Crises in palliative care—a comprehensive approach

doi:10.1016/S1470-2045(08)70278-X

The Lancet Oncology

Volume 9, Issue 11, November 2008, Pages 1086-1091

https://doi.org/10.1016/S1470-2045(08)70278-X Get rights and content

Summary

Palliative care aims to improve quality of life by early identification, impeccable assessment, and treatment of symptoms while meeting other needs of patients with advanced and progressive disease. It comprises disease-specific and symptom-guided interventions, with emphasis on preparing patients and their relatives for foreseeable, highly distressing clinical problems. Use of inappropriate mechanisms and algorithms in standard emergency treatment might be avoidable for the sake of patient-centred inpatient and outpatient palliative care during the last phase of life. This Review reflects a clinical attitude in palliative care that differs from oncological emergency management. We give examples of typical clinical crises at the end of life and discuss treatment to aid care before, during, and after such crises.

Introduction

In public perception and in medical understanding, the term “emergency” defines an unforeseen or sudden occurrence of danger that demands immediate action.¹ A patient with incurable cancer will inevitably face emergency situations during the course of disease that will create pressure to act; for instance, they might need urgent resuscitation. In cancer, emergencies defined by disease-specific processes include obstruction of the vena cava, compression of the spinal cord, pathological bone fractures, severe electrolyte disturbance (ie, hyponatraemia and hypercalcaemia), and treatment-related emergencies (eg, septic neutropenia and tumour-lysis syndrome). Aggressive management can enhance quality of life and overall survival in such situations, which have been discussed elsewhere.2, 3, 4

Most patients treated in palliative-care settings have incurable, progressive, and advanced cancer.⁵ Therefore, oncological emergencies such as those mentioned above are common. Palliative-care teams have to be capable to diagnose, assess, and treat oncological emergencies vigorously according to clinical standards in close cooperation with other cancer services, as occurs in a multiprofessional and interdisciplinary palliative-care setting. However, the priorities of palliative care gradually change toward the end of life, questioning the emergency nature of such situations.

The figure shows a 56-year-old man with locally advanced head and neck cancer. He might face various distressing situations such as acute dyspnoea, septic infection, or acute catastrophic bleeding. Definition of these situations as an “emergency” with its associated characteristics (eg, emergency calls, life-saving objective, pressure to act, and a chain of activities) would imply aggressive resuscitation that might be inappropriate for the end of life: the wishes of the patient for their remaining quality of life gain priority because death is an expected and accepted outcome.

Palliative care would define critical situations such as the one mentioned above as a crisis—a crucial or turning point¹ that will not necessarily draw immediate medical action by contrast with standard emergency situations. The focus is not “what can be done?” with diagnostic or therapeutic algorithms, but rather on “what is the appropriate treatment for this patient in this particular situation?”. For the patient shown in the figure, the medically and ethically appropriate choice of treatment for massive external bleeding would be to stay calm with the patient and cover blood with dark towels, with palliative sedation likely with the patient's consent.

Section snippets

Assessment

Prompt and complete assessment of a critical situation for symptoms and underlying disease-specific and pathophysiological processes is essential to reverse some events.⁶

Several factors in palliative crisis need inclusion in the therapeutic decision process. For example, the effect of a possible reversal of a distinct pathophysiological process on the patient's overall condition and whether active treatment could maintain or improve quality of life need consideration. The physical,

Appropriateness

The appropriate level of intervention in palliative care has been debated.⁸ In addition to solving the actual clinical problem, palliative care will lay the groundwork to handle critical situations in an outpatient setting and avoid emergency (re)admissions in accordance with the patient's and relatives' wishes. Most patients wish to die at home, and palliative-care institutions effectively contribute to avoiding unwanted emergency admission to hospital.⁹

Medicines

Medicines can treat various critical

Signs and symptoms

The needs of patients who are receiving palliative care include physical, psychological, social, and spiritual factors. Crises in spiritual life mainly challenge existential questions of life and death; social crises encompass acutely decompensating family or care structures at home. Psychological crises might be related to an inability to cope with disease progression or to a lack of protective options. Here, we focus on physical symptoms that lead to crises through exacerbation of a

Special considerations for final phase of life

Towards the final phase of disease, drowsiness, confusion, agitation, and moist respiration (so-called death rattle) are usually the commonest and most distressing problems (table 2).¹⁷

Moist respiration is caused by secretion in the trachea and larynx when patients are unable to clear their throat from saliva because of progressive weakness. For relatives and team members, this symptom could be a distressing crisis; however, the patient is commonly unconscious. Therefore, explanation to the

Conclusion

Therapeutic priorities gradually change during the course of disease towards the end of life, focusing on quality of life and on the patient's expectations and wishes. Therefore, the palliative-care approach to critical symptoms differs from that of oncological emergency management in the extent of symptom-guided versus disease-specific therapy, the extent of intervention related to individual preference, and in the anticipation and communication of foreseeable crises.

