world cancer report - iarc

PALLIATIVE CARE
SUMMARY
> Central to palliative care are symptom
relief and support for the patients and
their families, including regard for emotional,
cultural and other needs.
> A role for palliative care is best considered
early in the course of disease, possibly
at diagnosis.
> Optimal palliative care depends on adequate
infrastructure (personnel, facilities,
drugs) and methodology (modes of
delivery, dose adjustment by the
patient); its outcome should be evaluated.
> Adequate pain control is an essential
component of cancer care. Supportive
treatment is not limited to immediate
medical needs but should also take
account of individual and community
traditions.
Death from cancer, which is usually preceded
by significant morbidity, may occur:
- at the time of diagnosis (especially when
diagnosed at an advanced stage as is the
norm in less industrialized countries);
- during treatment with some major symptoms
the direct result of anticancer treatment
(surgery, radiotherapy, chemotherapy);
- when disease is progressive with less or
no effectiveness for anticancer treatment
(even if available).
In all stages, the patient needs comprehensive
care and a patient with an eventually
fatal disease requires good palliative
care from the time of diagnosis. Comprehensive
care should proceed concurrently
with anticancer treatment, whether with
curative or palliative intent. This approach
to palliative care – as relevant to the
entire care of a patient with probably
eventually fatal disease – is in sharp contrast
to other models of cancer care,
specifically including those in which palliative
care is squeezed into a small section
of the overall management.
Principles of palliative care
Goals for patients with probably incurable
disease should relate to optimum quality
of life as well as achievable prolongation
of life, but not to immortality. Hope is not
fostered by unrealistic goals; rather, these
foreshadow emotional despair.
Decisions should concern the overall care
of the patient, including anticancer therapies,
where evidence indicates that personal
benefit should ensue (tumour
response closely but not wholly parallels
patient benefit) and truly informed consent
is given by the patient under normal
circumstances, or by a duly qualified representative
if the patient is incompetent
[1-4].
Advances in palliative medicine and palliative
nursing in the last two decades have
markedly increased the options for therapy
that may be provided to patients with
complications of advanced disease, such
as gastrointestinal obstruction. Apart
from these broad considerations, the following
specific issues must be addressed
in the context of palliative care for a particular
patient:
- relief of major symptoms in all stages of
disease, especially cancer pain relief;
- comprehensive care for patients actually
close to death;
- support for family during the illness and
after the death of the patient.
The adequacy of palliative care
Evaluation of palliative care may be related
to structural issues (e.g. personnel,
facilities, drugs), processes (modes of
delivery of care) or outcomes [5]. In practice,
evaluation properly involves a combination
of all three categories which may
be assessed at the local, national and
international level [6].
Evaluation should include consideration of:
- availability of essential drugs, notably
oral morphine;
- availability of educated professionals
who can serve as a resource for existing
health services and families, and education/training
systems [7];
- evidence of sound decision-making with
due regard for the patient’s wishes;
- measurement of major symptoms and
their relief (especially pain), in the course
of anticancer treatment as well as on cessation.
The USA has undertaken significant
research in “End of Life Care”, which has
highlighted deficiencies. An authoritative
Committee on Care at the End of Life prepared
a comprehensive report for the
Institute of Medicine, Washington, DC, entitled
Approaching Death [8]. This report
offers a blueprint for change relevant at a
global level. Especially significant is the
model of care proposed (“mixed management”)
with palliative care in its core dimensions
present from time of diagnosis of
eventually fatal illness, and not tied to prognosis
(involving failure of all available anticancer
treatment). This constitutes a radically
new approach, with far reaching implications
for clinical practice, education,
research, quality assurance and administrators
(and funding agencies), and for specialist
palliative care practitioners.
Fig. 6.20 At all stages of disease, the cancer
patient needs comprehensive care. Mary Potter
Hospice, North Adelaide, South Australia.
Palliative care 297