Objectives This study aimed to examine malnutrition risk and its association with depression, anxiety and stress levels in hospitalised patients with lung cancer. Methods This correlational study included 456 individuals aged over 18 years who were diagnosed with lung cancer and hospitalised in a chest diseases hospital. Data were collected using an Introductory Information Form, the Nutritional Risk Screening-2002 and the Depression Anxiety Stress Scale-21. Results Malnutrition risk was detected in 92.5% of the patients. This high prevalence should be interpreted in light of the clinical characteristics of the sample, which predominantly consisted of patients with advanced-stage and metastatic lung cancer. Factors associated with malnutrition risk included cancer stage, metastasis status, number of meals, skipping meals, age and body mass index. Depression, anxiety and stress were associated with malnutrition risk in bivariate analyses; however, only stress remained independently associated after multivariable adjustment. Conclusions Malnutrition risk was highly prevalent among hospitalised patients with lung cancer. Psychological symptoms were associated with malnutrition risk in bivariate analyses; however, only stress remained independently associated with malnutrition risk in multivariable analysis. These findings support the integration of nutritional risk screening and psychological assessment in hospitalised patients with lung cancer.
OBJECTIVES:Cancer cachexia (CC) reduces treatment efficacy, quality of life and survival. However, few contemporary data quantify its prevalence or impact on death. This study assessed cachexia prevalence in advanced cancer using multiple diagnostic frameworks and explored its role in cancer-related mortality. METHODS:A retrospective analysis was conducted of all deaths over 3 years (August 2020 to August 2023) at a specialist palliative care unit. Using clinical, biochemical and CT body composition data, four definitions of CC (Evans et al, Fearon et al, Global Leadership Initiative on Malnutrition (GLIM) and the modified Glasgow Prognostic Score) were applied. A cachexia-related death was defined as one of global deterioration, infection, thrombo-embolic event or cardiac failure. Paired within-patient analysis compared measurements 30-90 days versus <30 days before death. Only patients with both measurements were included. RESULTS:There were 513 cancer-related deaths over 3 years, with lung (n=122, 23.8%) and colorectal (n=65, 12.7%) cancer most prevalent. 91.9% (n=421/458) of patients, with available data, met at least one definition of CC, with estimates ranging from 67.6% (Fearon, n=171/253) to 91.6% (GLIM, n=262/286) for specific definitions. Cachexia contributed to 69.6% (199/286) of deaths. Paired within-patient analyses showed C-reactive protein increased, while haemoglobin, albumin, body mass index and adipose tissue indices declined (all p<0.001). CONCLUSIONS:These findings support the hypothesis that cachexia develops in a large proportion of patients with advanced cancer and contributes to most cancer deaths. Highlighting the potential value of earlier identification and intervention during oncological care. Importantly, these results also highlight the importance of recognising cachexia in palliative care so that symptom management can be optimised accordingly.
Objectives To investigate public views about doctors as a point of access to voluntary-assisted dying (VAD), this study used a cross-sectional online survey with a quota-based sample of Queensland residents. Methods Participants aged 18 and over (n=1000) were recruited from the Octopus Group database, with quotas set for age, gender and geographical region. Data were collected through an online survey. This research explores: (1) whether people want doctors to raise VAD if they may be eligible for it and (2) whether people believe conscientious objectors should be required to provide contact details for the VAD statewide support service. Analyses also examined how views related to knowledge, attitudes and demographic factors. Results Participants expressed clear preferences regarding the role of doctors in VAD discussions. Sixty-seven per cent wanted doctors to raise VAD as an option if they were eligible and 76% supported requiring conscientious objectors to provide contact details for the statewide VAD support service. Participants who supported VAD legalisation were significantly more likely to endorse both doctor-initiated conversations and mandatory information provision by conscientious objectors, with female participants also showing stronger support for the latter. Conclusions This study found strong support among participants for doctors raising VAD where individuals were potentially eligible for it and for requiring objecting doctors to provide contact details of the statewide VAD support service. Findings reported here offer novel insights with potential implications for law reform and highlight the need for policy, education and training initiatives to help doctors and other health practitioners navigate VAD discussions within legal boundaries.
