Discussion of the do-not-resuscitate (DNR) orders with the family caregivers of cancer patients: An example from a major cancer center in Saudi Arabia.

OBJECTIVES: To explore the views of the family caregivers (FCGs) about the "do-not-resuscitate" (DNR) discussions and decision-making processes that occurred during hospitalization in a Saudi cancer center. METHODS: In this cross-sectional survey, the FCGs of inpatients with advanced cancer completed a self-administered questionnaire soon after giving the patients a DNR status designation by their oncologists. RESULTS: Eighty-two FCGs participated in the study, with a median age of 36.5 years and male preponderance (70.7%). The FCGs were mostly sons (41.5%), daughters (14%), or brothers (11%) of patients. Only 13.4% of mentally competent patients had the chance to listen to the DNR discussion. The discussion mainly occurred in the ward corridor (48.8%) or another room away from the patients' rooms (35.4%). In 36.6% of cases, the discussion took ≤5 minutes. Half of the FCGs stated that the oncologists' justifications for the DNR decision were unconvincing. The majority (84.2%) of the FCGs felt that the healthcare providers should share the DNR decision-making with patients (1.2%), families (69.5%), or both (13.4%). FCGs ≤ 30 years of age were more supportive of giving patients' families a chance to participate in the DNR decision-making process (p = 0.012). SIGNIFICANCE OF RESULTS: There is considerable room for improving the current practice of DNR discussions and decision-making processes in the studied setting. A readily feasible rectifying measure is to ensure the adequacy of time and privacy when planning for DNR discussions. We expect our findings to draw the attention of stakeholders to a compelling need for reviewing the current policies and processes, aiming to improve the experience of cancer patients and their FCGs.

Contribution of Eastern Mediterranean Region countries to palliative care journals from 1991 to 2020 and its relationship to the development of palliative care.

BACKGROUND: Palliative care (PC) is in an early stage of development in the Eastern Mediterranean Region (EMR) of the World Health Organization. A metric based on publishing in specialized PC journals may be useful in assessing PC development. This study was conducted to describe the contribution of EMR countries to PC research and to study the relationship between this contribution and the levels of PC development. METHODS: The Scopus database was used to search 21 PC journals (1991-2020) for articles with at least one EMR-affiliated author independently of his/her position in the article. As an indicator, the 3-year average articles per million population per year (AAMY) was calculated. Changes over time were calculated through a regression analysis. The relationship between the AAMY and the level of PC development and opioid consumption were assessed through Mann-Witney test using the worldmap PC development categories as a proxy, and Spearman analysis, respectively. RESULTS: The number of articles published during the 30-year period was 31,108 of which 402 (1.3%) were EMR-affiliated. There was a steady rise in the AAMY of the EMR (R2 = 0.894). The number of EMR-affiliated articles increased from 3 in the period 1991-1995 to 191 in 2016-2020. The 2018-2020 AAMY was significantly higher in countries with greater PC development than in those without (median [IQR] = 0.0975 [0.0254-0.1802] and 0.0098 [0-0.0256], p = 0.042). Also, it was significantly higher in countries that progressed to a higher level of PC development between 2006 and 2017 (p = 0.0159). There was a significant positive correlation between the average opioid consumption for the years 2017-2019 and the AAMY for the same period (p = 0.0043). CONCLUSIONS: There is a slow steady progress in the contribution of EMR countries to PC journals, which corresponds to the level of PC development and its progress in the region. A metric based on the contribution to specialized PC journals may be a useful indicator of PC development.

Opioid Prescribing Patterns Before and After an Inpatient Palliative Care Consultation.

BACKGROUND: To the best of our knowledge, the change in opioid prescription patterns upon referral to a palliative care team (PCT) was not previously investigated in the Middle East. OBJECTIVE: This study aimed to explore the change in the pattern of opioid prescription and the pain scores before and after referring inpatients to a PCT. METHODS: We conducted a retrospective review of patients' records including all inpatients ≥15 years newly referred to the PCT over a period of 21 months at King Faisal Specialist Hospital and Research Center, Riyadh. RESULTS: Of 631 patients, 52.3% were females, the median age was 54 years, and 96.7% had cancer. The proportion of patients on opioids before referral (83.4%) increased to 93.3% in the postreferral period, P < .0001. Patients receiving opioids on a regular basis increased from 31.9% before referral to 49.9% after referral to the PCT, P < .0001. Morphine was the most commonly prescribed opioid on a regular basis pre- and postreferral. Upon referral, the administration of opioids through the subcutaneous route increased from 3.7% to 10.9%, P < .0001. On average, pain scores were reduced by 1 point on a 0 to 10 numeric scale within 48 hours of seeing a patient by the PCT, P < .0001. CONCLUSION: Patients referred to a PCT are likely to get their opioid prescription optimized and pain scores improved shortly after the PCT involvement. Patients with cancer-related pain requiring opioids should be referred to a PCT as early as possible.

