Advertisement

Supportive Care in Cancer

, Volume 16, Issue 2, pp 113–122 | Cite as

Quality of end-of-life treatment for cancer patients in general wards and the palliative care unit at a regional cancer center in Japan: a retrospective chart review

  • Kazuki SatoEmail author
  • Mitsunori Miyashita
  • Tatsuya Morita
  • Makiko Sanjo
  • Yasuo Shima
  • Yosuke Uchitomi
Supportive Care International

Abstract

Goals

In Japan, most cancer patients die in the hospital. The aim of this study was to assess the quality of end-of-life treatment for dying cancer patients in general wards and palliative care unit (PCU).

Materials and methods

A retrospective chart review study was conducted. The following data on cancer patients who died in general wards (N = 104) and PCU (N = 201) at a regional cancer center were collected: do-not-resuscitate (DNR) decisions, treatments in the last 48 h of life, and aggressiveness of cancer care for dying patients.

Main results

DNR orders were documented for most patients (94% in general wards, 98% in PCU, p = 0.067) and families usually consented (97%, 97%, p = 0.307). Comparison of general wards with PCU showed that, in the last 48 h of life, significantly more patients in general wards received life-sustaining treatment (resuscitation, 3.8%, 0%, p = 0.001; mechanical ventilation, 4.8%, 0%, p = 0.004), large volume hydration (>1,000 ml/day, 67%, 10%, p < 0.001) with continuous administration (83%, 5%, p = 0.002) and fewer palliative care drugs (strong opioids, 68%, 92%, p < 0.001; corticosteroids, 49%, 70%, p < 0.001; nonsteroidal anti-inflammatory drugs, 34%, 85%, p < 0.001). Regarding aggressiveness of cancer care, patients received a new chemotherapy regimen within 30 days of death (3.0%), chemotherapy within 14 days of death (4.3%), and intensive care unit admission in the last month of life (3.3%).

Conclusion

We found that families, not patients, consented to DNR, and life-sustaining treatments were appropriately withheld; however, patients on general wards received excessive hydration, and the use of palliative care drugs could be improved. Application of our findings can be used to improve clinical care in general wards.

Keywords

Quality of health care Palliative care Terminal care Decision making Retrospective study Neoplasm Japan 

Notes

Acknowledgment

This research was supported by a grant from Health and Labor Science Research Grants, Third Term Comprehensive Control Research for Cancer. We would like to express our gratitude to the hospital staff for their cooperation in this study. The author would also like to thank Keiko Kazuma, RN, PhD (Department of Adult Nursing/Palliative Care Nursing, University of Tokyo) for contributing time and expertise to this study.