OBJECTIVES:Artificial intelligence (AI) tools have the potential to transform access to and delivery of palliative care globally-an urgent unmet need-in part by early identification of patients experiencing serious illness-related suffering. Although global consensus is emerging about the importance of ethical principles for AI, such as respecting autonomous choice, promoting patient well-being, reducing bias, trust, and more, little is known about how palliative care physicians perceive these issues. This study aims to improve understanding of palliative care physicians' perspectives about the ethics of AI-based prognostication. METHODS:A national, cross-sectional survey of palliative care physicians in the USA between January 2024 and March 2025 (N=2500; overall response rate=32.6%). RESULTS:Overall, 64% (n=342/534) of physicians felt use of AI-based prognostication was at least somewhat ethically challenging; female physicians had 2.06 times the odds of feeling that way (95% CI 1.34 to 3.19; p=0.001). Most physicians (81.4%, 429/527) were at least a little concerned that AI-based prognostication could lead to an overemphasis on time until death in decision-making; older physician age was associated with this concern. Physicians reported moderate levels of concern with individual ethics issues, but 32.3% (170/527) thought AI could positively affect patient trust and 56.0% (294/525) thought AI could help them practise the way they see best. CONCLUSION:Palliative care physicians see the potential of AI-based prognostication to improve palliative care and also express ethical concerns. Implementation of AI requires context-specific ethical guidance responsive to palliative care, where relationships and communication are paramount.
Death notification (DN) is a critical clinical task that initiates and influences the bereavement trajectory and carries profound implications for clinician well-being. Evidence links DN quality to cognitive-emotional processing of loss, attachment reorganisation and mobilisation of social support. A diverse ecosystem of DN protocols offers stepwise guidance, but outcome data, cultural adaptation and notifier support remain limited. Drawing on DN protocol methodology, DN and prolonged grief disorder mechanisms and contemporary grief theory, this State of the Science article argues that DN should be understood and operationalised as a mechanism-informed, trauma-aware intervention central to palliative and supportive care.
Objective Literature identifies that doctors struggle in navigating ethical issues at the end of life. Residents look to senior doctors for support. Senior doctors are aware of the latter’s needs. However, systemic factors and clinical demands preclude attention being given to the impact on both groups. The question arose as to what both groups working together would identify as the best support. Method Study design was qualitative, informed by the principles of co-design. 12 resident and 15 senior doctors participated in 6 workshops. Senior and resident doctors worked collaboratively to identify the best support. Inductive content analysis of the recorded group discussion followed. Results Practising medicine was practising ethics—both of which involved human relationships. Senior doctors acknowledged that constraints in the practice context and lack of clinical experience contributed to residents’ concerns about patient harm. Lack of support for resident doctors coping with ethical issues when patients were dying was itself an ethical issue. Coping, as a resident in a system under pressure, was challenging. Senior and resident doctors unanimously believed that taking time for support was paramount. Acknowledging human vulnerability was the second most valued strategy. Informal debriefing, either at the time or later, was identified as the third. Conclusion In determining how to support doctors and specifically residents we need to understand the context in which doctors work. Including both groups in identifying the solution, we found that central to any intervention is taking time to acknowledge the human impact and fostering relational support.
Corticosteroids are sometimes used in inoperable malignant bowel obstruction (MBO) despite limited evidence. The main randomised evidence comes from an old Cochrane review totalling 89 patients demonstrating a non-significant trend towards obstruction resolution and no survival benefit. Subsequent literature consists of retrospective and uncontrolled studies failing to control for spontaneous resolution, disease heterogeneity and concomitant therapies. Dose, duration and outcomes are inconsistently reported. Corticosteroid toxicities are potentially harmful. Overall, there are no high-quality data to support corticosteroids as a standard therapy in MBO. If a clinician wishes to use in selected patients, this should be as a time-limited therapeutic trial framed within the context of uncertainty.
