End-of-life care for patients with advanced cancer: ESMO Guideline

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.

Nursing considerations

• 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.

Rationalizing treatments

• 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.

Symptom management

• 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.

Psychological issues

• 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

• 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.

Bereavement care

• 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.

Reference:

"Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines," is published in the journal ESMO Open: Cancer Horizons.