Carin C.D. van der Rijt

The effect of the Liverpool Care Pathway for the dying: a multi-centre study:

We studied the effect of the Liverpool Care Pathway (LCP) on the documentation of care, symptom burden and communication in three health care settings. Between November 2003 and February 2005 (baseline period), the care was provided as usual. Between February 2005 and February 2006 (intervention period), the LCP was used for all patients for whom the dying phase had started. After death of the patient, a nurse and a relative filled in a questionnaire. In the baseline period, 219 nurses and 130 relatives filled in a questionnaire for 220 deceased patients. In the intervention period, 253 nurses and 139 relatives filled in a questionnaire for 255 deceased patients. The LCP was used for 197 of them. In the intervention period, the documentation of care was significantly more comprehensive compared with the baseline period, whereas the average total symptom burden was significantly lower in the intervention period. LCP use contributes to the quality of documentation and symptom control.

Attitudes of Patients With Incurable Cancer Toward Medical Treatment in the Last Phase of Life

PURPOSEnWhen cancer has advanced to a stage in which cure becomes unlikely, patients may have to consider the aim of further treatment. We studied the relationship of patients attitudes toward treatment with advance care planning and the development of these attitudes after diagnosis of incurable cancer.nnnPATIENTS AND METHODSnPatients with incurable cancer were interviewed and asked to fill out a written questionnaire about their attitudes concerning life-prolonging treatment and end-of-life decision making. These questions were repeated after 6 and 12 months.nnnRESULTSnOne hundred twenty-two patients (mean age, 64 years; standard deviation, 10.5 years; 53% women) participated in the study. Patients attitudes toward treatment could be categorized into the following three different profiles: striving for quality of life, striving for length of life, and no clear preference. Patients who were older, more tired, or had less positive feelings and patients who had more often taken initiatives to engage in advance care planning were more inclined to strive for quality of life than others. Patients with a history of cancer of less than 6 months were more inclined to prefer life prolongation than patients with a longer history of cancer. During follow-up, no changes in attitudes toward treatment were found, except for patients with a short history of cancer in whom the inclination to strive for length decreased.nnnCONCLUSIONnPatients who appreciate advance care planning were more inclined to strive for quality of life than other patients. Shortly after the diagnosis of cancer, patients typically seem to prefer life-prolonging treatment, whereas quality of life becomes more important when death is nearing.

Systematic Monitoring and Treatment of Physical Symptoms to Alleviate Fatigue in Patients With Advanced Cancer: A Randomized Controlled Trial

PURPOSEnSeveral guidelines on the treatment of cancer-related fatigue recommend optimizing treatment of accompanying symptoms. However, evidence for this recommendation from randomized clinical trials is lacking. We investigated whether monitoring and protocolized treatment of physical symptoms alleviates fatigue.nnnPATIENTS AND METHODSnIn all, 152 fatigued patients with advanced cancer were randomly assigned to protocolized patient-tailored treatment (PPT) of symptoms or care as usual. The PPT group had four appointments with a nurse who assessed nine symptoms on a 0 to 10 numeric rating scale (NRS). Patients received a nonpharmacologic intervention for symptoms with a score ≥ 1 and a medical intervention for symptoms with a score ≥ 4. Fatigue dimensions, fatigue NRS score, interference of fatigue with daily life, symptom burden, quality of life, anxiety, and depression were measured at baseline and after 1, 2, and 3 months. Differences between the groups over time were assessed by using mixed modeling.nnnRESULTSnSeventy-six patients were randomly assigned to each study arm. Mean age was 58 ± 10 years, 57% were female, and 65% were given palliative chemotherapy. We found significant improvements over time in favor of PPT for the primary outcome general fatigue (P = .01), with significant group differences at month 1 (effect size, 0.26; P = .007) and month 2 (effect size, 0.35; P = .005). Improvements in favor of PPT were also found for the following secondary outcomes: fatigue dimensions reduced activity and reduced motivation, fatigue NRS, symptom burden, interference of fatigue with daily life, and anxiety (all P ≤ .03).nnnCONCLUSIONnIn fatigued patients with advanced cancer, nurse-led monitoring and protocolized treatment of physical symptoms is effective in alleviating fatigue.

Patient evaluation of end-of-life care

The Dutch health care system is characterized by a strong emphasis on primary care. To get insight into the strengths and gaps in end-of-life care in the Netherlands, data are needed about use and patient evaluation of end-of-life care. We assessed the experiences of patients with end-of-life care during the last months of life. We followed 128 patients with incurable lung, breast, ovarian, colorectal or prostate cancer. At inclusion they were interviewed personally at home. During follow-up, every 6 months, we asked them to fill out a questionnaire on the end-of-life care they had received. One-hundred of them died during the research period. Eighty-seven of the deceased patients were able to fill out a questionnaire in the last 6 months of their lives. They reported that, on average, 4.2 disciplines were involved in their care. Most patients indicated to be satisfied with the care offered by their caregivers. Problems in end-of-life care concerned communication, difficulties in coordination, accessibility of end-of-life care and responding quickly to acute problems. We conclude that comprehensive and interdisciplinary end-of-life care may address patients needs, but that it simultaneously is a challenge to optimal communication among disciplines and between caregivers and the patient. Palliative Medicine 2007; 21: 243—248

Changes in and correlates of individual quality of life in advanced cancer patients admitted to an academic unit for palliative care.