Objectives Death literacy is a key factor in death-related psychosocial processes among caregivers. This research was carried out to determine the death literacy levels, care burdens and psychological well-being of individuals caring for cancer patients and to examine the relationships between these variables. Methods The research, planned in a descriptive and cross-sectional design, was carried out in the oncology clinics of a university hospital between 16 October 2024 and 1 January 2025. The sample of the study consisted of 170 caregivers using the convenience sampling method. Data were collected with the Descriptive characteristics form, Death Literacy Scale, Caregiving Burden Scale and Psychological Well-being Scale. Statistical analyses were performed with the SPSS V.25.0 program; non-parametric tests, correlation and multiple regression analyses were used. Results Participants’ death literacy and care burden levels were found to be moderate and their psychological well-being levels were found to be high. A low level of significant positive correlation was found between death literacy and psychological well-being. In contrast, no significant relationship was observed between death literacy and care burden. Education level and active participation in the care process are important factors that positively affect both death literacy and psychological well-being. Care burden was found to be higher in individuals with low education levels and single individuals. Conclusions There is a need for education-based structured interventions to support the coping skills with death of caregiving individuals, to increase their psychological well-being and to reduce their care burdens.
OBJECTIVES:Do-not-resuscitate (DNR) orders limit the use of cardiopulmonary resuscitation but are often interpreted more broadly. During COVID-19 surges, resource constraints may have increased variability in application, potentially affecting patients with DNR orders. We aimed to determine whether admission during COVID-19 surge months in 2020 versus non-surge months was associated with differences in use of life-sustaining treatments among hospitalised patients with DNR orders. METHODS:Using data from five states (Arizona, California, Iowa, Mississippi and New York), we identified non-surgical patients ≥40 years with early-DNR orders (within 24 hours of admission) admitted during COVID-19 surge versus non-surge months in 2020. In this retrospective cohort study, we determined patient-level odds of receiving mechanical ventilation (MV), renal replacement therapy (RRT) or central venous catheterisation (CVC) during COVID-19 surge versus non-surge periods and differences in hospital-level rates of each treatment. RESULTS:We identified 191 317 (13.3%) patients with early-DNR orders during COVID-19 surges and 149 022 (12.6%) in non-surge periods. Patient-level utilisation of MV, RRT and CVC was higher during surge periods (MV: 7.7% vs 5.9%, RRT: 4.1% vs 3.8%, CVC: 2.4% vs 2.0%) with similar results after accounting for case-mix differences. The range of risk-adjusted hospital rates for CVC and RRT was similar across time periods but higher for MV during surges. CONCLUSIONS:Resource strains did not lead to more restrictive care for patients with early-DNR orders during COVID-19 surges. Rather, higher rates of MV, RRT and CVC during surge periods likely reflect greater illness severity. The increased prevalence of early-DNR orders during surges warrants further investigation.
OBJECTIVES:Time toxicity-the time patients spend receiving treatment and associated care-is an increasingly recognised burden of cancer treatment. Literature has largely relied on calendar-day-based measurement, which may obscure meaningful variation in time burden. This study aimed to quantify time toxicity with greater granularity by measuring it in hours. METHODS:We conducted a retrospective cohort study of patients with recurrent prostate cancer enrolled in a clinical trial of concurrent high-dose-rate brachytherapy and hormonal therapy at a tertiary cancer centre in Canada. Electronic medical records were reviewed for 180 days following treatment initiation. Time toxicity was quantified as median days and median hours per month spent in care. Subgroup analyses were conducted by encounter type. Sensitivity analyses incorporated the estimated travel time. Type I error was 0.05. RESULTS:46 patients were included. Patients had a median of 6 healthcare encounters: 3 in Month 1, with the remaining 3 distributed across the following 5 months. Early encounters were predominantly treatment-related, whereas later encounters were largely monitoring or follow-up appointments. The median time toxicity was 13.7 hours over 6 months following treatment initiation, with 10.9 hours occurring in Month 1 and minimal time in subsequent months. Planned, in-person encounters accounted for nearly all toxicity. Incorporating travel time more than doubled time toxicity in sensitivity analyses. CONCLUSIONS:Time toxicity was front-loaded and driven primarily by planned, in-person care. Expressing time toxicity in hours provided clearer quantification of early time burden. More granular, patient-centred measurement of time toxicity should be prioritised in future cancer trials.
