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When lung cancer progresses to advanced stages, patients are destined to die over the ensuing weeks or months. Oftentimes, they suffer from the symptoms of their cancer (such as extreme pain) or the damage of chemotherapy intended to prolong their life. If they fail all treatments, they are oftentimes left to the care of their family. Typically, there are family members with no prior first-hand experience with the dying process. Oftentimes, Hospice Care services are contacted during the final days to help cope with the terminal stages of death.
I’ve written a number of blogs about the process of death and dying and how this should be approached with both grace and dignity for the patient and their family unit, as well as not abandoning hope for their future even though the goals of their lives may change to short-term goals as their cancer progresses. In the prestigious New England Journal of Medicine (Aug. 19, 2010), a major study (abstract below) was published examining the impact of early palliative care for patients with advanced lung cancer. Such patients have a substantial symptom burden and may receive aggressive care at the end of life.
The authors examined the effect of introducing palliative care early after the diagnosis of advanced lung cancer and compared the results with those who received standard cancer care alone. The results were amazing! Patients assigned to early palliative care had a better quality of life than those assigned to standard care. In addition, patients in the early palliative care had fewer depression symptoms, and they lived longer (!), even though they received less aggressive end of life care. The authors concluded that early palliative care led to significant improvements in quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative treatment had less aggressive care at the end of life, but lived longer.
I found in my oncology practice that patients and their families oftentimes did not want to call in Hospice Care for fear that it would signal that death was imminent. On the other hand, when a Hospice team is involved, there is often better management of patient symptoms, better care of any open wounds or symptoms of pain, and the family is relieved of the terrible emotional toil of solely providing the physical and emotional needs for a dying patient. The nurses, staff and physicians who dedicate their lives to Hospice Care are truly a special group who can bring skills and a sense of hope and dignity to the dying process, both for patients and their families.
This outstanding scientific study clearly demonstrates the value of early intervention that both patients and physicians should take note of. Hospice Care should not be instituted during the end stages of death, but much earlier so that patients might preserve their quality of life, have less depression, and in some circumstances may even live longer. The additional benefit I would also emphasize is the assistance of Hospice Care to the families and caregivers of a dying cancer patient. Usually they are not equipped to handle all the circumstances that can come up at this time and may feel an extreme sense of hopelessness, frustration and inadequacy when confronted with a circumstance that they are trying to navigate themselves.
The abstract of this referenced study is listed below.
Reference: Early palliative care for patients with metastatic non-small cell lung cancer. Temel JS et al. New England Journal of Medicine volume 363, pages 733-742, August 19,2010.
Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer
Jennifer S. Temel, M.D., et al. N Engl J Med 2010; 363:733-742August 19, 2010
Background: Patients with metastatic non–small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease.
Methods: We randomly assigned patients with newly diagnosed metastatic non–small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records.
Results: Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02).
Conclusions: Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)
NOTE: An accompanying editorial by Drs Kelley and Meier* concluded: “The study by Temel et al. represents an important step in confirming the beneficial outcomes of a simultaneous care model that provides both palliative care and disease-specific therapies beginning at the time of diagnosis. This study is an example of research that shifts a long-held paradigm that has limited access to palliative care to patients who were predictably and clearly dying. The new approach recognizes that life-threatening illness, whether it can be cured or controlled, carries with it significant burdens of suffering for patients and their families and that this suffering can be effectively addressed by modern palliative care teams. Perhaps unsurprisingly, reducing patients’ misery may help them live longer. We now have both the means and the knowledge to make palliative care an essential and routine component of evidence-based, high-quality care for the management of serious illness.”
*N Engl J Med 2010; 363:781-782, August 19, 2010