Abstract/Text: The case story of a 47-year-old man with advanced rectal carcinoma illustrates the professional services and care system strategies available to help clinicians serve patients coming to the end of life. For this patient, who understands his prognosis, primary care physician services include (1) prevention and relief of symptoms, (2) assessment of each treatment before and during implementation, (3) ensuring that the patient designates a surrogate decision-maker and makes advance plans, and (4) preparation of patient and family for the time near death. Good care may entail enduring unavoidably difficult times with patients and their families. Enrollment in a hospice program requires that decision-makers confront the prognosis and their uncertainties about it, consider the desirability of other services, recognize variations among available hospice programs, address financial issues, and weigh the distress of patients and loved ones at being labeled as "dying." Hospice provides competent, continuous, and reasonably comprehensive care, but it has some constraints. Function and symptoms for those living with serious chronic illness at the end of life generally follow 1 of 3 trajectories: (a) a short period of obvious decline at the end, which is typical of cancer; (b) long-term disability, with periodic exacerbations, and unpredictable timing of death, which characterizes dying with chronic organ system failures; or (c) self-care deficits and a slowly dwindling course to death, which usually results from frailty or dementia. Effective and reliable care for persons coming to the end of life will require changes in the organization and financing of care to match these trajectories, as well as compassionate and skillful clinicians.

Abstract/Text: The Palliative Performance Scale (PPS), a modification of the Karnofsky Performance Scale, is presented as a new tool for measurement of physical status in palliative care. Its initial uses in Victoria include communication, analysis of home nursing care workload, profiling admissions and discharges to the hospice unit, and, possibly, prognostication. We assessed 119 patients at home, of whom 87 (73%) had a PPS rating between 40% and 70%. Of 213 patients admitted to the hospice unit, 175 (83%) were PPS 20%-50% on admission. The average period until death for 129 patients who died on the unit was 1.88 days at 10% PPS upon admission, 2.62 days at 20%, 6.70 days at 30%, 10.30 days at 40%, 13.87 days at 50%. Only two patients at 60% or higher died in the unit. The PPS may become a basis for comparing drug costs at home and for studying the effects of treatments (e.g. hypodermoclysis) at various levels of physical performance. Validity and reliability testing are currently being undertaken.

Abstract/Text: The Karnofsky Performance Status Scale (KPS) was designed to measure the level of patient activity and medical care requirements. It is a general measure of patient independence and has been widely used as a general assessment of patient with cancer. Although there is a long history of use of the KPS for judging cancer patients, its reliability and validity have been assumed without formal investigation. The interrater reliability of the KPS was investigated in two ways, both of which gave evidence of moderately high reliability. The patients evaluated in their home were usually assigned a lower KPS score compared with a similar evaluation at the same time done in the outpatient clinic. Costruct validity of the KPS was demonstrated by strong correlation with several variables relating to physical function. On-study KPS score accurately predicted early death, but high initial KPS scores did not necessarily predict long survival. Patient deterioration with subsequent death within a few months could be predicted to a limited extent by a rapidly dropping KPS. These results suggest that the KPS has considerable validity as a global indicator of the functional status of patients with cancer and might be helpful for following other patients with chronic disease.

Abstract/Text: The aim of this work was to validate a previously constructed prognostic score for terminally ill cancer patients in order to determine its value in clinical practice. The Palliative Prognostic Score (PaP Score) was tested on a population of 451 evaluable patients consecutively entered in the hospice programs of 14 Italian Palliative Care Centers. The score subdivided patients into three specific risk classes based on the following six predictive factors of death: dyspnea, anorexia, Karnofsky Performance Status (KPS), Clinical Prediction of Survival (CPS), total white blood count (WBC), and lymphocyte percentage. The performance of the PaP Score index in the training and testing sets was evaluated by comparing mortality rates in the 3 prognostic risk categories. The score was able to subdivide the validation-independent case series into three risk groups. Median survival was 76 days in group A (with a 86.6% probability of 30-day survival), 32 days in group B (with a 51.6% probability of 30-day survival), and 14 days in group C (with a 16.9% probability of 30-day survival). Survival medians were remarkably similar to those of the training set (64 days in group A, 32 days in group B, and 11 days in group C). In the complex process of staging terminally ill patients, the PaP Score is a simple instrument which permits a more accurate quantification of expected survival. It has been validated on an independent case series and is thus suitable for use in clinical practice.

Abstract/Text: Although accurate prediction of survival is essential for palliative care, few clinical methods of determining how long a patient is likely to live have been established. To develop a validated scoring system for survival prediction, a retrospective cohort study was performed with a training-testing procedure on two independent series of terminally ill cancer patients. Performance status (PS) and clinical symptoms were assessed prospectively. In the training set (355 assessments on 150 patients) the Palliative Prognostic Index (PPI) was defined by PS, oral intake, edema, dyspnea at rest, and delirium. In the testing sample (233 assessments on 95 patients) the predictive values of this scoring system were examined. In the testing set, patients were classified into three groups: group A (PPI< or =2.0), group B (2.04.0). Group B survived significantly longer than group C, and group A survived significantly longer than either of the others. Also, when a PPI of more than 6 was adopted as a cut-off point, 3 weeks' survival was predicted with a sensitivity of 80% and a specificity of 85%. When a PPI of more than 4 was used as a cutoff point, 6 weeks' survival was predicted with a sensitivity of 80% and a specificity of 77%. In conclusion, whether patients live longer than 3 or 6 weeks can be acceptably predicted by PPI.

Abstract/Text: CONTEXT: Rapid-onset opioids for treating breakthrough pain (BTP) in patients with cancer are needed in the Japanese care setting.
OBJECTIVES: To examine the efficacy and safety of fentanyl buccal tablets (FBTs) for treating BTP in Japanese cancer patients.
METHODS: This was a randomized, double-blinded, placebo-controlled study. In subjects receiving around-the-clock (ATC) opioids at doses of 30 mg or more to less than 60 mg or 60-1000 mg of oral morphine equivalents (low and high ATC groups), dose titration was started from 50 to 100 μg FBT, respectively. Subjects whose effective dose was identified were randomly allocated to a prearranged administration order of nine tablets (six FBTs and three placebos), one tablet each for nine episodes of BTP (double blinded). Efficacy and safety of FBT were assessed for patients overall, and also for the low and high ATC groups.
RESULTS: A significant difference was observed between FBT and placebo for the primary endpoint of pain intensity difference at 30 minutes. The analgesic onset of FBT was observed from 15 minutes in several secondary variables (e.g., pain relief). Adverse events were somnolence and other events associated with opioids were mostly mild or moderate. Of the low and high ATC group subjects, an effective FBT dose was identified in 72.2% and 73.1%, respectively.
CONCLUSION: The safety of FBT and its analgesic effect on BTP were confirmed in Japanese cancer patients receiving opioids. Our findings suggest that analgesic onset may occur from 15 minutes after FBT, and that FBT can be administered to patients with low doses of ATC opioids.

Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.