Palliative care has been defined in a number of ways. The World Health Organization (WHO) has defined palliative care as
…an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.'
- provides relief from pain and other distressing symptoms;
- affirms life and regards dying as a normal process;
- intends neither to hasten nor postpone death;
- integrates the psychological and spiritual aspects of patient care;
- offers a support system to help patients live as actively as possible until death;
- offers a support system to help the family cope during the patients illness and in their own bereavement;
- uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; will enhance quality of life, and may also positively influence the course of illness;
- is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
This last point highlights that palliative care should be an active approach to patient management and, when appropriate, integrated into continuing approaches to disease control.
The WHO has also advocated the integration of comprehensive palliative care and pain management into cancer control programs. Palliative care programs are charged with providing pain relief, control of other symptoms, and psychosocial and spiritual support.This approach has been supported by the Australian Government through its National Palliative Care Strategy, and Palliative Care Australia, the national peak body for palliative care, which sets a goal that ‘all people who have a life limiting illness are able to access timely, high quality care appropriate to their needs’.
These plans highlight the importance of all health professionals, from primary care through all specialties, recognising their role in the provision of palliative care, with specialist palliative care services focussing on those patients with more complex needs. The need for access to palliative care is also recognised in other prostate cancer guidelines, again emphasising that it should be available when needed and not limited to the end of life.
Palliative care delivery has been characterised by a team working together to provide integrated care in all domains—physical, emotional, psychological and spiritual. The team can involve a range of medical, nursing and allied health personnel, including psychologists, social workers,physiotherapists, occupational therapists, speech pathologists and dietitians as well as pastoral care workers and volunteers. Many of the studies refer to this type of care as ‘multidisciplinary’ care but it is now more usually described as ‘interdisciplinary’ care to distinguish it from the multidisciplinary cancer care team which is assembled to plan cancer management.
Although there has been little written in relation to the specific palliative care needs of men with metastatic prostate cancer, there is ample evidence of high symptom prevalence in patients with advanced cancer. Teunissen et al reported a systematic review of 44 studies of symptom prevalence in patients with advanced cancer, with a total of 25,074 patients. Fatigue (74%) was the most prevalent symptom, followed by pain (71%), lack of energy (69%), weakness (60%) and anorexia (53%). This clinical pattern is relevant to men with advanced metastatic prostate cancer.
Models of palliative care
Interdisciplinary palliative care is widely available in the Australian healthcare context. The precise model of practice may vary depending on the location of care, the delineation of roles and the focus of the palliative care needs. Specialist palliative care services may be predominantly community based or consist of hospital-based consultative teams. These specialist services might also be delivered in inpatient palliative care units or in a hospice where the team is responsible for its own patient care and beds. The location of the team and its role may influence the timing of referral. Specialist palliative care services working in close association with oncology units can provide easy access to pain and symptom management for oncology patients.
The provision of palliative care is now seen to be an integral part of the standard clinical practice of any healthcare professional. In the case of men with metastatic prostate cancer these health professionals will include urologists and radiation and medical oncologists. In the community, care will be coordinated by general practitioners with support from community nursing services and other support services. All clinicians should feel comfortable in initiating palliative care or in making appropriate referrals when more advice or support is needed from a specialist palliative care practitioner.
In rural and remote Australia, access to some elements of the model may be limited. In these settings and in many community settings, care would usually be coordinated by primary care practitioners, in particular general practitioners and nurses. Limited resources and personnel in rural and remote settings mean that elements of direct interdisciplinary support seen in larger centres, such as multidisciplinary education and counselling interventions, may not be readily available in all settings and that this support and advice is usually provided periodically or through telephone contact to these practitioners by interdisciplinary specialist palliative care teams.
In addition, nursing homes in Australia are the site of much end-of-life care for older people, and delivery of palliative care to this population is also relevant.
In men with metastatic prostate cancer, there is considerable need for coordinated interdisciplinary palliative care from generalist or specialist services. Responding to this need could have a major clinical impact given the size of the population affected by metastatic prostate cancer, but would require an increase in resources for specialist palliative care services as well as continuing education for other health professionals.
Literature search on three key questions
- In men with metastatic prostate cancer, what is the evidence that referral to specialist palliative care can assist in supporting patient’s decision-making and treatment planning processes?
- In men with metastatic prostate cancer, what is the evidence that referral to specialist palliative care can assist in symptom control?
