Chest
Volume 123, Issue 1, Supplement, January 2003, Pages 312S-331S
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End-of-Life Care in Patients With Lung Cancer*

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Evidence-based practice guidelines for end-of-life care for patients with lung cancer have been previously available only from the British health-care system. Currently in this setting, there has been increasing concern in attaining control of the physical, psychological, social, and spiritual distress of the patient and family. This American College of Chest Physicians'-sponsored multidisciplinary panel has generated recommendations for improving quality of life after examining the English-language literature for answers to some of the most important questions in end-of-life care. Communication between the doctor, patient, and family is central to the active total care of patients with disease that is not responsive to curative treatment. The advance care directive, which has been slowly evolving and is presently limited in application and often circumstantially ineffective, better protects patient autonomy. The problem-solving capability of the hospital ethics committee has been poorly utilized, often due to a lack of understanding of its composition and function. Cost considerations and a sense of futility have confused caregivers as to the potentially important role of the critical care specialist in this scenario. Symptomatic and supportive care provided in a timely and consistent fashion in the hospice environment, which treats the patient and family at home, has been increasingly used, and at this time is the best model for end-of-life care in the United States.

Section snippets

Review of the Literature

A comprehensive search covering the past five years of English-language medical literature for practice guidelines on end-of-life care for patients with lung cancer, has revealed only specific contributions from the United Kingdom. These guidelines, while comprehensive for their National Health Service, are difficult to apply in medical practice in the United States but are listed for our consideration.

How Important Is Communication With Patient and Family in End-of-Life Care in Patients With Lung Cancer?

There is an increasing body of literature that reveals that patients want more information from their clinician than they receive. They want an opportunity to discuss their preferences and their goals of treatment within the context of the medical facts of their illness. They want to discuss plans for the end of life, but they may need the clinician to initiate the discussion. Death has the power to surprise even the prepared, but many of our patients are not prepared.

We do not yet know how

How Effective Are Advance Directives in Fulfilling the Level of Care Requested by End-of-Life Lung Cancer Patients?

After Cruzan vs Director, MDH72 and the Patient Self Determination Act,73 most patients are aware that they have the right to an advance directive. There is widespread support of these documents both within the medical community and among lay individuals74; however, the medical and legal sources, as given below, reveal that both physicians and patients frequently find them less than ideal, and therefore they are often rendered ineffective.

Advance directives are legal documents: living wills and

What Is the Role of the Hospital Ethics Committee in Resolving End-of-Life Problems in Patients With Lung Cancer?

The proliferation of hospital ethics committees (HECs) was precipitated by public controversy that burgeoned in the 1970s. Beginning with the case of Karen Quinlan in 1975, a series of highly publicized legal cases disclosed numerous unresolved issues regarding end-of-life care.92 These cases reflected the substantial uncertainty of patients, physicians, families and health-care institutions regarding the appropriate limits of life-prolonging treatment and the locus of decision-making

What Is the Role of the Critical Care Specialist in the End-of-Life Care of Lung Cancer Patients?

Spiraling costs and reform of health care have intensified pressure to reduce use of expensive resources, such as critical care services, for patients with poor prognoses, including those with advance lung cancer. This is understandable, considering that outcomes of ICU treatment for cancer patients are often unfavorable and that intensive care consumes a very large and disproportionate share of health-related expenditures. Potential distress for patients and families from invasive

What Is the Frequency of Use and Satisfaction With Hospice Environment in the End-of-Life Care of Patients With Lung Cancer?

Lung cancer is the most common cause of cancer deaths in both men and women, with only 15% of all patients living for 5 years.132 Since the majority of patients with lung cancer will die of their disease, it is imperative that end-of-life care be incorporated into their routine management. The goal of this palliative end-of-life care should be to achieve the best possible quality of life for patients and their families. In 1998, the American Society of Clinical Oncology Task Force on Cancer

Conclusion

No American clinical practice guideline is currently available that is specifically for end-of-life care for patients with bronchogenic carcinoma. Since the majority of those patients with an established diagnosis of non-small-cell lung cancer will die within 1 year, it is imperative that, with the possible exception of approximately 20% who might benefit from a complete surgical excision, extensive communication about the entire expected course of their disease occur between patients, their

Summary of Recommendations

  • 1.

    For patients with lung cancer at the end of life, it is recommended that clinicians increase their focus on the patient's experience of illness to improve congruence of treatment with patient goals and preferences: (a) be realistic, practical, sensitive, and compassionate; (b) listen; (c) allow/invite the patient to express his or her reaction to the situation; (d) provide a contact person; (e) and continually reassess the patient's goals of therapy as part of treatment planning. Evidence:

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