Changes in individual quality of life (IQoL) and its correlates in patients admitted to an academic palliative care unit are reported. Correlates tested were pain, fatigue, and reconceptualization (changes in content of quality of life, a measure of adaptation). IQoL was measured with a structured interview method that derives an IQoL score from evaluations of individually nominated life areas. Twenty-nine patients were included in the study and interviewed shortly after unit admission. Sixteen patients were interviewed before discharge (more than 1 week between interviews). The results show that mean IQoL scores improved notably. Pain and IQoL correlated negatively and moderately at admission, and correlations between fatigue and pain at discharge and IQoL were negative and strong. An increasing number of changes in life areas was moderately associated with worsening IQoL. Life areas most often nominated were relationships with family members and friends, symptoms and aspects related to maintaining control. Palliative Medicine 2007; 21: 199—205

Effectiveness of a multidisciplinary consultation team for cancer pain and palliative care in a large university hospital in the Netherlands

Background Multidisciplinary palliative care teams (PCTs) are increasingly employed for cancer patients. However, relatively few studies have prospectively assessed the clinical effectiveness of inpatient PCTs. Our aim was to evaluate the effectiveness of a multidisciplinary PCT for hospitalised cancer patients in a large university hospital in the Netherlands. Methods Clinical data and duration of hospitalisation were prospectively collected between January 2007 and December 2008. A group of cancer pain patients from 2006 served as a historical control. Results The number of consultations increased from 130 in 2006 to 235 in 2008. The reason for consultation changed from pain in 98% of consultations in 2006 to a diversity of palliative symptoms in 2008. In 2008 a significant decrease in mean pain intensity, including a 70% reduction in severe pain, occurred within 24 h following consultation, although the authors did not demonstrate that the effectiveness of the PCT in 2007 and 2008 surpassed that of routine oncological care including pain control in 2006. Similarly, the median severity for 7 out of 10 items from the Edmonton Symptom Assessment System (ESAS) decreased significantly within 72 h following consultation. The median number of days in hospital for patients for whom the PCT was consulted decreased from 14 days in 2006 to 10 days in 2008. Conclusions The authors conclude that a multidisciplinary PCT for clinical cancer patients may have a positive effect on pain, on ESAS symptoms and on duration of hospitalisation.

Opioid treatment failure in cancer patients: the role of clinical and genetic factors

AIMnTo identify clinical and genetic factors associated with outcome of opioid treatment.nnnPATIENTS & METHODSnWe performed an exploratory analysis in a cohort of 353 patients treated with fentanyl, morphine, oxycodone and/or hydromorphone for cancer-related pain, exploring selected clinical and pharmacogenetic factors for a correlation with treatment failure for all and per type of opioid.nnnRESULTSnUse of adjuvant pain medication, intensity of pain at rest and age were associated with treatment failure in the various cohorts. Only the genetic variants rs12948783 (RHBDF2) and rs7016778 (OPRK1) correlated statistically significant in univariate, but not in multivariable analysis.nnnCONCLUSIONnSeveral clinical and genetic factors were identified that warrant further study to clarify their role and use in opioid treatment.

Influence of aprepitant and localization of the patch on fentanyl exposure in patients with cancer using transdermal fentanyl

Background and Objectives The cutaneous fentanyl patch is widely used to treat continuous pain in patients with cancer. Its use is hampered by a high inter- and intrapatient pharmacokinetic variability. Factors that influence this pharmacokinetic variability are largely unclear. The aim of these studies was to test if common patient variables, i) the use of the moderate CYP3A4 inhibitor aprepitant and ii) the localization of the fentanyl patch (upper arm versus thorax) influence systemic exposure to fentanyl in patients with cancer using a transdermal fentanyl patch. Results The AUC0–6 h of fentanyl was 7.1% (95% CI: −28% to +19%) lower if patients concurrently used aprepitant, compared to the period when patients used fentanyl only. The AUC0–4 h of fentanyl was 7.4% (95% CI: −22% to +49%) higher when the cutaneous fentanyl patch was applied to the upper arm compared to application at the thorax. Conclusions Neither the concurrent use of aprepitant, nor the localization of the fentanyl patch showed a statistically significant influence on fentanyl pharmacokinetics. Methods We performed two prospective cross-over pharmacokinetic intervention studies. Both studies had two eight-day study periods. At day 8 of each study period blood samples were collected for pharmacokinetic analysis. In each study 14 evaluable patients were included.

Palliative care in a Dutch hospital: Developing a digital care pathway for palliative care.

17 Background: Awareness is growing that palliative care is an important part in the hospital. It is aimed to improve the quality of life of patients and their relatives in the end-stage of a disease by a multidimensional approach. Prior to the development and implementation of a digital Care Pathway for Palliative Care, we wanted to map the palliative care process during the last hospitalization prior to death of patients with malignancies.nnnMETHODSnWe studied the medical files of patients who died in the period 1 July 2011 - 1 July 2012 within six months after having been admitted to the Department of Oncology and Lung diseases in a general hospital. A checklist was used to collect data about the patients diagnosis; the care that was provided during their last stay in the hospital; and about characteristics of the dying process.nnnRESULTSnIn total 149 medical records were examined. Most of the patients (78%) were admitted because of complications or progression of the disease. During their last hospitalization, 90% of the patients underwent radiologic tests and 97% underwent blood tests. Furthermore, 38% of the patients received chemotherapy. Of all patients, 55% died during their last stay in the hospital. Medical files contained limited information about the care process: 18% contained information about provision of information to the general practitioner (GP) during admission, 78% contained reports of bad-news conversations. In 36%, the patients preference concerning their place of death was unknown. Further, there was no optimal communication with the GP after the patient had died in the hospital; 87% of the GPs were informed.nnnCONCLUSIONSnPalliative care in the hospital was found to involve suboptimal communication on several important topics. A structured medical file to guide palliative care may contribute to improvement of the care process. We are now evaluating the effects of a digital Care Pathway for Palliative Care, that includes marking of the palliative phase of a disease and supports adequate communication, advanced care planning, multidisciplinary cooperation and continuity of care.