References

  1. 1.
    Ellershaw J, Ward C (2003) Care of the dying patient: the last hours or days of life. BMJ 326(7379):30–34PubMedCrossRefGoogle Scholar
  2. 2.
    Plonk WM Jr, Arnold RM (2005) Terminal care: the last weeks of life. J Palliat Med 8(5):1042–1054PubMedCrossRefGoogle Scholar
  3. 3.
    The SUPPORT Principal Investigators (1995) A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 274(20):1591–1598CrossRefGoogle Scholar
  4. 4.
    Toscani F, Di Giulio P, Brunelli C, Miccinesi G, Laquintana D (2005) How people die in hospital general wards: a descriptive study. J Pain Symptom Manage 30(1):33–40PubMedCrossRefGoogle Scholar
  5. 5.
    Solloway M, LaFrance S, Bakitas M, Gerken M (2005) A chart review of seven hundred eighty-two deaths in hospitals, nursing homes, and hospice/home care. J Palliat Med 8(4):789–796PubMedCrossRefGoogle Scholar
  6. 6.
    Paice JA, Muir JC, Shott S (2004) Palliative care at the end of life: comparing quality in diverse settings. Am J Hosp Palliat Care 21(1):19–27PubMedCrossRefGoogle Scholar
  7. 7.
    Fins JJ, Miller FG, Acres CA, Bacchetta MD, Huzzard LL, Rapkin BD (1999) End-of-life decision-making in the hospital: current practice and future prospects. J Pain Symptom Manage 17(1):6–15PubMedCrossRefGoogle Scholar
  8. 8.
    Oh DY, Kim JH, Kim DW et al (2006) CPR or DNR? End-of-life decision in Korean cancer patients: a single center’s experience. Support Care Cancer 14(2):103–108PubMedCrossRefGoogle Scholar
  9. 9.
    Bailey FA, Burgio KL, Woodby LL et al (2005) Improving processes of hospital care during the last hours of life. Arch Intern Med 165(15):1722–1727PubMedCrossRefGoogle Scholar
  10. 10.
    Aldasoro E, Alonso AP, Ribacoba L et al (2005) Assessing quality of end-of-life hospital care in a southern European regional health service. Int J Technol Assess Health Care 21(4):464–470PubMedCrossRefGoogle Scholar
  11. 11.
    Goodlin SJ, Winzelberg GS, Teno JM, Whedon M, Lynn J (1998) Death in the hospital. Arch Intern Med 158(14):1570–1572PubMedCrossRefGoogle Scholar
  12. 12.
    Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S (2003) Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 21(6):1133–1138PubMedCrossRefGoogle Scholar
  13. 13.
    Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC (2004) Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22(2):315–321PubMedCrossRefGoogle Scholar
  14. 14.
    Barbera L, Paszat L, Chartier C (2006) Indicators of poor quality end-of-life cancer care in Ontario. J Palliat Care 22(1):12–17PubMedGoogle Scholar
  15. 15.
    Grunfeld E, Lethbridge L, Dewar R et al (2006) Towards using administrative databases to measure population-based indicators of quality of end-of-life care: testing the methodology. Palliat Med 20(8):769–777PubMedCrossRefGoogle Scholar
  16. 16.
    Braga S, Miranda A, Fonseca R et al (2007) The aggressiveness of cancer care in the last three months of life: a retrospective single centre analysis. Psychooncology 16(9):863–868Google Scholar
  17. 17.
    Statistics and Information Dept., Minister’s Secretariat, Ministry of Health, Labour and Welfare (2006) Vital statistics of Japan 2005 (in Japanese). Ministry of Health, Labour and Welfare, TokyoGoogle Scholar
  18. 18.
    Morita T, Hirai K, Sakaguchi Y et al (2004) Measuring the quality of structure and process in end-of-life care from the bereaved family perspective. J Pain Symptom Manage 27(6):492–501PubMedCrossRefGoogle Scholar
  19. 19.
    Morita T, Imura C, Fujimoto K, Shishido H, Tei Y, Inoue S (2005) Changes in medical and nursing care in cancer patients transferred from a palliative care team to a palliative care unit. J Pain Symptom Manage 29(6):595–602PubMedCrossRefGoogle Scholar
  20. 20.
    Morita T, Fujimoto K, Tei Y, Morita T, Fujimoto K, Tei Y (2005) Palliative care team: the first year audit in Japan. J Pain Symptom Manage 29(5):458–465PubMedCrossRefGoogle Scholar
  21. 21.
    Tokuda Y, Nakazato N, Tamaki K, Tokuda Y, Nakazato N, Tamaki K (2004) Evaluation of end of life care in cancer patients at a teaching hospital in Japan. J Med Ethics 30(3):264–267PubMedCrossRefGoogle Scholar
  22. 22.
    Masuda Y, Noguchi H, Kuzuya M et al (2006) Comparison of medical treatments for the dying in a hospice and a geriatric hospital in Japan. J Palliat Med 9(1):152–160PubMedCrossRefGoogle Scholar
  23. 23.
