Palliative cancer treatment

DEFINITION: Palliative treatment is active and compassionate care primarily directed toward symptom management and improving quality of life, targeting patients uneligible for curative cancer therapies. Because of the proliferation of supportive treatments that can extend life, palliative care can be lengthy, lasting for months to many years.

Symptom management and control: For the cancer patient, physical symptoms and discomfort may change in nature, quality, and intensity within short, unpredictable periods, often requiring close monitoring and therapeutic modifications at regular but nonspecific intervals. Possible or actual changes in mentation, functioning, and personal control may precipitate intense emotions that are unfamiliar, unwanted, and anxiety-provoking. Chronicity, remissions, and exacerbations of various uncomfortable symptoms; family separation; financial strain; functional limitations; and role disruptions are but a few of the issues that characterize the lives of individuals with advanced, progressive, or incurable illnesses. Even for those who experience lengthy disease-free intervals, the challenge of reducing the effects of the disease in their lives can be difficult, and assistance from multiple specialists is often needed. Common symptoms that are treated and controlled or relieved by palliative care interventions can include:

• Pain
• Difficulty breathing
• Loss of appetite and weight loss
• Fatigue
• Weakness
• Sleep problems
• Depression and anxiety
• Confusion

Palliative treatment in context: The palliative treatment experience must be examined within the context of the healthcare delivery system for its potential and its pitfalls to be fully understood. Treatment advances, societal attitudes, and changes in healthcare structure and financing have all had a dramatic impact on the delivery of palliative care and the creation of gaps between the philosophy and delivery of palliative care services. The secrecy that prevailed in the 1960s and prohibited disclosure of a cancer diagnosis by most physicians has given way to the practice of routinely imparting the particulars of diagnosis, treatment options, and prognosis. Despite this change, persistent cancer-related fears and negative attitudes among healthcare providers have led to a discrepancy between words and actions, resulting in the communication of emotionally laden information in a fashion ranging from overprotective and paternalistic to blunt and matter-of-fact. Further, patients who are not candidates for curative treatment often lack adequate information and resources to manage their abundant physical and psychosocial problems.

Discrepancies between attitude and practice have been demonstrated by clinicians who have been found to avoid clear, open discussions of topics such as prognosis and death despite consistently expressed beliefs regarding the importance of openness and honesty with all mentally competent patients. Therefore, while the prevailing attitude in healthcare supports disclosure of medical information and active involvement by patients in decisions that affect them, the actual behavior of healthcare providers reflects a more limited improvement in patient care. Clinician concerns and personal issues can affect patient communication, key decision-making, and transition points. The need for clinician support and access to resources is recognized as key to helping members of the palliative care team fully assist patients.

Psychiatric and medical comorbidity: The time during which palliative treatment is necessary has lengthened, causing an increase in the number of cases in which patients need psychiatric care alongside medical care. This phenomenon stresses patients, families, professional caregivers, and the healthcare system. Psychiatric problems tend to be treated based on whether the patient's insurance company provides reimbursement, and reimbursement occurs only when psychiatric symptoms emerge as disease states. Insurance rarely covers psychiatric interventions targeted toward symptom management and quality-of-life enhancement, although comprehensive, low-cost interventions supported by scientific evidence of their efficacy are available. Multisystem problems are generally poorly addressed by the medical system, which needs to be more cohesive and oriented toward specialty care.

Because recipients of palliative cancer treatment are not candidates for curative therapies, they are faced with their mortality and are vulnerable to intense fear and psychological distress. However, the healthcare system is oriented toward cure and survival, and it typically places a lower priority on treating and addressing psychosocial issues. Patients receiving palliative care are often concerned about issues such as impending death, pain or other physical discomfort that cannot be relieved, disfigurement, functional decline and increasing dependency on others, loss of mental acuity and bodily functions, and the effects of their illness on their families and friends. These patients must be closely monitored to manage symptoms and functional status changes and evaluate the level of relief achieved through targeted interventions.

