The Palliative Performance Scale (PPS), a modification of the Karnofsky Performance Scale, is presented as a new tool for measurement of physical status in palliative care. Its initial uses in Victoria include communication, analysis of home nursing care workload, profiling admissions and discharges to the hospice unit, and, possibly, prognostication. We assessed 119 patients at home, of whom 87 (73%) had a PPS rating between 40% and 70%. Of 213 patients admitted to the hospice unit, 175 (83%) were PPS 20%-50% on admission. The average period until death for 129 patients who died on the unit was 1.88 days at 10% PPS upon admission, 2.62 days at 20%, 6.70 days at 30%, 10.30 days at 40%, 13.87 days at 50%. Only two patients at 60% or higher died in the unit. The PPS may become a basis for comparing drug costs at home and for studying the effects of treatments (e.g. hypodermoclysis) at various levels of physical performance. Validity and reliability testing are currently being undertaken.
Rectal cancer is quite easy to identify. Simple methods of investigations and early symptoms should allow a good prognosis. This is patholphysiologically supported by slow increasement and relatively late filialisation along long metastatic roads. Therefore it is to be regretted, that of 632 patients, suffering from rectal cancer in the years 1955-1970, 179 (28,3%) could not be treated on cure. Even palliative procedures had a postoperative mortality of 24,6%. This delay in early diagnose reduced the time of survival from 72% 2-jears-survival, when operated on cure (see article) to 59,1% (see article), respectively from 52,1% 5-years-survival (see article) to 38,5% (see article). These results can be only improved by regular prophylactic examinations.
To determine how palliative care physicians view the accuracy and importance of prognostication, what information they consider, and what processes they use.
A questionnaire was sent to members of the Canadian Society of Palliative Care Physicians (CSPCP). Respondents recorded their perceptions about prognostication and the factors they considered when predicting survival. A patient scenario was described in which a prognosis was requested by two different people: a patient's daughter and a palliative care admissions coordinator.
90 responses were received from 219 CSPCP members (41.1 percent). There was moderate agreement between respondents' perceptions of their own accuracy and that of other physicians (K = 0.549). Of all the respondents, 89.9 percent believed that prognosticating was somewhat or very important. They considered clinical factors most commonly when prognosticating. A range of predictions was given for the scenario; often, the same physician gave different answers to the two people requesting a prognosis.
Palliative care physicians believe that prognostication is important and use clinical factors to estimate survival. They often give different estimates to different information recipients.
Heart failure is a chronic, fatally progressive and incurable condition characterized by periods of apparent stability interspersed with acute exacerbations. Treatment models have historically emphasized management of acute exacerbations of cardiovascular disease, during which end-of-life issues figure frequently and prominently, though in a setting that is inappropriate to address the comprehensive needs of patients and their families. Consequently, in comparison to patients with malignancy, heart failure patients at the end of life are less likely to access palliative resources, and more likely to access in-patient care and cardiovascular procedures.
Recent reports and position statements have emphasized the following critical needs for provision of optimal heart failure care: a) Cardiovascular specialists require training to obtain basic skills for provision of palliative care to management of end-of-life issues; b) Discussion of end-of-life issues should be introduced as early as feasible in patients with heart failure and should be updated with changes in clinical status; c) Provision of palliative care should be integrated into a team approach; d) Patients with heart failure frequently suffer symptoms which are not typically considered 'cardiovascular', such as pain, social/functional and psychological. Patients should be assessed for these symptoms, which should be treated.
This report summarizes many of these suggestions and outlines future directions for the expansion and improvement of this critical need for heart failure patients.
