lehmann KA, Grond S. Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 2001; 93:247-57 3. Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 1995; 63:65-76 4. Swarm RA, Abernethy AP, Anghelescu DL, et al. Adult cancer pain. J Natl Compr Canc Netw 2010;8:1046-86 5. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid –induced hyperalgesia. Pain Physician 2011; 14:145-61 6. Council on Scientific Affairs, American Medical Association. Good care of the dying patient. JAMA 1996;275:474-8 7. Field MJ, Cassel CK, eds. Approaching death: improving care at the end of life. Washington DC: : National Academy Press, 1997 8. de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life : a literature review and recommendations for standards. J Palliat Med 2007; 10:67-85 9. Olsen ML, Swetz KM, Mueller PS. Ethical decision-making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clinic Proc 2010;85:949-54 10. Lossignol D. End-of-life sedation: is there an alternative? Curr Opin Oncol. 2015;27(4): 358-64
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