OBJECTIVES:To analyse patient-reported concerns regarding palliative chemotherapy using text mining and to identify how these concerns evolve according to treatment phase and patient characteristics. METHODS:We conducted a retrospective cross-sectional text-mining study of free-text responses from 479 patients with advanced solid tumours treated at a single institution between 2015 and 2025. A total of 584 responses were analysed. Text data were processed using KH Coder (version 3), employing morphological analysis and co-occurrence network analysis based on the Jaccard coefficient. Words appearing two or more times were included and a threshold of Jaccard coefficient≥0.1 was applied. Frequently occurring words were categorised into four domains according to the nature of the concerns. Analyses were stratified by treatment phase, age and family structure. Sensitivity analyses were performed to assess robustness. RESULTS:'Adverse effects' were the most frequently reported concern across all groups. Symptom-related concerns decreased after treatment initiation, whereas concerns regarding treatment value and continuation increased. Practical concerns declined over time, while uncertainty-related concerns remained relatively stable. Co-occurrence network analysis showed a shift from broad and multifaceted concerns before treatment to more structured and treatment-focused concerns during treatment. Findings were consistent across sensitivity analyses. CONCLUSIONS:Patient concerns during palliative chemotherapy are dynamic and structured, evolving according to treatment phase and social context. Free-text analysis provides clinically meaningful insights beyond structured questionnaires and supports the need for tailored, ongoing communication addressing both medical and psychosocial concerns.
BACKGROUND:Informal caregivers are essential to the provision of cancer care at the end of life, yet the economic costs they bear remain poorly understood and are neither routinely captured nor used in economic evaluation. The absence of consistent data collection and agreed methods for valuation risks underestimating these costs in both policy and practice. AIM:To synthesise the current evidence on the costs borne by informal caregivers for individuals with cancer who have accessed palliative care or are at the end of life and to highlight methodological considerations in measuring these costs. DESIGN:A systematic search and narrative synthesis. DATA SOURCES:MEDLINE, CINAHL, PsycINFO and Cochrane databases were searched for relevant studies published in English between 2013 and 2023. RESULTS:The analysis included 18 studies. Costs to caregivers were categorised into direct costs (eg, out-of-pocket expenses), indirect costs (eg, employment impact) and time costs associated with caregiving tasks. Carer costs varied by cancer stream, functional status and phase of illness. Significant inequities were evident, with carers who were female, rurally located or from socioeconomically disadvantaged groups experiencing higher burdens. There was no standard methodology for measurement of caregiving costs. Heterogeneity in study design, populations and valuation methodologies limited direct comparison of cost estimates across settings. CONCLUSIONS:Informal caregiving imposes significant and unevenly distributed costs. There is a need for an economic tool to standardise how these costs are measured. This would promote integration of carer cost into economic evaluations and would inform policies that support equity and sustainability in cancer care.
PURPOSE:Financial toxicity is increasingly recognised as a significant consequence of cancer treatment yet little is known about its impact on patients with cancer enrolled in pharmacological clinical trials. This review aimed to quantify direct medical and indirect non-medical financial toxicities experienced by these patients, and assess how they are measured and reported. DESIGN:We conducted a systematic review of Ovid Medline, Ovid Embase and the Cochrane Central Register of Controlled Trials from inception to 30 April 2025. Studies were included if they reported on direct or indirect financial toxicity among patients with cancer enrolled in pharmacological clinical trials. Cost data were extracted and adjusted to 2025 US dollars. Study methodology and outcomes were noted. Study quality was assessed using the AXIS tool. RESULTS:Three studies, all conducted in the USA, were included. Two reported direct financial toxicity of US$250-US$300 a month and two reported indirect toxicity exceeding US$800/month. Key cost drivers for indirect toxicity included housing and travel-related expenses. All studies had methodological concerns, including the use of unvalidated self-developed surveys and omission of key cost domains, such as lost income and caregiver burden. CONCLUSIONS:There is sparse evidence, but this review suggests that financial toxicity among trial participants is substantial, and may exceed that of the general cancer population. Further research using standardised, validated methods across diverse contexts is needed.
