Robert Dunlop

Cytokines and Advanced Cancer

Cytokines have a major role in promoting the growth and spread of cancers. Elevated levels of several cytokines have been described in cancer patients. Evidence from animal and human studies suggests that cytokines may contribute to a wide range of symptoms in advanced cancer, including: asthenia, pain, drowsiness, cognitive failure, agitated delirium, autonomic dysfunction, anorexia, cachexia, fever and metabolic abnormalities. Considerable effort is being directed at finding anticytokine treatments, raising the possibility of new options for symptoms that are currently difficult to control.

Delivering Palliative Care in Different Settings

The previous chapters have outlined strategies and techniques for managing the variety of physical, emotional, social and spiritual problems associated with advanced cancer. The setting in which patients and families are cared for has an important influence on how these strategies are implemented. Palliative care was first developed in the in-patient hospice setting. However, the principles of palliative care were quickly adapted to the care of terminally ill patients at home. Although the number of in-patient units has grown rapidly, the even greater emphasis on home care properly reflects the fact that cancer patients spend most of the last six months of life at home.

Evolution of Palliative Care

The twentieth century has seen a dramatic increase in medical advances. Cures are now possible for many illnesses, life expectancy has been extended for other chronic diseases, and, even when treatment is not possible, the pathophysiology of the condition is likely to be understood. These advances in medical science have bought new life and hope for many patients.

Psycho-Social Care

In palliative medicine, psycho-social needs are considered just as important as physical symptoms. The patient and the family constitute the ‘unit’ of care. Each person in the family will have needs which must be recognised and met. The psychological and social issues which confront cancer patients and their familiescan be more significant than the physical symptoms.

Teamwork and Palliative Care

Throughout this book, the importance of inter-disciplinary teamwork has been emphasised as a fundamental principle of palliative care. There are many examples of inter-professional working in other areas of health care, for example, gerontology and paediatrics. In palliative care, the degree of role overlap between disciplines, coupled with the inherent stresses of working with the terminally ill, create particular difficulties. This chapter focuses on how teamworking can be achieved. The definition of a team is explored, followed by a review of the roles played by team members. Selection of team members is examined and the chapter concludes with ab analysis of the strategie needed to maintain team cohesion.

Management of Other Symptoms

This chapter covers some of the other symptoms experienced by cancer patients. The symptoms selected for this chapter occur frequently or can be very distressing Weight loss, poor appetite and weakness occur in almost all patients. Confusion and terminal restlessness are less common but no less distressing when they do occur. Hypercalcaemia and hyponatremia are metabolic complications of cancer which cause multiple symptoms, but they are considered in the section on confusion (page 71). Mouth and skin problems can be troublesome. Convulsions are associated with brain tumours and require careful management.

Spiritual Care and Suffering

The modern hospice movement introduced the concept of whole person care, focusing on the spiritual as well as the physical, psychological and social needs of patients and families. Spiritual care requires a personal and a professional commitment to the patient and the family as they search for meaning in the illness. This commitment is the essence of palliative care.

Management of Respiratory Symptoms

The major respiratory symptoms associated with advanced cancer include breathlessness, cough and haemoptysis. These symptoms occur with primary lung cancers, metastatic disease to the lungs and in association with other conditions.

Ethical Issues and Palliative Care

The care of terminally ill patients and families can raise some difficult ethical dilemmas. There are dilemmas about whether to start or stop ‘active’ anti-cancer treatments. Palliative care is directed at symptom control; what if the patient refuses to take medications to relieve symptoms? What happens if a patient wants to die at home but the family refuses to care for the patient? What about euthanasia? These, and other, problems are constantly presenting themselves to palliative-care practitioners. Because the emotional atmosphere is already charged when caring for the terminally ill, it is important to understand the ethical issues before they are confronted.

Evaluation of Palliative-Care Services

Dame Cicely Saunders recognised the importance of evaluating palliative-care services when St Christopher’s Hospice was founded. The financial considerations were a factor. Potential donors had to be convinced of the value of palliative care. However, it was even more important to establish the credibility of this entirely new field of medicine. If the principles of palliative care were to be established in general medical practice, they had to be backed up by sound, highquality research. The rapid growth of palliative care and its spread throughout the world testifies to the wisdom of Dame Cicely’s foresight.