Caring for Patients at the End of Life
Summary of Key Points
• Oncology clinicians must assess patients’ willingness to accept prognostic information and deliver this information clearly and truthfully.
• Patient decisions about resuscitation preferences and disease-directed therapy, including phase 1 trials, should be discussed in the context of their prognosis, values, and goals.
• A sense of purpose can be maintained by patients who work on completing legacies, reconciliation, saying goodbye, and making plans for support or care of bereaved survivors.
Distress
• Physical comfort is a prerequisite for exploring other sources of distress; consultation with anesthesia pain or palliative care specialists can be useful.
• Depression can be ameliorated even in the last weeks of life; delirium can be mistaken for pain and may be exacerbated if it is treated with increases in opioid medication alone.
• Problematic relationships can create open wounds as painful as any physical injury.
• Families with young children are in need of specialized counseling and support.
• Ongoing losses (in physical attractiveness or physical or mental function or of roles in the family, community, or workplace) contribute to spiritual and existential distress. Life reviews and reconnection with sources of spiritual support, including religious rituals, can help.
Hospice Care
• Hospice is the gold standard of care at the end of life. Hospice teams are multidisciplinary (including a physician, nurse, social worker, chaplain, and volunteers), but the referring physician remains in charge of the plan of care. Hospice programs provide care in the home, including all medications and durable medical equipment related to the terminal diagnosis. Patients need not have signed a “do not resuscitate” order to enroll in hospice.
• Barriers to hospice referral include physician and patient reluctance to accept a terminal prognosis (i.e., less than 6 months); current inadequate reimbursement for palliative therapies; and physician, family, and patient misconceptions about entry criteria and services provided.
