being a good dead is one of the most important in palliative care

1. Chemotherapy Near the End of Life
First— and Third and Fourth (Line)—Do No Harm
Khoirul Anwar
Pembimbing :
dr. Kartika W, Sp.PD KHOM
BookS Reading
Having a “good death” is one of the most important goals of palliative care..

2. Background
NEAR DEAD AGRESSIVE
CHEMOTHERAPY ?
QUALITY OF
LIFE
END STAGE
CANCER
PALIATIVE
CARE
“A GOOD DEATH”
NEAR THE END
OF LIFE
PERSEPECTIVE
PATIENT ?
PATIENT FAMILY ?
POPULATION ?
PALIATIVE CARE
PERSEPECTIVE
DOCTORS ?
NURSES ?
CULTURE
RELIGION
SOCIAL
EDUCATION

3. Near Dead Chemotherapy
to help them live LONGER
chemotherapy in metastatic cancer
to help them live BETTER
NEAR THE END
OF LIFEQUALITY
OF LIFE ?

4. Near dead chemotherapy
• Mod / poor PS  QOD ⬇
• Good PS  QOD not
improve
Near Dead ChemoTx  QOL

5. Massarelli E et al, Lung Cancer.
2003;39(1):55-61.
Near Dead ChemoTx  benefits?
late-line therapy is not effective for small cell lung
cancer (NSCLC) treatment as having a 0% to 2%
response rate for third- and fourth-line use
Schnipper LE et al. ClinOncol.
2012;30(14):1715-1724
patients with good performance status were the
ones most likely to receive chemotherapy near the
end of life
Prigerson HG et al. AMAOncol.
doi:101001/jamaoncol.2015.2378.
palliative chemotherapy  worsened QOD for
patients with good performance status.
Why the oncologists still use systemic therapy so close to patient death ????

6. AnshushaugM et al. ActaOncol. 2015;54(3):395-402
Near Dead ChemoTx  worldwide
A Norwegian study characterizing patients receiving palliative chemotherapy
• 3% ECOG 2
• 16% ECOG 3 and 4
• 10% received chemotherapy in the last 30 days of life
• Among those patients, 21% lung cancer; 15% colorectal; 13% prostate; and 9%,
breast cancer.
Jones SE et al. J Clin Oncol. 2005;23(24):5542-5551.
Of the breast cancer patients
• 12% were receiving second-line therapy (associated with 3- to 6-month duration of
response)
• 19% third-line therapy (2 to 4 month duration of response)
• 21% third-line therapy or higher
Why the oncologists still use systemic therapy so close to patient death ????

7. NEAR DEAD AGRESSIVE
CHEMOTHERAPY ?
“A GOOD DEATH”
NEAR THE END
OF LIFE
PERSEPECTIVE
PATIENT ?
PATIENT FAMILY ?
POPULATION ?
PERSEPECTIVE
DOCTORS ?
NURSES ?
CULTURE
RELIGION
SOCIAL
EDUCATION

8. “A GOOD DEATH”
Having a “good death” is one of the most important goals of palliative care..
• being mentally aware
• not being a burden to
others
• being able to help
others
• having funeral
arrangements planned
• and spirituality
WESTERN
“fighting against cancer.”
• fighting against the
disease until one’s last
moment
• believing that one used
all available treatments
• living as long as possible
EASTERN
Steinhauser KE et al. 2000. JAMA 284: 2476–
2482
Miyashita M et al. 2007. Ann Oncol 18:1090–
1097

9. “A GOOD DEATH”

10. “A GOOD DEATH”
• The good death components differed for patients and the general population
compared to oncologists and oncology nurses
• Patients favored “fighting against the disease until one’s last moments”; and patients
who emphasized maintaining hope and pleasure, unawareness of death and good
relationship with family favored fighting against cancer
• However, those who emphasized physical and psychological comfort preferred not to
fight

11. • Can not precisely predict life
expectancies
 estimates of patient survival were
inaccurate approximately 80% of the
time (Christakis NA et al. 2000;320(7233):469-
472)
• It is hard to say no to chemotherapy 
make an oncologist feel they are
depriving the patient of all hope.
• FIGHTING AGAINTS CANCER
• Want systemic treatment until the bitter
end
 patients with incurable NSCLC would
desire chemotherapy, even in the
setting of severe toxi ceffects for a 1-
week gain in survival (Silvestri G et al.
1998; 17(7161): 771-775)
• Patient Hope
Why the oncologists still use systemic therapy so close
to patient death ????
ONCOLOGIST FACTORS PATIENT FACTORS
EDUCATION, COMMUNICATION and
NEGOTIATION ??

12. EOL Consultation
 Early EOL discussions are prospectively associated with less aggressive care and greater
use of hospice at EOL.

13. EOL Consultation
 Palliative Care (PC) consultation and a higher intensity of PC were associated with less
aggressive care near death in patients with advanced pancreatic cancer.

14. Why the oncologists still use systemic therapy so close
to patient death ????
ONCOLOGIST FACTORS PATIENT FACTORS
EDUCATION, COMMUNICATION and
NEGOTIATION ??
Even when oncologists communicate
clearly about prognosis and are honest
about the limitations of treatment
many patients feel immense pressure
to continue treatment.
Patients with are encouraged by
friends and family  to keep fightingThe doctor feel the last 6 months of
life are not best spent in an oncology
treatment unit or at home suffering
the toxic effects of largely ineffectual
therapies

15. Why the oncologists still use systemic therapy so close
to patient death ????
ONCOLOGIST FACTORS PATIENT FACTORS
GUIDELINE
to prohibit chemotherapy for all
patients near death without irrefutable data defining
who might actually benefit, but if an oncologist
suspects the death of a patient in the next 6 months,
the default should be no active treatment.
Let us help patients with metastatic cancer make
good decisions at this sad stage.
Let us not contribute to the suffering that cancer, and
often associated therapy, brings, particularly at the end.

16. MATUR NUWUN