Ethical aspects: Care providers must be mindful that the psychological vulnerability of patients receiving palliative care may put some individuals at risk for unnecessary suffering, exploitation, and victimization based on the cure-oriented values inherent in modern healthcare. For example, a common issue among patients, family members, and providers concerns the use of aggressive treatment protocols in the presence of progressive, incurable disease. Patients may seek or be recruited to participate in experimental protocols to possibly extend their lives. Questions of medical ethics and the meaning of informed consent arise regarding the participation of terminally ill subjects in these studies. Some experts question whether having a particular medical condition or status (such as being terminally ill) diminishes full participation in the process of informed consent.

The need for healthcare professionals to establish structured dialogue with patients, family members, and care providers regarding treatment goals and expectations is essential. Treatment planning should take into account the fact that certain individuals with a terminal illness may respond to participation in an investigational treatment with increased hope of survival, regardless of their real chances of survival. These issues, however, become even more complex as changes in healthcare financing prohibit reimbursement for experimental therapies. Some people are unable to undergo experimental therapies, and others may assume the costs of aggressive yet often medically futile treatments, creating compelling ethical issues and tensions. The combination of rapid medical and technological advances, diminishing ability to finance rising healthcare costs, growing numbers of chronically ill patients living longer periods, and an ever-widening gap in healthcare access between the affluent and poor is adding to the problem.

Patients, their families, and healthcare providers must separate and clarify personal values, thoughts, and emotional reactions to these delicate issues if individualized, quality palliative care is to be provided. Psychiatric consultation liaison nurses, psychiatrists, social workers, and chaplains can be invaluable in assisting patients, family members, and staff to grapple with these issues in a meaningful and productive manner.

Dying and terminal care: Once the terminal care period has begun, it is usually not the fact of dying but the quality of life that is primary for patients and families. Palliative care that continues into the terminal stage of cancer should continue to relieve physical and psychological symptoms and promote comfort and well-being until the patient dies. Often, patients and families who have received palliative services in earlier stages of the illness will be more open and accepting of palliative efforts in the final stage of life. Additionally, caregivers must recognize that their work is emotionally draining, and they should seek guidance and support whenever possible.

Professional caregivers should target therapeutic interventions toward increasing the dying patients’ sense of personal control and self-efficacy within the context of their functional decline and increased dependency. It is often therapeutic to inform patients of available resources aimed at discussing and addressing any concerns regarding death and dying. From a practical standpoint, professional caregivers may help patients by inquiring about any unfinished business, including wills and conversations with family and friends, and providing them with the necessary support and encouragement to accomplish these final goals.

Personal values, socioeconomic status, cultural background, and religious beliefs can influence patients’ expectations and experiences as they approach death. For example, a stoic attitude that minimizes or negates discomfort may be related to a cultural value learned and reinforced through years of family experiences. Similarly, an extremely emotional response to routine events during the terminal phase of illness does not necessarily signal mental maladjustment but rather the person’s cultural norm. Awareness of the person’s cultural, religious, ethnic, and socioeconomic background is important in understanding individual behaviors and limiting value judgments.

Psychiatric complications and terminal care:Delirium, depression, suicidal ideation, and severe anxiety are among the most commonly occurring psychiatric complications encountered in terminally ill patients. When severe, these problems require urgent and aggressive assessment and treatment by psychiatric personnel who can initiate pharmacologic and psychotherapeutic treatment strategies. Importantly, psychiatric emergencies require the same rapid intervention as medical crises. Despite the seemingly overwhelming nature of psychosocial responses in cancer patients, most cope effectively, and it is important to recognize that intense emotions are not the same as maladaptive coping.

Hospice care:Hospice care involves structured programs that offer supportive and palliative care at the end of life. The patient, family, and healthcare team decide when hospice care should begin, but typically, patients are eligible for a hospice program when they are estimated to have about six months to live. Hospice care can be home or institution-based. Hospice care aims to manage physical and emotional symptoms, allowing patients to live their last days with dignity and as high a quality of life as possible. Most hospice programs offer family-centered care, which involves the patient and family in decision-making, reducing distress and enhancing control. A hospice team usually consists of a physician, an advanced practice nurse, a bedside nurse, nursing assistants, social workers, and chaplains. Hospice treatment goals may include increased survival time, symptom control, and enhanced quality of life.

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