OBJECTIVES:The aim of this study was to investigate the extent of involvement of physical therapists in employment support for patients with cancer, types of support they provide in practice and attributes of the patients they support. METHODS:This is a nationwide e-survey in Japan. A questionnaire was sent to 385 facilities of physical therapists affiliated with academic societies in Japan to investigate the status of involvement of physical therapists in employment support for patients with cancer. The attributes of the patients they support were surveyed. RESULTS:Responses were received from 105 of 385 facilities (27.3%). Employment support by physical therapists was implemented in 46 facilities (43.8% of responding facilities). Among the types of support provided, physical interventions were the most common (46 facilities), followed by psychoeducational interventions (7 facilities) and vocational interventions (5 facilities). Regarding the attributes of the patients, the proportion of adolescent and young adult patients with cancer receiving physical interventions in designated cancer care hospitals was significantly higher. Additionally, the barriers to physical therapist involvement in employment support for patients with cancer were staff shortages and the absence of a dedicated department. CONCLUSIONS:Only approximately 40% of Japanese physical therapists were involved in employment support among patients with cancer, centred on physical interventions. The further expansion of employment support provided by physical therapists in Japan is necessary.
While reducing oral intake is a natural occurrence when a person is dying, there may be situations where the healthcare team need to decide whether to withhold, initiate, continue or withdraw clinically assisted hydration (CAH), in discussion with the dying person and significant others. Speech and language therapists (SLTs) are increasingly part of the healthcare team, managing a person's dysphagia and communication when they are nearing the end of their life. An SLT can assist with differentiating between clinical symptoms, help determine whether oral fluid intake is as comfortable as possible, enhance oral hygiene, ensure a person can make informed choices around their hydration, and support the person and those close to them to understand the healthcare team's decision-making. The SLT's specialist knowledge and skills can enhance the multidisciplinary team's care quality. This article aims to provide an overview of the clinical and ethical considerations of CAH in adults, relevant to the field of SLT, alongside the SLT role. Given there is no clinical consensus on the benefits and risks of CAH in the last week of life, healthcare teams need to take a person-centred approach when considering the options around CAH. Oral fluid intake, where possible, should be encouraged. Respect for a person's autonomy, alongside effective communication, ensures that a competent individual can decide whether to accept CAH if offered.
OBJECTIVES:To evaluate the first year of a neurologist-led Advance Care Planning (ACP) consultation implemented within a tertiary hospital neurology department, and to assess its impact on end-of-life (EOL) care, alignment with patient preferences, and healthcare utilisation among patients with advanced neurological disease. METHODS:A retrospective observational study of all patients referred to a specialised ACP consultation between May 2023 and June 2024 at the Fundación Jiménez Díaz University Hospital (Madrid, Spain). Referral was guided by a NECPAL (NECesidades PALiativas) - based tool. ACP discussions followed the LagunAdvance framework and generated individualised care plans documented using structured communication and therapeutic appropriateness fields. Fisher's exact test was used to compare differences before and after referral, and Bayesian methods were used where appropriate. RESULTS:Eighty-six patients (median 83 years) were included. Severe cognitive impairment (68%) and moderate-severe dependency (88%) were common. Communication limitations affected 38%. ACP planning was completed for all patients. Engagement with palliative care teams occurred in 24%, and 47% used Web Dialogue. Healthcare utilisation decreased significantly following ACP: emergency department visits fell from 48% to 22% (p<0.001), and hospital admissions from 32% to 16% (p=0.020). Thirty-two patients (37%) died during follow-up; 66% died in their preferred location. Diagnostic interventions in the last week of life were infrequent (15%). CONCLUSIONS:A neurologist-led ACP consultation is feasible and improves key EOL outcomes for patients with advanced neurological disease, including reduced acute care use and greater alignment with patient preferences. This model may support broader integration of palliative principles within neurology services.
OBJECTIVES:Inaccurate prescribing of as needed medications in haematology/oncology patients poses a significant risk to patient safety and symptom control. This quality improvement initiative aimed to reduce as needed prescribing errors from 30% to below 10% over 12 weeks at Galway University Hospital. METHODS:A multidisciplinary 'Medication Safety Team' was formed, and a baseline audit using point prevalence surveys revealed a 30% as needed error rate, predominantly in dose and frequency domains. Semistructured interviews with non-consultant hospital doctors (NCHDs) identified barriers such as limited knowledge of resources, time pressure and inadequate education. Four Plan-Do-Study-Act cycles were implemented focusing on tools, education, resources and awareness. RESULTS:As needed prescribing errors reduced from 30% to 8%. Stakeholder feedback indicated improved confidence and clarity in prescribing practices. Sustainability is addressed with the introduction of QR-code resources at the point of care and embedding of education at induction for NCHDs. CONCLUSIONS:This initiative demonstrates that structured, stakeholder-driven interventions can meaningfully improve prescribing accuracy. Systematic integration of education and resources supports long-term impact, offering a replicable model for enhancing medication safety in palliative and oncology care settings.
