Advanced prostate cancer

In men with advanced prostate cancer, what is the evidence that specialist palliative care can assist patients and families in providing effective end of life care?

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In men with advanced prostate cancer, what is the evidence that specialist palliative care can assist patients and families in providing effective end-of-life care?

Specialist palliative care services were also shown to assist patients and their families in providing effective end-of-life care. A reduction in the number of hospital admissions was seen in one study[1] and is of particular relevance because it occurred in a population of nursing home residents where hospital avoidance would be an aim of palliative management. A reduction in time spent in hospital was shown in several studies.[2][3][1][4][5] Although death at home is often regarded as a desired outcome for palliative care interventions, only two of nine studies[6],[7][8][9] showed a significant increase in deaths at home. In Jordhøy[7], time at home was not significantly increased, but time spent in a nursing home in the last month of life was reduced. In a second study that related to a nursing home population there was also no significant difference in the proportion of carers who believed that then patient died where he/she wanted to.[1]

The increase in the number of patients completing advance care plans was taken as evidence of preparation for death[10], as was the increase in the number of patients who completed funeral arrangements.[11]

Informal or family caregivers derived significant benefit from the involvement of palliative care services in terms of their satisfaction with the care delivered, improvement in communication and their own improved quality of life.

Caregivers expressed increased satisfaction with quality of care.[12][2] [13][7][8][9][1][14][15] Hughes[12] reported an increase in satisfaction in relation to access to care and the technical quality, interpersonal elements and outcomes of care. Kane[2] [14] also found that carers reported better interaction with professionals and greater satisfaction with their own involvement in care. Ringdal[9] and Jordhøy[7] identified caregiver satisfaction with the availability of doctors to the family. This study also identified significantly improved satisfaction with a number of aspects of the information carers were given about the patient’s prognosis and progress. Increased satisfaction with communication was also identified by Hughes[12] and SUPPORT.[16]

Where 24-hour practical nursing care in the home (hospital in the home) was compared with usual home care by a GP and district nurse[17], significantly more unmet need for night nursing support and for support for the carer in looking after the patient was identified in the control group. A study on the impact of an intervention in caregivers’ coping skills showed a reduction in both task burden and the burden of the patients’ symptoms for carers.[18]

However in one study[13], caregiver morale was lower in carers whose relative survived more than 30 days after discharge from hospital. This may reflect the continuing burden of caring when the expectation was for a short terminal illness.

A significant finding was an improvement in carers’ overall quality of life[12][18] with Hughes[12] finding improvement in several specific domains relating to quality of life, including physical function, physical and emotional aspects of role function, mental health and social function. Addington-Hall[3] and Raftery[5] identified a decrease in caregiver expression of anger at the thought of the patient’s death.

Provision of end-of-life care is a significant burden for informal caregivers. The evidence suggests this burden can be reduced through adequate provision of palliative care services, leading to improved outcomes for the family. This has the potential to have a major impact given the size of the population.

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Evidence summary and recommendations

Evidence summary Level References
In men with metastatic prostate cancer there is evidence that coordinated interdisciplinary palliative care can assist patients and families in providing effective end-of-life care, with more time spent out of hospital and reduction in the burden of providing care. II [12], [6], [18], [2], [10], [13], [17], [11], [3], [7], [8], [9], [1], [14], [15], [5], [16]
Evidence-based recommendationQuestion mark transparent.png Grade
Men with metastatic prostate cancer and their families should be referred for a coordinated palliative approach to assist in providing effective end-of-life care.

