Eduardo de Santibañes, Victoria Ardiles, Fernando A. Alvarez, Virginia Cano Busnelli and Martin de Santibañes (eds.)Extreme Hepatic Surgery and Other Strategieshttps://doi.org/10.1007/978-3-319-13896-1_26

26. Improving Quality of Life in Patients with Unresectable Disease

Mariela Bertolino¹, Noemí Díaz¹ and Guillermo Mammana¹

(1)

Palliative Care Unit, Hospital General de Agudos Dr. Enrique Tornú and Fundación FEMEBA, Buenos Aires, Argentina

Mariela Bertolino (Corresponding author)

Email: marielabertolino@gmail.com

Guillermo Mammana

Email: gm@palcare.com.ar

Abstract

Colorectal cancer is a frequent neoplasia, with considerable physical and psychological symptom burden and mortality. The management of stage IV patients has significantly changed over the last decades and is nowadays interdisciplinary, allowing an important increase in survival and in quality of life. The limited possibilities available for the treatment of colorectal metastases are no longer the rule. Therefore, to provide optimal outcomes for patients with liver metastases, it is imperative to consider all treatment options available, based on each patient’s comorbidities, tumor extent, preferences, and available technical and professional resources. Nevertheless, it must be acknowledged that there are unique aspects for decision-making that involve clinical, ethical, and communication aspects.

Acute and persistent pain are frequent, and require a multidimensional assessment and approach and the adequate use of opioids.

The inclusion of palliative care, in addition to other specialties, during the course of the illness will promote physical, psychological, social, and spiritual well-being, and meaningful life experiences for patients and their families.

Keywords

Colorectal cancerLiver metastasesPalliative careMultimodal treatmentSurgeryPain treatmentOpioidsDecision-makingCommunicationPsychosocial stress

Introduction

Colorectal is one of the most frequently diagnosed cancers, with high incidence and mortality; 70% of patients develop liver metastasis. Without treatment, the median survival in this population is 6–12 months. Although surgical resection is the gold standard for colorectal liver metastasis (CLM) treatment, achieving cure or enhancing survival is currently possible in many patients; others are not surgical candidates because of insufficient residual liver tissue, extrahepatic disease, anatomic constraints of the tumor, or medical comorbidities [1]. For this group, palliative therapy remains the only option: it permits local symptom control and prolonged survival in some cases. As established methods are continuously improved, new palliative therapies are tested in clinical trials and subsequently introduced into clinical practice. The present review provides an overview of current CLM treatment, with or without resection. This chapter gives the basis for an interdisciplinary and integrative approach [1, 2].

Palliative care (PC): It is a type of care that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of avoidable suffering (WHO). It is made up of actions in the physical, psychological, social, and spiritual fields which promote well-being and meaningful life experiences during the course of the illness [3].

We will describe two ways of providing PC:

1.

Primary PC or palliative approach: this is the PC standard that must be provided by all the reference teams, such as surgery, internal medicine, oncology, etc., within their ordinary duties of patient care. In surgery in particular, this includes highly-specialized surgical procedures of palliative intervention.
2.

Palliative care as specialty: this is the standard of care provided by a trained interdisciplinary team in order to solve problems which are persistent or complex from the perspective of symptoms or are of a psycho-socio-existential nature. Thus, it is proposed that patients who cannot be alleviated by the intervening base team are referred to specialized PC teams [4, 5]. A PC intervention can be performed at any time during the course of the cancer progression. A distinction must be made between Early PC and PC at the end-of-life stage. The concept of continuous or integrated PC during all the course of the cancer does not restrict the application of this outlook exclusively for the end-of-life stage [2, 4–6]. PC is an addition and a complement to curative or palliative interventions by the specialties which treat the base pathology. Therefore, even if PC has developed mainly in patients with advanced cancer, every situation with a high level of suffering, in any dimension, may be assisted with an approach focused on care, which may complement specific treatment of pathologies such as surgery or oncology-specific treatment.

PC team: the comprehensive assistance of patients and their families requires a multi-dimensional, interdisciplinary approach. The team can be made up of specialists in different areas: doctors, nurses, psychologists, social workers, occupational therapists, spiritual advisors, and volunteers, among others.

Teamwork: this is a challenge, requiring fluent interaction and dialogue, speaking a common language, and keeping all the different specialties in a symmetrical relationship. Individual responsibility, a proactive attitude, and respect for one another are of paramount importance.

A PC team relates and integrates to other teams assisting the patient (surgery, oncology, radiotherapy, anesthesiology, and others) [2].

The benefits of this type of work can be described both at the level of assistance to patients and families and at the level of the members of the teams. In connection to this last point, we can highlight emotional support, prevention of burnout syndrome, reciprocal training, and the opportunity of sharing experiences and hard decisions [6, 7].

In order to achieve better results, it is key to work in relationships of cooperation, coordination, and flexibility among the different professionals that compose the team that provides care (primary doctor, hospital and home teams, etc.). The primary doctor and/or specialty consultant has a pivotal role, and specialized PC teams ideally act as support. An interdisciplinary approach is required to provide PC, but specialized teams made up of all the professions will not be required for each patient.

The team’s structures must be adapted to the needs of the population, its culture, and its healthcare system, so that there are hospital support care teams, outpatient care teams, hospitalization units, hospices, home-based care teams, and day centers.

