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What Is the Role for Palliative Care in Patients With Advanced Hematologic Malignancies?

Introduction and Scope of the Problem Approximately 178,000 people are diagnosed with hematologic malignancies every year in the United States. These patients face highly unpredictable illness trajectories and intense treatment plans, resulting in complex psychological and physical symptoms. The high symptom burden of this population spans the entire disease continuum from diagnosis to the end of life and leads to poor quality of life. Accordingly, patients…

What Is the Clinical Course of Advanced Solid-Tumor Cancers?

Introduction and Scope of the Problem Although the National Cancer Institute (NCI) defines advanced cancer as “unlikely to be cured or controlled by treatment,” recent advances in therapy have favorably altered the illness trajectory for patients with many types of cancer. The overall rate of cancer-related deaths in the United States decreased by 15% from 2007 to 2017 and by an average of 1.5% per year…

What Is the Role for Palliative Care in Patients With Advanced Solid-Tumor Malignancies?

Introduction and Scope of the Problem Cancer has become one of the leading causes of premature death globally. The World Health Organization predicts that by 2040 there will be 27 million new cancer diagnoses annually. As the global burden of cancer continues to rise, so too do the number of cancer survivors living with the physical and emotional sequelae of cancer and its treatments. This represents…

What Are the Special Communication Issues Involved in Caring for Pediatric Patients?

Introduction and Scope of the Problem Differences in Pediatric and Adult Decision Making One important difference when communicating with seriously ill pediatric patients compared to seriously ill adult patients is that the pediatric patient, in most circumstances, does not have the authority to make their own medical decisions. Decision-making authority is the legal ability to consent to treatment, or equally important, to decline recommended treatments. For…

What Are the Elements of Advance Care Planning and What Is the Evidence That Advance Care Planning Changes Patient Outcomes?

Introduction and Scope of the Problem Patients and families facing a serious illness are confronted with multiple decisions about medical care. These decisions are high-stakes, are stressful for all involved, and have numerous downstream effects for patients, families, providers, and the health care system. Advance care planning (ACP) seeks to improve this decision-making process by preparing for these moments ahead of time. While ACP was initially…

What Are the Key Elements to Having a Conversation About Communicating Serious News and Setting Goals?

Introduction and Scope of the Problem The two most common communication tasks faced by palliative care clinicians are communicating serious news and discussing transitions in goals of care. Although these skills are often taught as part of general medical, nursing, and social work curricula, the skills needed by palliative care clinicians are generally more complex. Table 32.1 presents some common topics in palliative care conversations that…

How is Prognosis Estimated and Communicated for People Facing Serious Illness?

Introduction and Scope of the Problem Prognostication—the process of addressing “what to expect” for an individual’s disease course—is essential for meaningful decision making at all stages of serious illness. Estimating prognosis is most commonly applied to estimating life expectancy, but estimates may also be applied to other important markers in an illness trajectory, including when and if treatment will lead to a cure, the development of…

How Do Symptoms Change for Patients in the Last Days/Hours of Life?

Introduction and Scope of the Problem Many people faced with a life-threatening illness wonder what the last hours to days of their life will entail. They may express concerns that their symptoms will be difficult to control or that they will suffer at the very end of life. Equally concerning is the fear that their care will burden others or that observing their death will be…

What Are Effective Pharmacological and Nonpharmacological Treatments for Delirium?

Introduction and Scope of the Problem Delirium is a neuropsychiatric disorder characterized by an acute change in consciousness, attention, and cognition, with a tendency to fluctuate through the course of a day. It is defined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) by the following characteristics: (1) a disturbance of consciousness (awareness of the environment) with disturbance in attention…

What Is Delirium and How Should It Be Managed?

Introduction and Scope of the Problem The word delirium is derived from the Latin term meaning “off track.” Delirium has many descriptors, including acute confusion, altered mental status, sundowning, intensive care unit (ICU) psychosis, organic psychosis, acute brain failure, toxic metabolic state, cerebral insufficiency, and encephalopathy. All of these terms are used to describe an acute cognitive impairment associated with medical illness, which can be labeled…

What Is the Approach to the Patient Seeking a Hastened Death?

Introduction and Scope of the Problem The very nature of the terms “physician-assisted suicide,” “physician aid in dying,” and “medical aid in dying” may evoke strong feelings from opponents as well as advocates who would wish to focus this evidence review on questions of morality or steps to promote its use. This review will not address the legal and ethical issues involved in responding to a…

How Are Anxiety and Fear Best Treated in Patients With Serious Illness and in Those Facing the End of Life?