OBJECTIVES:The continual evaluation of quality indicators (QIs) for cancer pain management is essential to maintaining and improving its quality. However, free-text notes in electronic medical records (EMRs) must be reviewed to accurately assess pain management QIs, and the heavy workload of this process can be limiting.Therefore, this study evaluated the performance of natural language processing and machine learning for assessing pain management QIs using EMR data. METHODS:This single-centre cross-sectional study included adult patients with cancer who died at a Japanese university hospital between 1 January 2022 and 31 December 2024. Clinical notes concerning inpatients and outpatients were extracted from the EMR system. A model was developed to automatically identify documentation related to pain management from free-text notes. We then compared the model's QIs assessment with a manual review concerning the number of patients who underwent pain screening. RESULTS:The study included 865 patients, and 2 119 377 clinical records were used to evaluate QIs. The model achieved 85%-96% accuracy, and the F1 score ranged from 0.38 to 0.58 for identifying pain-screening documentation. The pain screening rate for the centre's inpatients was 100%, according to the manual and model-based evaluations. For the outpatients, the rates were 35.0% and 35.9%, respectively, by the manual and model-based evaluations. CONCLUSIONS:Pain management QIs can be accurately assessed using natural language processing and machine learning applied to EMRs, with performance comparable to that of manual reviews. This approach may improve cancer pain management by providing clinician feedback and visualising achievement rates.
Purpose To systematically map and synthesise current evidence on family resilience among family caregivers of patients with cancer. Method A scoping review was conducted following the Joanna Briggs Institute framework. Databases including MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus and CNKI were searched in July 2024 and updated in August 2025. The reference list of relevant studies and Google Scholar were also searched. Primary studies published in English and Chinese in peer-reviewed journals were included. Study selection, quality appraisal and data extraction were conducted by two reviewers independently. Narratives, tables and figures were used to present synthesised results. Results 50 studies were included, involving family caregivers across various cancer types and phases of the cancer trajectory. Inconsistent instruments were identified across the studies. The factors were categorised into three core elements of family resilience: risk factors, protective factors and psychosocial and functional outcomes. Furthermore, the review summarises the relationships among these elements and notes a scarcity of empirically tested interventions to enhance family resilience. Conclusions This review provides insights into current evidence on family resilience among family caregivers of patients with cancer. Future research should prioritise the specific phase of the cancer trajectory. In addition, more rigorous methodologies are required for conceptual measurement, exploration of factors and intervention development.
BACKGROUND:Delirium and agitation are common and distressing in the last days of life. In specialist palliative care practice, descriptions such as 'terminal agitation' appear to be used more commonly than diagnostic terms. We aimed to explore the discourse surrounding these terms in this setting, their use and impact on management. METHODS:In this systematic review, we searched electronic databases (Medline, Embase and PsycINFO) for papers focusing on delirium and agitation in the last days of life in palliative care settings. Three reviewers independently selected papers. The frequency of use of terms of interest was noted and surrounding text extracted. Text data were subjected to thematic synthesis. RESULTS:29 studies were included and three themes identified in the context of the last days of life: (1) definitions and terminology (varied and inconsistent); (2) causes, diagnosis and recognition in the palliative care setting (eg, 'terminal' delirium viewed as irreversible); and (3) management and impact (terminology influences assessment and management, and the clinical and emotional impact on patients, family and staff).Review limitations include the restriction to English language papers and being unable to access some relevant full texts. CONCLUSION:We found that inconsistent terminology and ambiguous definitions surrounding agitation and delirium had an impact on care of people with delirium-related and non-delirium-related agitation in the last days of life. The synonymous use of agitation and delirium may compound under-recognition of hypoactive delirium, and the use of the prefix 'terminal' may preclude appropriate assessment of potentially reversible factors despite proximity of death. PROSPERO REGISTRATION NUMBER:CRD42024582291.
