End-of-life care for patients with advanced cancer: ESMO Guideline
The European Society for Medical Oncology (ESMO) has released a new clinical practice guideline for the care of adult cancer patients at the end of life (EoL).
The guideline, published in the journal ESMO Open: Cancer Horizons, details care that is focused on comfort, quality of life, and approaching death of patients with advanced cancer. Recommendations were compiled by a multidisciplinary group of experts based on available scientific data and the authors' collective expert opinion.
Communication and the family
- Effective communication and shared decision making are essential at EoL.
- Strategic preparation of patient and family, respecting personal wishes and beliefs, is critical to reducing adverse bereavement outcomes.
- The nursing role is considered vital to the care of patients and families at EoL.
- The role of PC teams is critical to the care of patients and families at EoL.
Prognostic factors in advanced cancer
- Clinicians need to be watchful for objective physical symptoms indicating prognosis of days to weeks, especially declining PS.
- Poor prognosis is associated with declining PS and onset/worsening of symptoms such as dyspnoea, dysphagia, weight loss, xerostomia, anorexia and cognitive impairment.
- Routine use of prognostic tools may improve accuracy of physician predictions.
- Chemotherapy (ChT) and immunotherapy should not be used in the last weeks of life.
- RT may have symptomatic benefit for pain or bleeding but is not recommended in the last days of life.
Routes of drug administration
- In the absence of a central venous catheter, continuous s.c. infusion is the preferred route, being effective, feasible, safe and inexpensive.
- In the last days of life, s.c. cannulae should be placed on the trunk or abdomen, rather than extremities, due to potentially diminished peripheral perfusion.
Nutrition and hydration
- In patients with an expected survival of less than a few weeks or days, the invasiveness of nutritional interventions should be decreased and dietary counselling and oral supplements should be provided.
- In patients with an expected survival of less than a few weeks, comfort-directed care is the recommended approach, including alleviating thirst, eating-related distress and other debilitating symptoms.
- Artificial nutrition should not be initiated in the last weeks of life.
- Artificial hydration does not improve or prevent symptoms of thirst.
Medication and intervention review
- Prophylactic anticoagulation should not be used at EoL.
- Red blood cell and platelet transfusions may have limited benefits in the last weeks of life.
- The intensity of pain should be assessed regularly, particularly using validated instruments to include patients with reduced consciousness or cognition.
- Pain treatment should be personalised and monitored also in the last days of life.
- Non-oral routes of administration should be used, such as s.c. or i.v., whenever benefits outweigh burden>
- Concern about hastening death should not influence decisions regarding opioid therapy.
- The antiemetic drug of choice in advanced cancer is metoclopramide titrated to effect.
- Alternative antiemetic options include haloperidol, levomepromazine or olanzapine.
- There is limited evidence to guide antiemetic use of cyclizine or 5-HT3 receptor antagonists.
- Metoclopramide should not be used in complete bowel obstruction.
- Octreotide and haloperidol are recommended for NV in malignant bowel obstruction.
- Treatment with regular, low-dose, slow release (SR) opioids is recommended for palliating severe chronic breathlessness in advanced disease.
- Benzodiazepines are effective at providing sedation and potentially anxiolysis in acute management of severe symptomatic distress associated with delirium.
- Administration of quetiapine may offer benefit in symptomatic management of delirium.
- Deprescribing is worthwhile in older patients, although there is insufficient data to support this recommendation for all cancer patients from the specific perspective of delirium prevention.
- Sedation is considered as a treatment of last resort where symptoms are refractory to available treatment.
- Assessment and treatment of anxiety and existential distress should be undertaken early in the disease as these are highly prevalent in cancer patients at EoL.
- Early detection and treatment of psychological distress leads to better adherence to treatment, better communication, reduced patient anxiety and reduced depression.
- Spiritual distress should be assessed as part of routine cancer care.
- Clinicians can use compassionate listening skills to be present to patients' suffering and help assess and address spiritual distress.
- Interventions for spiritual distress include referral to spiritual care professionals, mindfulness, art, narrative and music therapy, meaning-oriented therapy and dignity therapy.
- For in-depth spiritual assessment and counselling, referral should be to a trained chaplain or spiritual care professional.
- Clinicians should have processes in place to carry out initial screening for psychosocial distress among carers/family members in the pre-death phase.
- Referral for intervention and support to psycho-oncology, social work, spiritual care or other appropriate disciplines should be considered for carers with a history of prolonged caring, as they are vulnerable to anxiety, depression and social and financial distress before and after death.
- Staff need education about grief and loss in order to recognise background factors in carers that may pre-dispose some to poor outcome in bereavement.
- Assess for pre-death dissatisfaction or conflict about the nature or direction of care or lack of preparedness for death among family members and use targeted communication strategies to address concerns .
- Teams should review the death from the family perspective and if there were any unexpected difficulties a team member should contact the family in the post-death period.
- Information about normal and adverse grief trajectories and about routes of access to appropriate levels of support should be made available to all families to facilitate help-seeking after death.
- Information about, and referral to, specialist services offering evidence-informed interventions are priorities for those who are potentially at risk of complicated or prolonged grief disorder.
"Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines," is published in the journal ESMO Open: Cancer Horizons.