Clinical awareness, a

Search strategy and selection criteria

Data for this Review were identified by searches of Medline, Current contents, PubMed, and references from relevant articles using the search terms: “emergency” and “palliative care” or “palliative medicine”. Papers published in English and German, and abstracts of articles published in other languages, between 1980 and 2007 were included.

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Cited by (58)

Comparing the use of aggressive end-of life care among frail and non-frail patients with cancer using a claims-based frailty index
2024, Journal of Geriatric Oncology
Despite mounting consensus that end-of-life (EOL) care for patients with cancer should focus on improving quality of life, many patients continue to receive aggressive, disease-oriented treatment until death. Within this group, patients with increased frailty may be at higher risk of adverse treatment-related outcomes. We therefore examined the relationship between degree of frailty and receipt of aggressive EOL care among Medicare-insured patients with cancer in Ohio.
From the Ohio Cancer Incidence Surveillance System (OCISS) linked with Medicare claims, we identified patients diagnosed with breast, colorectal, lung, or prostate cancer who died between 2012 and 2016. Frailty was operationalized using a validated claims-based frailty index. Six quality indicators reflecting receipt of aggressive EOL care were identified from claims: (1) any cancer-directed treatment, (2) >1 emergency department (ED) visit, (3) >1 hospital admission, (4) any intensive care unit (ICU) admission in the last 30 days of life, (5) entry to hospice in the last three days of life, and (6) in-hospital mortality. Multivariable logistic regression analysis was performed to control for demographic factors, Medicare and Medicaid dual enrollment, and cancer type and stage in the relationship between frailty and aggressive EOL care.
Overall, 31,465 patients met selection criteria. Patients with moderate/severe frailty were less likely than non−/pre-frail patients to receive any aggressive EOL care (adjusted odds ratio [aOR] 0.92 [95% confidence interval 0.86–0.99]). This group was also less likely to undergo cancer-directed treatment in their last 30 days or to enter hospice in their last three days. Increasing frailty was associated with lower odds of admission to the ICU in the last 30 days of life (mild frailty: aOR 0.88 [0.83–0.94]; moderate/severe frailty: aOR 0.85 [0.78–0.92]) or of dying in-hospital (mild frailty: 0.85 [0.79–0.91]; moderate/severe frailty: aOR 0.74 [0.67–0.82]), but higher odds of having >1 ED visit in the last 30 days of life (mild frailty: aOR 1.43 [1.32–1.53]; moderate/severe frailty: aOR 1.61 [1.47–1.77]).
These findings suggest the need for more explicit discussion of emergency care seeking for patients with cancer at the end of life.
Predictors of survival following carotid blowout syndrome
2022, Oral Oncology
Citation Excerpt :
Among patients undergoing re-irradiation, mortality rates approximated 80%, as demonstrated in a systematic review by McDonald et al.[4] Surviving patients remain at risk for numerous complications, with permanent neurologic sequalae reported between 10 and 50%.[1,5,6] Carotid blowout events may be highly disturbing to patients, families, and staff, with the psychological burden persisting well beyond the initial blowout.[7–9] Risk factors for the development of CBS include total radiation doses ≥70 Gy, oropharyngeal tumors, radical neck dissection, local wound infections and soft tissue necrosis, pharyngocutaneous fistulas, and malnutrition.[1–3,10–12]
Carotid blowout syndrome (CBS) is a rare, life-threatening complication for patients with head and neck cancer (HNC). The primary objective was to identify factors associated with survival following CBS.
A retrospective analysis of HNC patients treated at a single tertiary care hospital with CBS between 2016 and 2020 was performed. A multivariate Cox proportional-hazards model identified independent predictors of survival. A p value of <0.05 was considered significant. Kaplan-Meier survival analysis was performed.
45 patients were identified. The majority were male (80.0%) with a mean age of 64 years at time of blowout. Oropharynx was the most common primary site (48.9%) and 73.3% of patients had stage IV disease. 35 (77.7%) patients had active tumor at time of CBS. 93.3% of patients previously received RT with a mean total dose of 62.5 ± 14.8 Gy. Threatened/type I, impending/type II, and acute/type III CBS occurred in 6.7%, 62.2%, and 31.1% of cases, respectively. Patients underwent either embolization (80.0%) or endovascular stent placement (20.0%). The 30-day and 1-year OS rates were 70.1% and 32.0%, respectively. Primary oropharyngeal tumors (adjusted hazard ratio [aHR], 4.31 [1.30–15.15 95% confidence interval]), active tumor at time of CBS (aHR 8.21 [2.10–54.95]), ICA or CCA rupture (aHR 5.81 [1.63–21.50]), and acute/type III CBS (aHR 2.98 [1.08–7.98]) were independent predictors of survival.
Primary oropharyngeal tumors, active tumor at time of CBS, ICA or CCA rupture, and acute/type III hemorrhage were independent predictors of survival. Multidisciplinary management and prompt, protocol-directed intervention may improve outcomes following CBS.
Causes of Hospital Admissions in Domus: A Randomized Controlled Trial of Specialized Palliative Cancer Care at Home
2018, Journal of Pain and Symptom Management
Citation Excerpt :
