An initiative to end-of-life decisions in cancer care

摘要

Care of cancer patients more than often becomes limited to providing only comfort measures at the advanced stage of their diseases. Patients or family should be given accurate, relevant and comprehensible information about the goals of the treatment options. These discussions should paint a realistic picture of the outcome to be expected with specific estimates of survival and anticipated quality of life; and patients appreciate these initiatives. Discussions need to be directed toward whether intensive care unit (ICU) admission should be considered or cardiopulmonary resuscitation (CPR) be initiated for an acute cardiopulmonary arrest. A model, comprised of 16 readily variables, can be used at the time of ICU admission to estimate the probability of mortality in critically ill cancer patients. Family members and physicians agree on end-of-life decisions approximately 70% of the time. In the rest, disagreement usually centres on the physician's view that life support is futile and patient's not so clear understanding of their true prognosis despite being told by their physicians. The resolution of this conflict involves clinical ethics committees and, in extreme cases, legal counsel deliberations. Based on in-depth literature search, the present review article aims at multidisciplinary initiative to approach end-of-life care in cancer patients with comprehensive decision-making. Key Messages Set goals of care relative to cancer stage Relay accurate, relevant, comprehensible information about goals to patient or family Initiate discussions DNR orders No difference between withholding and withdrawing life sustaining therapy Comfort measures and attention to patient when goal changes to palliation Awareness of ethical, legal and economic considerations in end-of-life care Introduction The physician's role is “to cure sometimes, to relieve often and to comfort always” 1 . In cancer patients, cure is always not possible. Seventy-eighty percent patients present in advance stage of their diseases where cure is not possible; giving symptom relief and providing comfort become the main goal of treatment plan. The goal of care must be relative to cancer stage. If the appropriate stage of the patient's illness can be recognized, treatment can be tailored to the patient's needs by knowing the goals of treatment for that stage. In this framework, CPR or ICU transfer does not become a decision that needs to be made urgently but can be anticipated well in advance and becomes simply an aspect of care that can be considered in the light of the overall goals of treatment. At the onset of each stage and throughout the patient's care, goals of therapy need to be defined, refined, and carefully discussed. Thus, the question of whether to use a certain treatment modality, including CPR, is no longer a decision of whether to treat or not to treat. Rather the question becomes what is the most appropriate treatment that can be offered to this patient.This review article is based on information gathered from searching Medline database. Furthermore, the reference lists of retrieved articles were screened. Data from abstracts, letters, and unpublished data were not considered. The aim of this review is to present a systematic approach towards initiating end-of-life decisions in cancer patients after a thourough and comprehensive search of literature. Goals of Care Haines, Zalcberg, and Buchanan 2 have proposed a five-step staging system for patients with cancer that offers a framework for discussing goals of care relative to cancer status.