The Use of Antidiabetic, Antihypertensive, and Lipid-lowering Medications in the Elderly Dying with Advanced Cancer.

BACKGROUND: Maintenance of medications that are unconducive to the quality of life is difficult to justify in dying terminally-ill cancer patients. OBJECTIVE: We aimed at determining the prevalence of administering antidiabetic, antihypertensive, and lipid-lowering medications to elderly patients dying with cancer. METHODS: We reviewed the medical records of patients above 60 years of age with advanced cancer who died in a palliative care unit. The collected data included the use of antidiabetic, antihypertensive, and lipid-lowering medications during the last week of life. RESULTS: Of 103 patients, 51.5% were female and the median age was 69 years. The most common cancers included gastrointestinal (40.8%), gynecological (13.6%), and head and neck (12.6%). All patients had advanced cancer and 59.2% had hypertension, 52.4% had diabetes mellitus, and 19.4% had dyslipidemia. During their last week of life, 38.8% received antidiabetic, 23.3% received antihypertensive, and 3.9% received lipid-lowering agents. The data showed that 68.5% of people with diabetes received antidiabetic medications, 37.7% of hypertensive patients received antihypertensive medications, and 20% of dyslipidemics received lipid-lowering agents. Hypoglycemia was reported in 7.5% of patients receiving antidiabetic drugs, while hypotension was reported in 66.7% of patients receiving antihypertensive agents. CONCLUSION: Many elderly patients dying with advanced cancer in a palliative care unit were maintained on medications for chronic conditions until the very late stages of their lives. For such imminently dying patients, benefits of such medications are unlikely and burdens are possible. Further research is needed to explore physicians' justifications, if any, for maintaining such patients on apparently futile medications.

Validation of an Arabic Questionnaire for Symptom Assessment.

BACKGROUND: Impeccable assessment of symptoms is central to palliative care (PC) practice. OBJECTIVES: The study objectives are (1) to test the validity of the Arabic Questionnaire for Symptom Assessment (AQSA) as a self-administered (SA) tool for assessing the severity of the listed symptoms among PC patients and (2) to test the validity of AQSA when completed by a proxy. METHODS: The AQSA is a tool for assessing the severity of 11 symptoms in addition to the overall suffering experience on a 0 to 10 numeric scale. Symptom scores on the SA AQSA were compared to scores obtained through interviews with patients. The same procedure was repeated with patients' sitters to explore the validity of using the tool for symptom assessment by proxy. RESULTS: The study involved 107 pairs (a patient and a sitter, each) with a mean age of 46.3 years (females 59.8%) for patients and 35.9 years (females 65.7%) for sitters. The correlation coefficient ( r) for agreement between SA and interview-based (IB) scores for patients ranged from .65 ( P < .0001) for drowsiness to .86 ( P < .0001) for pain. The SA AQSA showed positive correlation between sitters' and patients' scores, with r ranging from .28 ( P = .004) for depression to .62 ( P ≤ .0001) for vomiting. CONCLUSIONS: The strong positive correlation between SA and IB AQSA indicates that the former is a valid tool. When the SA AQSA is used by proxy, it showed moderate to strong positive correlation with patients' actual scores for most of the symptoms.

Using Neuroleptics to Treat Delirium in Dying Cancer Patients at a Cancer Center in Saudi Arabia.

Neuroleptics are commonly used for treating delirium as a common problem in terminally ill cancer patients. However, prescribing patterns are believed to substantially vary among health professionals. The aim of this study is to determine the pattern of prescribing neuroleptics for treating delirium in cancer patients dying in a palliative care unit in Saudi Arabia. We reviewed the medical records of adults with advanced cancer who died in the palliative care unit over 23 months. In addition to patients' demographics, data collection included the pattern of prescribing neuroleptics for the treatment of delirium during the last week of life. For the 271 patients included (57.6% females), the median age was 54 years. Although 62% of patients were on around-the-clock (ATC) neuroleptics to treat delirium, about two thirds of these were requiring rescue doses (PRN [pro re nata]) as well. The ATC neuroleptics included haloperidol alone (89.3%), levomepromazine alone (2.4%), or both (8.3%). All neuroleptics were administered via the parenteral route. On average, the maximum daily doses of the ATC neuroleptics were 4 mg for haloperidol and 15.5 mg for levomepromazine. Patients with primary or metastatic brain cancers were less likely to be on neuroleptics (P < .0001). The authors conclude that in their palliative care unit, haloperidol is by far the most commonly used neuroleptic, followed by levomepromazine, to treat the common problem of delirium in patients dying with advanced cancer. The generally low doses of neuroleptics required may be attributed to several factors in this population, including cultural motives.

Impact of bilateral breast cancer on prognosis: synchronous versus metachronous tumors.