Some hospital admissions are caused by oncologic emergencies, and they may be difficult if not impossible to avoid. These may include bone fractures, superior vena cava syndrome, spinal cord compression, metabolic disorders (hypercalcemia, hyperuricemia), abdominal surgical (obstruction, perforation, bleeding, infection, hepatobiliary), or febrile neutropenia.7–9 Therefore, a major challenge is to identify which admissions are avoidable.
Avoidable hospital admissions are important negative indicators of quality of end-of-life care. Specialized palliative care (SPC) may support patients remaining at home.
Therefore, the purpose of this study was to investigate if SPC at home could prevent hospital admissions in patients with incurable cancer.
These are secondary results of Domus: a randomized controlled trial of accelerated transition to SPC with psychological intervention at home (Clinicaltrials.gov: NCT01885637). Participants were patients with incurable cancer and limited antineoplastic treatment options and their caregivers. They were included from the Department of Oncology, Rigshospitalet, Denmark, between 2013 and 2016. The control group received usual care. Outcomes were hospital admissions, causes thereof, and patient and caregiver perceptions of place of care (home, hospital, etc.) at baseline, four weeks, eight weeks, and six months.
During the study, 340 patients were randomized and 322 were included in modified intention-to-treat analyses. Overall, there were no significant differences in hospital admissions between the groups. The intervention group had more admissions triggered by worsened general health (22% vs. 16%, P = 0.0436) or unmanageable home situation (8% vs. 4%, P = 0.0119). After diagnostics, admissions were more often caused by clinical symptoms of cancer without progression in the intervention group (11% vs. 7%, P = 0.0493). The two groups did not differ significantly in overall potentially avoidable admissions. Both groups felt mostly safe about their place of care.
The intervention did not prevent hospital admissions. Likely, any intervention effects were outweighed by increased identification of problems in the intervention group leading to hospital admissions. Overall, patients and caregivers felt safe in their current place of care.
Palliative Care, Terminal Care, and Counseling
2017, Maxillofacial Surgery, 3rd Edition: Volume 1-2
Breathlessness during the Last Week of Life in Palliative Care: An Australian Prospective, Longitudinal Study
2016, Journal of Pain and Symptom Management
Citation Excerpt :
Breathlessness has been reported to worsen in people with advanced disease especially in the last months of life despite evidence-based, symptomatic treatments.4,5,7 People with worsening breathlessness particularly fear that they may suffocate.7 Half of all caregivers perceive that the person for whom they were caring was “uncomfortable” or “very uncomfortable” in the last two weeks of life.8
Breathlessness is a major cause of suffering and distress, and little is known about the trajectory of breathlessness near death.
To determine the trajectory and clinical-demographic factors associated with breathlessness in the last week of life in patients receiving specialist palliative care.
This was a prospective, longitudinal cohort study using national data on specialist palliative care from the Australian Palliative Care Outcomes Collaboration. We included patients in the Australian Palliative Care Outcomes Collaboration who died between July 1, 2013 and June 30, 2014 with at least one measurement of breathlessness on a 0–10 numerical rating scale in the week before death. The trajectory and factors associated with breathlessness were analyzed using multivariate random-effects linear regression.
A total 12,778 patients from 87 services (33,404 data points) were analyzed. The average observed breathlessness was 2.1 points and remained constant over time. Thirty-five percent reported moderate to severe distress (numerical rating scale ≥4) at some time in their last week. Factors associated with higher breathlessness were younger age, male gender, cardiopulmonary involvement, concurrent fatigue, nausea, pain, sleeping problems, higher Australia-modified Karnofsky Performance Status, and clinical instability in the multivariate analysis. Respiratory failure showed the largest association (mean adjusted difference 3.1 points; 95% confidence interval, 2.8–3.4).
Although breathlessness has been reported to worsen in the last months, the mean severity remained stable in the final week of life. In specialized palliative care, one in three people experienced significant breathlessness especially in respiratory disease.
Risk factors of sudden unexpected death in patients with advanced cancer near the end of life
2022, Palliative and Supportive Care

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ReviewCrises in palliative care—a comprehensive approach

Summary

Introduction

Section snippets

Assessment

Appropriateness

Medicines

Signs and symptoms

Special considerations for final phase of life

Conclusion

Search strategy and selection criteria

Prim Care

Presse Med

J Pain Symptom Manage

Curr Probl Cancer

J Pain Symptom Manage

J Pain Symptom Manage

J Thorac Cardiovasc Surg

Handbook of oncological emergencies

Eur J Cancer Care

Oncological emergencies

Internist (Berl)

Oncological emergencies

Ann Oncol

What are the problems in palliative care? Results from a representative survey

Support Care Cancer

ABC of palliative care. Emergencies

BMJ

Living well at the end of life

Emergencies in palliative care

Ann Acad Med Singapore

Symptom control in care of the dying

Dying at home: emergency medications for terminal symptoms

Am J Hosp Palliat Care

Palliativ- und Notfallmedizin: Teamarbeit durch Kommunikation

Z Palliativmed

Definition of palliative care

Review
Crises in palliative care—a comprehensive approach