Despite advances in the treatment of cancer, many people will die from their disease. This summary is intended to address care during the last days to last hours of life, including common symptoms, ethical dilemmas that may arise, and the role of the oncologist in caring for patients and their families during this time.

Although greatly feared by our death-denying society, the end of life can be a time of great personal growth for patients and their families. This growth depends on thoughtful discussions and careful decision making about advance care planning, optimally beginning soon after diagnosis and continuing throughout the course of the disease. Planning includes establishing the goals of care, clarifying acceptable treatment options, and determining where a patient wishes to spend the final days of life, including discussions regarding palliative care and hospice. When these discussions do not take place and plans are not made, the final hours may be filled with suffering and distress. (Refer to the PDQ summary on Transitional Care Planning for more information on home care needs.)

Palliative care is an approach that improves the quality of life for patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychosocial, and spiritual problems.[1] Although available in some centers, formal palliative care services are not available at many hospitals and are less likely to be available in the home. Regardless of the availability of palliative care services, all oncologists and other professionals caring for people with cancer must be proficient in aggressive symptom management and discussions of advance care planning. These activities are optimally conducted with the palliative care team so that both patient and family hear a consistent message and do not feel abandoned by the physician, with whom they have developed a strong bond.

Hospice is a specialized form of interdisciplinary health care that alleviates physical, emotional, social, and spiritual discomfort during the last phase of life. Hospice is a program of care provided by an interdisciplinary team designed to keep a patient at home with family and friends. Pain management and symptom management are paramount, along with bereavement and volunteer components. Hospice provides palliative care, with which it is frequently confused; however, the focus of hospice is on patients with life-limiting, progressive disease (usually with a prognosis of no more than 6 months if the disease were to take its natural course).

Utilization of hospice care has increased in the United States, with more than one million individuals seeking such care. People who had cancer made up approximately 41% of these admissions in 2007.[2] However, a disturbing trend is reflected in the very short median length of stay in hospice of just 20.0 days. This trend suggests that advance care planning is not taking place early in the course of the disease, that the ability of health care providers to prognosticate is poor, and that referrals are made too late; it may also reflect denial on the part of professionals, patients, or their families regarding disease progression.

References

1. World Health Organization.: National Cancer Control Programmes: Policies and Managerial Guidelines. 2nd ed. Geneva, Switzerland: World Health Organization, 2002. 
   
   
2. NHPCO Facts and Figures: Hospice Care in America. October 2008 Edition. Alexandria, Va: National Hospice and Palliative Care Organization, 2008. Available online. Last accessed November 3, 2008. 
   
   

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