BACKGROUND: The clinical significance of bilateral breast cancer is unclear and its influence on prognosis is controversial. MATERIALS AND METHODS: Between 2005 and 2009 we identified 110 cases of bilateral breast cancer (BBC) ; 49 patients had synchronous (duration between the occurrence of carcinoma in both breasts was less than 12 months) and 61 had metachronous (duration was more than one year with no ipsilateral local recurrence). We compared the patient characteristics including age, menopausal status, clinical stage, tumor size, histological classification, lymph node status, and hormone receptor and Her-2 status. We also compared the treatment given and overall and disease free survival (DFS) of both groups. RESULTS: Synchronous cases tend to present more aggressively than metachronous cases and age at first presentation adversely affects survival. The 5 year overall survival was 78.7% for metachronous and 60% for synchronous. Patients with positive hormonal status had better five year disease free survival in metachronous compared to synchronous cases, at 76% and 63%, respectively. Age at first presentation >45years had better DFS (65%) compared to those with age ≤45 years (52%) at 5 years follow up. CONCLUSIONS: Patients with synchronous breast cancer may have worse prognosis. Young age and hormone receptor negative were risk factors in our study. Close follow up and early detection of contralateral breast cancer is mandatory.

The impact of implementing referra criteria on the pattern of referrals and admissions to a palliative care program in Saudi Arabia.

Referral criteria were developed to rationalize transfer-of-care requests and referrals to a hospital-based palliative care program (PCP) in Saudi Arabia. This study aimed to explore the impact of an approved referral criteria policy on the pattern of referrals to a PCP. Two periods, 19 months each, were identified: one before the implementation of the referral criteria (precriteria), and the other started 6 months later (post-criteria). During the two study periods, the palliative care unit (PCU) received 620 admissions related to 518 patients. Of them, 314 (50.6%) were in the precriteria period. A total of 1,216 new cancer referrals were received by the PCP during the study period, with 53.2% received during the precriteria period. The postcriteria period was associated with a proportional increment in admissions to the PCU through the emergency room (P <0.001) by the palliative care team (P = 0.001) for patients whose care had been previously transferred completely to the PCP. The median survival of referred patients decreased from 2.27 months during the precriteria period to 1.73 months during the postcriteria period (P = 0.0051). The findings suggest that the implementation of the referral criteria policy was associated with a more rational pattern of transfer-of-care referrals to the PCP. However, more educational efforts and organizational actions are needed to prevent delayed referrals of cancer patients to palliative care teams.

Hypercalcemia in advanced head and neck squamous cell carcinoma: prevalence and potential impact on palliative care.

Hypercalcemia is common in patients with advanced head and neck squamous cell carcinoma (HNSCC). In this study, hypercalcemia was detected in 46 (51%) of 90 eligible patients with HNSCC over 4 years. Compared with nonhypercalcemics, hypercalcemics were more likely to be referred to palliative care, while they were inpatients (P = 0.004). During the last 3 months of follow-up, hypercalcemic patients were more likely than nonhypercalcemics to be hospitalized for > or = 14 days (P = 0.01) and to visit the emergency room more than once (P = 0.04). The median survival from the first hypercalcemic episode was 74 days (95% CI, 0-234). With data calculated from the date of referral to palliative care, hypercalcemics had a shorter survival than did nonhypercalcemics (43 vs 128 days, respectively; P = 0.046). Early detection and management of hypercalcemia in patients with HNSCC may improve the chance of preventing distressing symptoms and reducing unnecessary frequent emergency room visits and lengthy hospitalization.

Predictive impact of electrolyte abnormalities on the admission outcome and survival of palliative care cancer referrals.

BACKGROUND AND AIM: Electrolyte abnormalities are common among patients with advanced cancer. Our aim was to estimate the prognostic significance of such abnormalities in a palliative care setting. METHODS: A retrospective review of the medical records of inpatients with cancer referred to palliative care over a 25-month period. The five electrolytes studied were potassium, sodium, calcium, magnesium, and phosphate. The prognostic impact of related abnormalities on admission outcome and overall survival was estimated in univariate analysis. RESULTS: From 866 new cancer referrals, 259 (30%) were eligible for analysis. Abnormalities in sodium, calcium, and magnesium levels were associated with a significant difference in inpatient death rates (p = 0.004, 0.001 and 0.04, respectively) and overall survival (p = 0.0008 and 0.0008, and < 0.0001, respectively). The status of potassium and phosphate had no significant impact on admission outcome or overall survival. The three electrolyte abnormalities associated with the highest inpatient death rate were hypercalcemia, hypernatremia, and hypermagnesemia (69%, 68%, and 62%, respectively). Patients with these abnormalities had the shortest median survival as well (12, 8, and 12 days, respectively). CONCLUSION: Some electrolyte abnormalities may be useful as prognostic indicators in the palliative care setting. However, their prognostic value needs to be investigated in prospective studies and adjusted against proven prognostic indicators.