domingo, 4 de noviembre de 2018

Palliative and End-of-Life Care in Lung Cancer

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By Liji Thomas, MDReviewed by Yolanda Smith, B.Pharm.

Palliative care is holistic care that is focused on helping patients with life-threatening or grave illnesses to achieve a better quality of life to the very end. It is aimed at averting or treating problems caused by the illness or its treatment, in the physical, emotional, social and spiritual spheres of the patient’s life, even if there is no prospect of a cure. It may be termed “comfort care”, because it aims at providing total support to the patient and the patient’s family and managing symptoms throughout the course of the disease.

Aims

The goals of palliative/end-of-life (EOL) care may be summarized as:

Alleviating physical suffering in order to ensure a higher quality of life
Giving spiritual, psychological and social support to both patient and family
Encouraging open communication with the patient
Coordinating care from different angles
Honoring the values and care preferences expressed by the patient
Preparing for death without unnecessary suffering, while allowing the family and the patient to achieve closure

The people involved in palliative care work as a team, comprising physicians, nurses, social workers, dietitians and psychologists. Some may have chaplains as well. They come to understand the patient’s personal problems and may recommend to the primary care physician, ways and means to reduce distress and pain for the patient. This kind of care is at a premium when the disease can no longer be cured.

Another approach is hospice care, which is generally opted for when a patient is not expected to live longer than 6 months. The hospice team often provides medical, emotional and spiritual support including pain management in the patient’s own home or in a hospice.

For palliative care in lung cancer, a symptomatic approach is usually followed. The most common symptoms in lung cancer patients and the appropriate management is discussed below.

Breathing difficulty

Breathing may be eased with the help of simple exercises, avoiding unnecessary trips up and down the stairs, using a fan to blow cool air towards the face, and chest physiotherapy. If necessary, home oxygen therapy and medications may be prescribed to improve breathing. Underlying pleural effusions and other medical conditions will require treatment.

Pain

Pain treatment needs to be tailored to the patient’s needs, and is available through various approaches. The healthcare givers will try to identify the nature of pain by:

Acute or chronic
Due to the cancer or the treatment, or both
Break through of the pain medication threshold
Superficial or deep

How the pain is controlled will depend on what previous treatments were given, the individual’s response and the extent to which the treatment interfered with normal functioning. Other illnesses, patient prognosis and personal preferences also operate as modifying factors.

Other Symptoms

Other symptoms such as fatigue, nausea, vomiting and insomnia may be present. Palliative care providers screen for such problems so as to pick them up early, and care is provided to control them as soon as possible. This may include medication, radiation, chemotherapy or surgery. Other measures include physiotherapy or relaxation techniques.

Emotional needs

Being distressed and anxious about one’s cancer is often a natural part of dealing with lung cancer, and may be associated with every stage, from diagnosis to end of life. Open communication about one’s needs is the best way to handle this. It is important to treat anxiety, as it interferes with sleep, increases nausea and vomiting, and increases pain sensation. If medication is needed, the palliative care team will usually help to make it available. In addition, or alternatively, support groups, counseling and family meetings may be organized in accordance with the patient’s needs or desires.

Financial and legal needs

Social workers will be able to help identify sources of financial support for the patient and the care-giver. Free prescriptions are also available and the palliative team will be able to assist the patient to access them. They will also offer help in dealing with insurance, employment benefits, and other medical benefits such as transportation or housing during the period of illness. Additionally, patients will be able to deal with legal documents, such as lasting power of attorney, which will empower caregivers to handle essential matters when the patient is no longer able to do so.

Spiritual concerns

The palliative team can guide patients and their caregivers to people who will help them find answers to questions regarding the meaning of their sufferings and of life in general, in order to maintain hope and finally reach acceptance and closure.

End-of-life care

The palliative care team will continue to provide care through the last years or months of life. End-of-life care is usually offered to people who are expected to face death within 12 months. These include people with:

Advanced incurable illness, including dementia and malignancies
General ill-health which has advanced to a stage where death is near
Conditions in which sudden fatal crises can occur
Acute life-threatening illnesses or conditions

The patient’s primary healthcare providers are entrusted with the responsibility of passing on the knowledge as to which palliative or support services are available and how to get in contact with them.

The palliative care team is deeply involved in helping patients make the shift from treatment for the disease to end-of-life care. Patients and families need to prepare for the various changes and demands that will accompany this phase, with the help available to manage them. It will help the patient and caregiver plan what to do as the illness becomes progressively more severe. It will include decisions as to when and whether one should be admitted to hospital, a hospice or stay at home. This is based on the wishes of the patient and the caregiver, the clinical condition and the services that are available in the vicinity.

Benefits of palliative/EOL care

The benefits of a planned transition include:

Being treated in accordance with one’s values and choices
Less distress associated with the change
Healthcare burden which is unproductive
Working through grief more openly

Timely and adequate palliative and end-of-life care in lung cancer helps patients and their families to enjoy a better quality of life as life approaches its end. The main components responsible for this are its ability to support patients emotionally, provide good communication about their needs and that of their caregivers and families, and provision of practical assistance.