Debbie Selby

Malignant Bowel Obstruction: Natural History of a Heterogeneous Patient Population Followed Prospectively Over Two Years

CONTEXT The management of malignant bowel obstruction (MBO) is often challenging and frequently involves multiple treatment modalities, including chemotherapy, surgery, stenting, and symptomatic medical management. OBJECTIVES To describe the natural history of patients diagnosed with MBO who were admitted to a tertiary level hospital and followed by a multidisciplinary team that included medical oncologists, surgical oncologists, and palliative care specialists. METHODS Thirty-five patients admitted under medical or surgical oncology with a diagnosis of MBO were followed over a two-year period or until the time of death. Primary malignancies included colon, rectum, pancreas, biliary, breast, bladder, carcinoid, renal cell, gastric, lung, and melanoma. Clinical outcomes of interest included survival, percentage of patients receiving surgery and/or chemotherapy, total parenteral nutrition (TPN), insertion of venting gastrostomy tube, disposition, and rates of readmission to hospital. RESULTS Median survival was 80 days and three patients were alive at the time of study closure. At our center, 34% of patients underwent surgical intervention, 37% received at least one dose of post-MBO chemotherapy, and 43% received TPN. There was a cohort of patients (17%) who were alive at one year. CONCLUSION Interventions such as chemotherapy and TPN may be appropriate in a carefully selected subgroup of patients. A collaborative approach is required for the optimal clinical management and palliation of MBO.

Room for improvement? A quality of life assessment in patients with malignant bowel obstruction.

This prospective study followed 35 patients admitted to hospital with malignant bowel obstruction (MBO) to evaluate quality of life (QOL). Subjects completed the Edmonton Symptom Assessment Scale (ESAS) and Rotterdam Symptom Checklist (RSCL) at recruitment, and at one week, one month and three months. The highest ranked ESAS scores at recruitment (which was generally 18-36 hours post admission to hospital) included loss of appetite (median=7.5), fatigue (6.5) and overall well-being (6.0). The total ESAS score improved by 7.5, 11.5 and 11.0 points respectively at one week, one month and three months (p<0.05, p<0.01, NS). RSCL median scores for physical and psychological subscales were high at baseline (36.2, 42.9) and improved significantly at one week and one month (p<0.05). Psychological functioning appeared to be worsening by three months and at no time did activity level improve significantly. The overall QOL score was extremely poor at baseline (6.0 median) improving to 3.3 at one month (median fall=1.0, p<0.05) and 3.4 at three months. Further work should address the lack of improvement in activity and apparent deterioration in psychological functioning after one month.

Predictors of Survival in Patients With Non-Curative Stage IV Cancer and Malignant Bowel Obstruction

Malignant bowel obstruction (MBO) occurs in up to 15% of patients admitted to palliative care wards and management can be clinically challenging. Survival is generally poor with a reported median survival of 1–3 months; however, there are no studies describing predictors of survival for patients with MBO.

Personalizing prognosis in a patient with serious illness

Addressing prognosis for a patient with a serious or progressive, life-limiting illness presents a unique challenge. What a person understands about his or her illness and what he or she expects to occur substantially affects both the decisions made regarding care and the overall outcomes.[1][1]

Should a reversible, but lethal, incident not be treated when a patient has a do-not-resuscitate order?

Despite the frequency of use of do-not-resuscitate orders, there is still uncertainty regarding their optimal use. We discuss a controversial issue concerning end-of-life care arising from two cases from the Office of the Chief Coroner for Ontario: What are the limits of medical therapy for patients

A qualitative analysis of the elements used by palliative care clinicians when formulating a survival estimate

Objective For patients with advanced and/or incurable disease, clinicians are often called upon to formulate and communicate an estimate of likely survival duration. The objective of this study was to gain a deeper appreciation of this process by identifying and exploring the specific elements that may inform and/or impact a clinicians estimate of survival (CES). Methods Semistructured interviews were conducted among a group of palliative care clinicians in the setting of a tertiary academic health sciences centre. Qualitative data were subsequently analysed using a grounded theory approach. Results Five major themes were identified as being central to the process of CES formulation: use of objective patient-specific elements, strength of the patient-clinician relationship, purpose and context of an individual CES, perceived role of hope and the overall likelihood of CES inaccuracy. Conclusions For any given patient, several elements have the potential to inform and/or impact the process of CES formulation. Study participants were aware of objective clinical factors known to correlate with actual survival duration and likely integrate this information when formulating a CES. Formulation occurs within a larger context comprised of a number of elements that may influence individual estimates. These elements exist against a background of awareness of the overall likelihood of CES inaccuracy. Clinicians are encouraged to develop a personalised and standardised approach to CES formulation whereby an awareness of the menu of potentially impacting elements is consciously integrated into an individual process.

Joint pain in AML: successful pain control with radiotherapy.

We present a case supporting the use of radiation therapy for palliation of joint pain associated with acute myelogenous leukemia. Prior to radiation therapy to the affected joints, and despite standard pain management, this patient was entirely bedridden and in significant pain. Following radiation, she was able to participate in physiotherapy with minimal to no pain until her death several weeks later. A brief literature review of joint involvement in acute myelogenous leukemia is discussed.

Octreotide for control of bleeding peristomal varices in palliative care.

by the paperwork to facilitate the hospice transferd time that would better be spent at the bedside addressing symptoms and offering education and support. All these issues are magnified in teaching hospitals because of the added layer of various levels of clinicians in training. For hospitals, unless the work processes are exquisitely defined and agreed on, there is often confusion about ‘‘who does what’’ between the hospital and hospice staff. Second, the process of patient discharge and readmission is costlydhospital staff must devote time and resources to manage the electronic medical record requirements, to counsel patients and families on the care transition, and to engage in handoffs to the hospice team. For hospices that are already struggling with short lengths of stay, a large bolus of short-stay patients could worsen finances because of the burden of providing high-cost care for a short period. Finally, a robust palliative care team should be capable of meeting patient and family needs through the inpatient dying process; thus, palliative care staff may view hospice resources as redundant, especially if the endof-life care environment remains unchanged. In discussions with colleagues, many hospitals and health systems have started partnership models with regional hospices to reduce inpatient mortality rates. One could imagine this could lead to a redirection of hospice resources from patients’ homes and freestanding hospice facilities to acute care hospitals. Worse, patient safety issues contributing to elevated inpatient mortality rates could be missed or ignored, as hospice flipping is used to cloak more difficult-tosolve inpatient care issues. In a new health care era, wherein clinicians are often employed by health care institutions and perhaps apprehensive to advocate for patient interests if in conflict with hospital administration goals, it is incumbent on palliative care clinicians to put the patient and family first in making these care decisions. When transition to inpatient hospital hospice services is the best option to meet a patient or family need, then we should help facilitate this process. But let us keep our priorities aligned with the foundational principles of hospice and palliative medicine, and avoid ‘‘treating for the test.’’

Maintenance of continuity of care in a rotating-physician model in an outpatient palliative care clinic

Palliative care is a field in which continuity of care (COC) may be seen as particularly relevant, given its role in providing comprehensive and compassionate full person care for patients with advanced illnesses. The role of continuity of physician care in this setting has not been fully explored. The purpose of this study was to explore patient concerns both before and after a scheduled rotation of palliative care physicians in an outpatient clinic, with a particular

Beyond resuscitate and do-not-resuscitate.

We thank Simon and colleagues[1][1] for their response to our article.[2][2] We applaud the initiatives they describe. We think it important that they combine the Goals of Care Designations with the documentation of the discussions leading to the decisions made by each individual patient. We are