Introduction and Scope of the Problem This chapter focuses on anxiety and fear in patients with serious illness and those facing the end of life. If left untreated, anxiety and fear may lead to poor care outcomes and prognoses. In addition, anxiety and fear can lead to significant impairments in physical and psychosocial functioning, as well as a decreased quality of life. Anxiety disorders are also…

What Treatments Are Effective for Depression in Palliative Care Settings?

Introduction and Scope of the Problem Depression is a profoundly distressing emotional experience, both for patients and family members. In the setting of serious illness, it is amplified by physical symptoms, fear of dying, family distress, and grief. Depression impairs the ability to enjoy life, interferes with connection, is associated with feelings of emptiness and meaninglessness, increases suicide risk, and causes anguish to family and friends.…

What Is the Role of Parenteral and Enteral Nutrition in Patients With Cancer and With Noncancer Illness?

Introduction and Scope of the Problem Artificial nutrition (AN) and artificial hydration (AH) are umbrella terms that describe medical interventions for patients who are unable to eat and need alternative means of obtaining nutrition or fluids. These interventions can be given intravenously (parenteral nutrition or PN) or by means of a tube placed into the stomach or proximal small bowel (enteral nutrition or EN). For patients…

What Therapeutic Strategies Are Effective in Improving Anorexia and Weight Loss in Nonmalignant Disease?

Introduction and Scope of the Problem Cachexia is a term commonly understood by health care professionals. It describes a condition characterized by the presence of involuntary weight loss and culminating in a state of emaciation. Until recently, no agreement had been reached on an operational definition of and diagnostic criteria for cachexia; this lack of definition motivated international groups of experts to develop a uniformly accepted…

What Therapies Are Effective in Improving Anorexia and Weight Loss in Cancer?

Introduction and Scope of the Problem The onset of involuntary weight loss is often the first clinical sign of the presence of malignant disease. In cancers that are incurable by currently available therapies, significant weight loss can be seen in any palliative care setting. The estimated prevalence of cancer cachexia is variable. Given the prevalence of obesity in Westernized countries, the marked shift in body weight…

What Interventions Are Effective for Relieving Acute Bowel Obstruction in Cancer and Other Conditions?­

Introduction and Scope of the Problem Malignant bowel obstruction (MBO) is common, occurring in up to 15% of patients with cancer, and is the most common indication for palliative surgical consultation. Most frequently associated with gastric, colorectal, and ovarian malignancies, MBO occurs from spread of the primary disease causing either intraluminal obstruction or external compression by peritoneal metastases, or from treatments for the primary disease (e.g.,…

How Should Medications Be Initiated and Titrated to Prevent and Treat Nausea and Vomiting in Clinical Situations Unrelated to Chemotherapy?

Introduction and Scope of the Problem Nausea, vomiting, and retching are common and distressing symptoms encountered in patients with advanced illness. Among patients with cancer, up to 70% report these symptoms. Patients with other advanced illnesses may also report these symptoms, including more than half of patients with end-stage kidney disease, end-stage liver disease, and acquired immunodeficiency syndrome. Nausea, especially when accompanied by emesis, can result…

How Should Medications Be Initiated and Titrated to Reduce Acute and Delayed Nausea and Vomiting in the Setting of Chemotherapy?

Introduction and Scope of the Problem Chemotherapy-induced nausea and vomiting (CINV) remains one of the most unpleasant, distressing, and feared symptoms for cancer patients. Without sufficient antiemetic prophylaxis, 30% to more than 90% of patients experience CINV with moderately emetogenic chemotherapy (MEC) or highly emetogenic chemotherapy (HEC) within the first 24 hours of administration. Moreover, 20% to 30% of patients may experience anticipatory nausea and vomiting.…

What Medications Are Effective in Preventing and Relieving Constipation in the Setting of Opioid Use?

Introduction and Scope of the Problem Constipation resulting from opioid use, commonly referred to as opioid-related constipation, opioid-induced bowel dysfunction, or opioid-induced constipation, is one of the most distressing symptoms experienced by patients, especially those with advanced illness. The prevalence of constipation from all causes, including opioid-induced constipation, in hospitalized patients with cancer ranges from 10% to 70%, with more than 50% of patients reporting constipation…