RESUMEN
Limited information is available regarding the quality of end-of-life care at cancer centers. We sought to characterize the end-of-life decision-making process for advanced cancer patients admitted to our tertiary cancer center, and to examine the association between goals of care and practice patterns. Information on patient characteristics, investigations, cancer treatments, and goals of care was collected retrospectively for consecutive patients who died at the inpatient unit of the Vancouver Cancer Center between January 1, 2005 and December 31, 2006. One hundred eighteen advanced cancer patients had a median admission duration of 10 days (range 1-64 days). A median of two tests per day was performed, with a decreasing trend over time (P<0.001). Forty percent received cancer treatments during hospitalization, with 75% terminated prematurely. Do-not-resuscitate orders, supportive care plans, and diagnosis of dying were documented for 96%, 86%, and 76% of the patients, respectively. Early establishment of supportive care plan and diagnosis of dying were associated with timely discontinuation of cancer treatments (Spearman coefficients 0.47 and 0.60, respectively). Multivariate analysis revealed that timely diagnosis of dying was associated with early establishment of code status (P=0.042), supportive care plans (P<0.001), and discontinuation of cancer therapy (P=0.005). Cancer patients who died at our oncology center were investigated and treated intensively during their short hospitalization. Early establishment of goals of care may be associated with changes in practice consistent with improved quality of care.
Asunto(s)
Instituciones Oncológicas/estadística & datos numéricos , Objetivos , Neoplasias/psicología , Neoplasias/terapia , Adulto , Anciano , Anciano de 80 o más Años , Actitud Frente a la Muerte , Canadá , Instituciones Oncológicas/normas , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Relaciones Profesional-Familia , Calidad de la Atención de Salud , Órdenes de Resucitación , Adulto JovenRESUMEN
BACKGROUND: Constipation is a common and distressing condition in patients with cancer, especially those taking opioid analgesics. Many institutions prevent and treat constipation with titrated laxatives, which is known as a bowel protocol. An effective and well-tolerated bowel protocol is a very important component of cancer care, and there is little evidence on which to base selection of the most appropriate agents. This study compares a protocol of the stimulant laxative sennosides alone with a protocol of sennosides plus the stool softener docusate, in hospitalized patients at an oncology center. The docusate-containing protocol had an initial docusate-only step for patients not taking opioids, and four to six 100-mg capsules of docusate sodium in addition to the sennosides for the rest of the protocol. METHODS: Thirty patients received the sennosides-only (S) protocol and 30 the sennosides plus docusate (DS) protocol. The efficacy and adverse effects of the protocols were monitored for 5-12 days. The two protocols were used sequentially, creating two cohorts, one on each protocol. Eighty percent of patients were taking oral opioids and 72% were admitted for symptom control/supportive care. RESULTS: Over a total of 488 days of observation it was found that the S protocol produced more bowel movements than the DS protocol, and in the symptom control/supportive care patients this difference was statistically significant (p < 0.05). In the S group admitted for symptom control/supportive care 62.5% had a bowel movement more than 50% of days, as compared with 32% in those receiving the DS protocol. Fifty-seven percent of the DS group required additional interventions (lactulose, suppositories or enemas) compared to 40% in the S group. Cramps were reported equally by 3 (10%) patients in each group. Eight patients (27%) experienced diarrhea in the S group compared to 4 (13%) in the DS group. CONCLUSIONS: The addition of the initial docusate-only step and adding docusate 400-600 mg/d to the sennosides did not reduce bowel cramps, and was less effective in inducing laxation than the sennosides-only protocol. Further research into the appropriate use of docusate and into the details of bowel protocol design are required.