Despite advances in the treatment of cancer, many people will die from their disease. This summary is intended to address care during the last days to last hours of life, including common symptoms, ethical dilemmas that may arise, and the role of the cancer care professional in caring for patients and their families during this time.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
The diagnosis of an occult primary tumor is made only if no primary tumor is detected after careful search and does not appear during therapy. Patients with cervical lymph node metastases histologically related to a previously treated primary tumor and patients with lymphomas and adenocarcinoma are excluded. If the biopsy is an undifferentiated carcinoma (in particular, a lymphoepithelioma), the most probable primary site is in Waldeyer ring; for example, the nasopharynx, base of...
Although greatly feared by our death-denying society, the end of life can be a time of great personal growth for patients and their families. This growth depends on thoughtful discussions and careful decision making about advance care planning, optimally beginning soon after diagnosis and continuing throughout the course of the disease. Planning includes establishing the goals of care, clarifying acceptable treatment options (including discussions regarding palliative care and hospice), and determining where a patient wishes to spend the final days of life. When these discussions do not take place and plans are not made, the final hours may be filled with suffering and distress.
In a large study of people with advanced cancer, patients who reported having end-of-life discussions with their physicians (n = 188) had significantly lower health care costs than did patients who did not have these discussions (n = 415). This was demonstrated by a reduction in resuscitation, ventilator use, and intensive care stay. There was no difference either in survival time or in the likelihood of receiving chemotherapy for patients who discussed end-of-life preferences with physicians (n = 75) and those who did not (n = 70). Higher costs were associated with worse quality of life at death, as rated by the patient's caregiver (hospice nurse or family member).
In a U.S.-based multisite, prospective, longitudinal study, advanced cancer patients and their caregivers were followed to assess the association between end-of-life discussions and medical care, patient mental health, and caregiver adjustment. The cohort consisted of 332 patients who died a median of 4 months after enrollment, with 123 (37%) reporting end-of-life discussions with physicians at baseline. Results demonstrated an association between discussions and less aggressive medical care near death and earlier referrals to hospice. Aggressive care was associated with worse patient quality of life and caregiver adjustment.