- In men with metastatic prostate cancer, what is the evidence that referral to specialist palliative care can assist patients and their families in providingeffective end-of-life care?
Issues requiring more clinical research study
Clinical questions considered, but for which no evidence was found during systematic review
The search on effective end-of-life care included a review of site of care and site of death, family caregiver satisfaction with care, and impact on the burden of providing end of life care. Although there were no randomised controlled trials specific to metastatic prostate cancer, there were a number of randomised controlled studies identified that dealt with palliative care interventions for patients with advanced cancer, including men with prostate cancer. It was therefore felt that those studies that reached at least Level II evidence with a size of effect rating of at least 2, could be generalised to men with metastatic prostate cancer. The studies covered a wide spectrum of different interventions ranging from educational and counselling sessions, to nurse-led interventions for care at home, and full interdisciplinary palliative care team involvement in care. Double-blinding was not possible, and loss to follow-up through death or deterioration was high. Individual studies were generally small and underpowered, and pooling of data to gain power was not possible because of the problem of heterogeneity of interventions. Concealment of randomisation was also problematic with only three studies overall rated ‘high’ for quality of concealment of treatment allocation schedule.
Men with metastatic prostate cancer should be referred for interdisciplinary palliative care to assist in symptom control and provide emotional, social and spiritual support. This support has been shown to relieve caregiver burden and assist families and carers in providing effective end-of-life care. The involvement of an interdisciplinary palliative care team can improve symptom control and assist in the emotional, spiritual and social wellbeing in patients with advanced cancer.
At any time in the course of the illness, a patient and his family may need support from a communitybased service or a hospital-based consultative team, or even assessment and management by an inpatient palliative care unit. Often palliative care services that work closely with oncology units will gain earlier referrals for pain and symptom management for their prostate cancer patients. The nature of prostate cancer and the age of onset often mean that other medical conditions and co-morbidities may well require the involvement of aged care and geriatric support services at this time as well.
These factors highlight the importance of continuing research to support palliative care in the management of prostate cancer. All health professionals involved in the care of men with metastatic prostate cancer should feel comfortable in initiating palliative care or in making an appropriate referral for specialist interdisciplinary palliative care.
As to how best discuss prognosis and end-of-life issues with the patient and his care-givers, please see Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers.
- ↑ World Health Organisation. Palliative care. World Health Organisation 2008 Available from: http://www.who.int/cancer/palliative/definition/en.
- ↑ Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative Care: the World Health Organization's global perspective. J Pain Symptom Manage 2002 Aug;24(2):91-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12231124.
- ↑ Commonwealth Department of Health and Aged Care. A National Framework for Palliative Care Service Development. National Palliative Care Strategy, Canberra 2000 Jan 1 Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/palliativecare-pubs-npcstrat.htm.
- ↑ Palliative Care Australia. A Guide to Palliative Care Service Development: a population based approach. Primary Care and Palliative Care 2005 Jan 1 Available from: http://www.palliativecare.org.au/Portals/46/Factsheet%20-%20palliative%20care%20service%20development.pdf.
- ↑ National Collaborating Centre for Cancer. Prostate Cancer: diagnosis and treatment. National Institute for Health and Clinical Excellence NICE clinical guideline 58, London UK 2008 Jan 1 Available from: http://www.nice.org.uk/nicemedia/live/11924/39626/39626.pdf.
- ↑ Teunissen SC, Wesker W, Kruitwagen C, de Haes HC, Voest EE, de Graeff A. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage 2007 Jul;34(1):94-104 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17509812.
- ↑ Rummans TA, Clark MM, Sloan JA, Frost MH, Bostwick JM, Atherton PJ, et al. Impacting quality of life for patients with advanced cancer with a structured multidisciplinary intervention: a randomized controlled trial. J Clin Oncol 2006 Feb 1;24(4):635-42 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16446335.
- ↑ 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: http://www.ncbi.nlm.nih.gov/pubmed/11147984.
- ↑ 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: http://www.ncbi.nlm.nih.gov/pubmed/12433764.
- ↑ 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: http://www.ncbi.nlm.nih.gov/pubmed/16329131.
- ↑ Clayton JM, Hancock KM, Butow PN, Tattersall MH, Currow DC, Adler J, et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust 2007 Jun 18;186(12 Suppl):S77, S79, S83-108 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17727340.