The cancer journal
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Caring for dying patients is challenging for oncologists, but a crucial aspect of cancer care. It requires highly developed communication skills and an understanding of prognostication at the end of life, which can potentially be improved by training and use of appropriate tools. Psychosocial concerns are as important as physical symptoms. ⋯ Symptoms affecting dying patients' comfort, including pain, dyspnea, delirium, and terminal secretions, require different clinical management as death approaches. Equally important is the ability to discuss transitions in goals of care from cure to comfort and supporting families and patients to make wise decisions without feeling they have been abandoned. Involving a palliative care team supports both oncologists and patients by providing whole-person assessment and care and excellent symptom control and can offer bereavement services to follow up family members after death.
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This review aims to describe available standards for delivery of palliative and supportive care for cancer patients and discuss to what extent these guidelines have been evaluated and disseminated into standard care. Ovid searches were conducted to identify relevant guidelines, randomized studies comparing guideline-based care to usual care, and articles describing the use of guidelines in the usual care setting. Published guidelines address specific issues related to symptom management. ⋯ Clinical trial publications rarely address supportive care in detail. Guideline efficacy has not been evaluated, and their dissemination into standard care has been poor. A conceptual framework for better implementation of existing guidelines might improve usage and outcomes.
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Review
The oncologist's role in managing depression, anxiety, and demoralization with advanced cancer.
The incidence of psychological distress-depression, anxiety, delirium-in patients with cancer ranges from 35% to 50%. Demoralization, a new concept, has not been included in most studies. The role of the oncologist in managing depression, anxiety, and demoralization involves diagnosing the problem, providing verbal support, first-line psychotropic medications, and referral to the psycho-oncology team. ⋯ Demoralization acts as a bridge from traditional psychiatric terminology to newer concepts used to describe the particular psychological distress characteristic of advanced cancer. Word concepts, such as meaning, spiritual, dignity, and existential, capture the patients' distress that is not defined by formal psychiatric taxonomy. Management modalities for depression, anxiety, and demoralization are discussed.
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The interdisciplinary team is fundamental to the successful delivery of quality palliative care. Ideally, the oncologist is an integral part of either the palliative care or hospice team and serves to maintain continuity of care through the end of life. In the United States, barriers can complicate the oncologist's easy integration into the hospice team as patients often remain at home. ⋯ Thus, there is a need to enrich the general oncologist's knowledge of specialized palliative medicine, as recommended by the major cancer organizations, including the American Society of Clinical Oncology and the European Society of Medical Oncology. It is important to know when to incorporate a palliative or hospice care team into the routine management of a cancer patient and what benefits these referrals can provide. Oncologists have an obligation to provide high-quality palliative care to all patients in an integrated fashion, including patients with advanced cancer enrolled in clinical trials for early therapeutics.
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Given that such a substantial proportion of oncology patients have advanced and/or incurable cancer oncologists invariably face enormous challenges in maintaining or improving the quality of life of this cohort of their practice. The provision of supportive and palliative care for these patients is a core element of quality cancer care. As the primary professional health care provider to the cancer patient, the oncologist has a special, significant, and challenging role in the care of these patients and their families. This article addresses the scope of these responsibilities and challenges and provides some introductory insights relating to practice that will be elaborated upon in the other contributions in this special issue of the Cancer Journal.