It is crucial that different levels of care and different structures of PC work seamlessly in order to adequately respond to each situation.

Interaction Between Surgery and Palliative Care in the Case of Planning a CLM Resection

This book shows that the limited possibilities available for the treatment of unresectable colorectal metastases are no longer the rule. Therefore, to provide optimal outcomes for patients with CLM, it is imperative to consider all treatment options available based on each patient’s comorbidities and tumor extent and available technical and professional resources [8–11].

When the teams of surgery and PC collaborate, these are the fundamental questions they need to pose:

What is the support PC can provide to oncological surgery? What support can oncological surgery provide to PC?
Which are the benefits to be expected from their interaction?

Thus, it is possible to plan strategies, adapt them to the needs of each patient, the team that provides him care, and his affective environment. These strategies should deal with:

Pain management and control of other symptoms (anorexia, nausea, itching, etc.).
Psycho-socio-spiritual support
Joint deliberation for decision-making, recognizing that each case is unique regarding: communication with patient and family, tests or procedures that can be diagnostic or therapeutic, and type of follow-up chosen (surgery with PC support, surgery and PC, PC with surgery support, or PC exclusively).
Help in practical issues to set up care: in an institution or planning the release.
Assessment and reciprocal inter-professional support for the follow-up of complex cases.
Assessment of palliative surgical treatment, even in patients with advanced illnesses who are initially referred exclusively to PC, in order to avoid their under-treatment due to their being palliative patients.

Even if the word, applied to surgery, has historically had a connotation frequently associated to therapeutic failure, surgeons have a lot to offer for symptom control and the improvement of quality of life for patients with advanced illnesses.

PC during surgical care is, most of the times, more about rediscovery and relabeling and not of learning new ideas. Palliative surgery makes up a significant share of a surgeon’s professional practice. Despite it being less common that surgeons receive formal training in PC, many recognize the palliative nature of a great part of their daily work.

Decision-Making and Communication

Decision-making in the context of an oncological patient with CLM should not differ from others: a joint discussion between patient, family and team about the recommended interventions, respecting the patient’s wish once his competence is ascertained [12, 13].

Every decision-making process entails truly informed consent, one which is autonomous and competent on the part of the patient, and also an instance of joint discussion with the attending team.

Nevertheless, in the context of a patient with CLM diagnosis, be it potentially resectable or not, we must acknowledge that there are unique aspects for decision-making: these involve ethical, clinical, and communication aspects. Truthful information on diagnosis and prognosis is essential for a proper decision-making process to take place. There are two situations that can make therapeutic dialogue and deliberation harder: reluctance to communicate truthfully and violent truth [14].

Reluctance to talk about diagnosis and possible prognosis is something that can affect both healthcare professionals and patients, and even the patient’s relatives in some cultural contexts. If communication is ambiguous, or one is afraid to face reality, any analysis could turn out to be erroneous, particularly when the ambiguity is in the diagnostic information. On the other hand, providing information harshly should be avoided, as should be not adapting to the time a patient needs to process the situation in the least traumatic way.

In these cases, it is important to take into account that:

1.

The patient is a subject with different degrees of vulnerability and needs a gradual approach to the truth of his clinical condition, and his real possibilities.
2.

Honest dialogue, even if painful on occasion, is one of the building blocks of trust and cooperation in the doctor–patient relationship.
3.

Vulnerability is not synonymous with incompetence.

Thus, communication is one of the main tools in health care. A powerful barrier is scarce, incomplete, or evasive information which the patient or family often face. Our task, then, is to explore what the patient knows and how much he wishes to know. Then we will assess how to gradually offer options and professional support, so that the patient and family can adapt to all the new and difficult situations they are going through. Focusing on communication with the patient with this outlook means that the healthcare team will strive to achieve what is best for him, with regard to the subjective parts.

For the communication of diagnosis, it is necessary to establish a possible action plan. For this, it is key that professionals talk to the patient and his affective environment with an accessible vocabulary, and permanently confirming understanding. Special attention should be paid to convictions and relationship conflicts which could affect decision-making.

The goal of communication should be for the patient to feel listened to and helped to explore his innermost motivations to receive or reject treatment, as well as his preferences and fears at each stage of the illness.

It is also necessary to take into account that families can be dysfunctional or complex, and this affects the course of the illness and the way decisions are made.

The communication of goals in surgery, cure, attempts to control the disease’s progression, or providing PC, is paramount, and has emotional implications for patients, relatives, and doctors. Other interventionist practices for specific treatment of pathologies that will be addressed in other chapters of the book are: systemic chemotherapy, regional techniques, thermoablative methods, radiofrequency ablation, vascular embolization, transarterial chemoembolization, and placement of stents or perihepatic catheters, among others [1].

Communicating in a sincere and cautious way, promoting ideas of hope of relief and togetherness, will be beneficial to all.

Competences in the areas of communication and decision-making regarding PC can be achieved through specialized training, even when these areas have not been discussed during in the undergraduate studies. This is the reason, and given the high frequency of palliative surgeries (with the technical and emotional complexities they entail), that the American College of Surgeons has created a Task Force of Palliative Care, and the American Board of Surgery has demanded that all residents receive training in the psychological support of patients, and in symptom control [15–17].

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