INTRODUCTION: The lack of registration of women who have received no or alternative treatment for breast cancer has been criticised. No distinction is made in the Danish Cancer Register between these patients and those who only receive palliative treatment for other reasons, such as old age, advanced disease, and competing illnesses. We have estimated the number of women in this group of patients, who, in reality, had not received any treatment with the intent to cure under the health care system, and whether a meaningful analysis of survival for these patients is feasible. METHOD: All women with breast cancer diagnosed during the years 1978-1995 were extracted from the Cancer Register, and we isolated those who had been registered as having had no or only palliative treatment and who had survived for a minimum of 45 days after diagnosis. A search was made in the Danish Breast Cancer Co-operative Group register for unreported treatment and the residual group was followed up individually. RESULTS: Out of 49.058 women with histologically or cytologically verified breast cancer, the Cancer Register listed 840 women with no registered treatment of their disease. Of these, there were 103 cases of carcinoma in situ. A match with the DBCG register revealed that 188 women had nevertheless been operated on. Among the remaining 549 women, 99 were truly untreated, and for 77 of these the reasons given were another or advanced disease or old age. Only 22 women had initially declined treatment for no specific reason. Five of these had later decided on subsequent curative treatment, which leaves 17 women in the category "breast cancer untreated at her own request" ("untreated breast cancer at own will"). Nine are dead, five had their tumour excised at biopsy, and the remaining three are alive with tumours diagnosed by fine needle aspiration biopsy (1) or thru-cut biopsy (2) after 7.7 and 4 years, respectively. CONCLUSION: This report has shown that a survival analysis based on the Cancer Register of untreated breast cancer in relation to treated breast cancer is not meaningful. A true estimation of survival after untreated versus treated breast cancer can only be achieved through a randomised study, which would be unethical.
OBJECTIVE: Development of a prognostic tool for patients with unresectable pancreatic cancer to distinguish between with low or high probabilities of survival 3 to 9 months after diagnosis. DESIGN: Data about individual patients from five studies were pooled. A multivariate proportional hazards model with time-dependent covariates was developed, including age, sex, and metastases. An extended model was developed on a subset of patients, including weight loss, pain, and jaundice at diagnosis. SETTING: Multicentre study, The Netherlands, Norway, USA, UK, and Canada. SUBJECTS: 1020 patients with unresectable pancreatic cancer. MAIN OUTCOME MEASURES: Prediction of prognosis. RESULTS: Patients with metastases, pain, or weight loss at diagnosis had a significantly poorer prognosis than the others. Older men had a worse prognosis than younger men, while older women had a better prognosis than younger ones. Patients with jaundice had a relatively good prognosis. Differences in survival among the studies were incorporated in a prognostic score chart. CONCLUSION: The prognostic score chart can be used to select patients with relatively low expectation of survival for endoscopic palliation, and patients with relatively high expectation for surgical palliation.
The effect of surgical training level, experience, and operation volume on complications and survival in colorectal cancer during a 10-year period in a medium-volume university hospital was retrospectively studied.
Four hundred and fifty-six patients were resected for primary colorectal adenocarcinoma during the 10-year period of 1981-1990, and of these, 387 patients underwent resection with curative intent. The surgeons were divided into three groups according to training level and volume: group 1, surgeons in training and other surgeons operating annually on only 1-4 patients; group 2, surgeons specializing in gastrointestinal surgery (average annual volume 4-13 operations); group 3, specialists in gastrointestinal surgery (average annual volume 3-8 operations). Postoperative morbidity and mortality rates, as well as long-term survival rates, were analysed, and comparisons were made between the patients in the three groups.
There were no statistically significant differences between the three groups in postoperative morbidity or mortality. Cancer-specific 5-year survival rate of all patients was 57%, and that of those resected in the aforementioned three groups was 51%, 63%, and 55%, respectively, P=0.087. The 5-year survival rates for colon cancer were 59% (total), 52%, 69%, and 58%, respectively, P=0.067, and for rectal cancer were 51% (total), 42%, 53%, and 52%, respectively, P=0.585.
There were no significant differences in the rates of postoperative mortality, morbidity, and long-term overall survival between the volume groups. However, in patients with colon cancer, there was a trend for better survival for those operated on by the surgeons specializing in gastrointestinal surgery, and in rectal cancer patients, a tendency of fewer local recurrences in those operated on by the specialist surgeons.