    Voltz R, Akabayashi A, Reese C et al (1998) End-of-life decisions and advance directives in palliative care: a cross-cultural survey of patients and health-care professionals. J Pain Symptom Manage 16(3):153–162PubMedCrossRefGoogle Scholar
  24. 24.
    Asai A, Miura Y, Tanabe N, Kurihara M, Fukuhara S (1998) Advance directives and other medical decisions concerning the end of life in cancer patients in Japan. Eur J Cancer 34(10):1582–1586PubMedCrossRefGoogle Scholar
  25. 25.
    Ruhnke GW, Wilson SR, Akamatsu T et al (2000) Ethical decision making and patient autonomy: a comparison of physicians and patients in Japan and the United States. Chest 118(4):1172–1182PubMedCrossRefGoogle Scholar
  26. 26.
    Nauck F, Ostgathe C, Klaschik E et al (2004) Drugs in palliative care: results from a representative survey in Germany. Palliat Med 18(2):100–107PubMedCrossRefGoogle Scholar
  27. 27.
    Tschann JM, Kaufman SR, Micco GP (2003) Family involvement in end-of-life hospital care. J Am Geriatr Soc 51(6):835–840PubMedCrossRefGoogle Scholar
  28. 28.
    Bozzetti F, Cozzaglio L, Biganzoli E et al (2002) Quality of life and length of survival in advanced cancer patients on home parenteral nutrition. Clin Nutr 21(4):281–288PubMedCrossRefGoogle Scholar
  29. 29.
    Cerchietti L, Navigante A, Sauri A, Palazzo F (2000) Hypodermoclysis for control of dehydration in terminal-stage cancer. Int J Palliat Nurs 6(8):370–374PubMedGoogle Scholar
  30. 30.
    Morita T, Hyodo I, Yoshimi T et al (2005) Association between hydration volume and symptoms in terminally ill cancer patients with abdominal malignancies. Ann Oncol 16(4):640–647PubMedCrossRefGoogle Scholar
  31. 31.
    Bruera E, Sala R, Rico MA et al (2005) Effects of parenteral hydration in terminally ill cancer patients: a preliminary study. J Clin Oncol 23(10):2366–2371PubMedCrossRefGoogle Scholar
  32. 32.
    Lawlor PG, Gagnon B, Mancini IL et al (2000) Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med 160(6):786–794PubMedCrossRefGoogle Scholar
  33. 33.
    Morita T, Tei Y, Tsunoda J, Inoue S, Chihara S (2001) Underlying pathologies and their associations with clinical features in terminal delirium of cancer patients. J Pain Symptom Manage 22(6):997–1006PubMedCrossRefGoogle Scholar
  34. 34.
    Dalal S, Bruera E (2004) Dehydration in cancer patients: to treat or not to treat. J Support Oncol 2(6):467–479, 483PubMedGoogle Scholar
  35. 35.
    Goncalves JF, Alvarenga M, Silva A (2003) The last forty-eight hours of life in a Portuguese palliative care unit: does it differ from elsewhere? J Palliat Med 6(6):895–900PubMedCrossRefGoogle Scholar
  36. 36.
    Centeno C, Sanz A, Bruera E (2004) Delirium in advanced cancer patients. Palliat Med 18(3):184–194PubMedCrossRefGoogle Scholar
  37. 37.
    Bruera E, Franco JJ, Maltoni M, Watanabe S, Suarez-Almazor M (1995) Changing pattern of agitated impaired mental status in patients with advanced cancer: association with cognitive monitoring, hydration, and opioid rotation. J Pain Symptom Manage 10(4):287–291PubMedCrossRefGoogle Scholar
  38. 38.
    Morita T, Tei Y, Inoue S (2003) Agitated terminal delirium and association with partial opioid substitution and hydration. J Palliat Med 6(4):557–563PubMedCrossRefGoogle Scholar
  39. 39.
    Stromgren AS, Groenvold M, Sorensen A, Andersen L (2001) Symptom recognition in advanced cancer. A comparison of nursing records against patient self-rating. Acta Anaesthesiol Scand 45(9):1080–1085PubMedCrossRefGoogle Scholar
  40. 40.
    Stromgren AS, Groenvold M, Pedersen L, Olsen AK, Spile M, Sjogren P (2001) Does the medical record cover the symptoms experienced by cancer patients receiving palliative care? A comparison of the record and patient self-rating. J Pain Symptom Manage 21(3):189–196PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Kazuki Sato
    • 1
    Email author
  • Mitsunori Miyashita
    • 1
  • Tatsuya Morita
    • 2
  • Makiko Sanjo
    • 1
  • Yasuo Shima
    • 3
  • Yosuke Uchitomi
    • 4
  1. 1.Department of Adult Nursing/Palliative Care Nursing, School of Health Sciences and Nursing, Graduate School of MedicineThe University of TokyoTokyoJapan
  2. 2.Department of Palliative and Supportive Care, Palliative Care Team and Seirei HospiceSeirei Mikatahara General HospitalShizuokaJapan
  3. 3.Department of Palliative MedicineTsukuba Medical Center HospitalIbarakiJapan
  4. 4.Psycho-Oncology Division, Research Center for Innovative OncologyNational Cancer Center Hospital EastChibaJapan

Personalised recommendations