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  1. 1.0 1.1 1.2 1.3 1.4 Casarett D, Karlawish J, Morales K, Crowley R, Mirsch T, Asch DA. Improving the use of hospice services in nursing homes: a randomized controlled trial. JAMA 2005 Jul 13;294(2):211-7 Available from:
  2. 2.0 2.1 2.2 2.3 Kane RL, Wales J, Bernstein L, Leibowitz A, Kaplan S. A randomised controlled trial of hospice care. Lancet 1984 Apr 21;1(8382):890-4 Available from:
  3. 3.0 3.1 3.2 Addington-Hall JM, MacDonald LD, Anderson HR, Chamberlain J, Freeling P, Bland JM, et al. Randomised controlled trial of effects of coordinating care for terminally ill cancer patients. BMJ 1992 Nov 28;305(6865):1317-22 Available from:
  4. Kane RL, Berstein L, Wales J, Rothenberg R. Hospice effectiveness in controlling pain. JAMA 1985 May 10;253(18):2683-6 Available from:
  5. 5.0 5.1 5.2 Raftery JP, Addington-Hall JM, MacDonald LD, Anderson HR, Bland JM, Chamberlain J, et al. A randomized controlled trial of the cost-effectiveness of a district co-ordinating service for terminally ill cancer patients. Palliat Med 1996 Apr;10(2):151-61 Available from:
  6. 6.0 6.1 Moore S, Corner J, Haviland J, Wells M, Salmon E, Normand C, et al. Nurse led follow up and conventional medical follow up in management of patients with lung cancer: randomised trial. BMJ 2002 Nov 16;325(7373):1145 Available from:
  7. 7.0 7.1 7.2 7.3 7.4 Jordhøy MS, Fayers P, Saltnes T, Ahlner-Elmqvist M, Jannert M, Kaasa S. A palliative-care intervention and death at home: a cluster randomised trial. Lancet 2000 Sep 9;356(9233):888-93 Available from:
  8. 8.0 8.1 8.2 Jordhøy MS, Fayers P, Loge JH, Ahlner-Elmqvist M, Kaasa S. Quality of life in palliative cancer care: results from a cluster randomized trial. J Clin Oncol 2001 Sep 15;19(18):3884-94 Available from:
  9. 9.0 9.1 9.2 9.3 Ringdal GI, Jordhøy MS, Kaasa S. Family satisfaction with end-of-life care for cancer patients in a cluster randomized trial. J Pain Symptom Manage 2002 Jul;24(1):53-63 Available from:
  10. 10.0 10.1 Engelhardt JB, McClive-Reed KP, Toseland RW, Smith TL, Larson DG, Tobin DR. Effects of a program for coordinated care of advanced illness on patients, surrogates, and healthcare costs: a randomized trial. Am J Manag Care 2006 Feb;12(2):93-100 Available from:
  11. 11.0 11.1 Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med 2004 Jan 12;164(1):83-91 Available from:
  12. 12.0 12.1 12.2 12.3 12.4 12.5 Department of Veterans Affairs Cooperative Study Group on Home-Based Primary Care, Hughes SL, Weaver FM, Giobbie-Hurder A, Manheim L, Henderson W, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA 2000 Dec 13;284(22):2877-85 Available from:
  13. 13.0 13.1 13.2 Hughes SL, Cummings J, Weaver F, Manheim L, Braun B, Conrad K. A randomized trial of the cost effectiveness of VA hospital-based home care for the terminally ill. Health Serv Res 1992 Feb;26(6):801-17 Available from:
  14. 14.0 14.1 14.2 Kane RL, Klein SJ, Bernstein L, Rothenberg R, Wales J. Hospice role in alleviating the emotional stress of terminal patients and their families. Med Care 1985 Mar;23(3):189-97 Available from:
  15. 15.0 15.1 Zimmer JG, Groth-Juncker A, McCusker J. Effects of a physician-led home care team on terminal care. J Am Geriatr Soc 1984 Apr;32(4):288-92 Available from:
  16. 16.0 16.1 The Support Principle Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 32202 Jan 1;274(20):1591-8 Available from:
  17. 17.0 17.1 Grande GE, Todd CJ, Barclay SI, Farquhar MC. A randomized controlled trial of a hospital at home service for the terminally ill. Palliat Med 2000 Sep;14(5):375-85 Available from:
  18. 18.0 18.1 18.2 McMillan SC, Small BJ, Weitzner M, Schonwetter R, Tittle M, Moody L, et al. Impact of coping skills intervention with family caregivers of hospice patients with cancer: a randomized clinical trial. Cancer 2006 Jan 1;106(1):214-22 Available from:

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