Search

Background: Decisions about palliative systemic treatment are key elements of palliative and end-of-life care. Such decisions must often be made in complex, clinical situations. Aim: To explore the content of medical records of patients with advanced non-small cell lung cancer and pancreatic cancer with specific emphasis on doctors’ notes about decisions on palliative systemic treatment. Design: Medical record review (2009–2012) of 147 cancer patients containing 276 notes about palliative systemic treatment. We described the proportion of notes/medical records containing pre-specified items relevant to palliative systemic treatment. We selected patients using the nationwide Netherlands Cancer Registry. Setting: Hospital based. Results: About 75% of all notes reported doctors’ considerations to start/continue palliative systemic treatment, including information about the prognosis (47%), possible survival gain (22%), patients’ wish for palliative systemic treatment (33%), impact on quality of life (8%), and patient’s age (3%). Comorbidity (82%), smoking status (78%) and drinking behaviour (63%) were more often documented than patients’ performance status (16%). Conversations with the patient/family about palliative systemic treatment were reported in 49% of all notes. Response measurements and dose adaptations were documented in 75% and 71% of patients who received palliative systemic treatment respectively. Conclusion: Medical records provide insight into the decision-making process about palliative systemic treatment. The content and detail of doctors’ notes, however, widely varies especially concerning their palliative systemic treatment considerations. Registries that aim to measure the quality of (end-of-life) care must be aware of this outcome. Future research should further explore how medical records can best assist in evaluating the quality of the decision-making process in the patient’s final stage of life. [ABSTRACT FROM AUTHOR]

Recognition of the dying phase, i.e., the period during which death is expected to occur within hours or days, is important because it enables marking the imminence of death, informing the patient and his relatives, and adjusting care where needed. Careful communication about a patient's limited prognosis prepares patients and their family for impending death and saying goodbye. The authors describe two cases of patients dying a relatively unexpected death in a hospice, which is uncommon in this setting. These unexpected deaths had a severe impact on the relatives and on the professional care team. Both patients used dexamethasone. The authors postulate that there is a relationship between the use of dexamethasone and difficulty in recognizing the dying phase. Dexamethasone can make patients feel better, increase their appetite, and influence the stress response. These effects could mask the signs of impending death, such as “being bedbound,” “only drinking sips,” and “being subcomatose.” Review of the literature yielded no articles that support or reject this hypothesis. Because dexamethasone is used regularly in the palliative phase of a chronic disease, there is a need for further exploration of its effects in the dying phase. [ABSTRACT FROM AUTHOR]