Hospice & Palliative Care

End Stage Disease Progression and Complications – Oncologic Disorders (Learning Hospice)

TNM staging system:

T: size and extent of the primary tumor

N: presence or absence of lymph node

M: presence or absence of distant metastasis

Stages 0-IV

Example: T4, N3, M1 Colon Cancer is considered Stage IV Cancer with Metastasis

End-stage disease oncologic disorders may vary depending on the type of cancer and the areas of metastasis but often includes the following:

  1. Pain: This is the most common complication due to pressure from tumors on surrounding tissue, causing ischemia and nerve compression. Pain may be localized or generalized. Opioids are the treatment of choice, usually on a continuous round-the-clock schedule with additional doses for breakthrough pain at end-stage to provide as much comfort as possible.
    • Spinal Cord Compression in Cancer
      • Definition: compression resulting from direct pressure from the tumor mass or displacement of bony fragments into the spinal canal secondary to vertebral metastases from breast, lung, or prostate (most common).
        • Occurs in5-30% of cancer patients
        • 2nd most frequent complication
        • Affects comfort and function, quality and trajectory of life
      • Symptoms: back pain most common presenting symptom followed by lower motor neuron deficits (hypotonicity, hyperreflexia, paralysis), urinary dysfunction, and constipation
  2. Nausea/ vomiting: Anti-emetics and /or medical marijuana may help to reduce nausea and vomiting. The patient’s diet should be altered to include those foods the patient can best tolerate, often soft, bland or liquid foods.
  3. Dyspnea: Dyspnea is common, and supplementary oxygen may help to provide some relief.
    • Superior Vena Cava Syndrome: A syndrome that develops from the obstruction or compression of the superior vena cava resulting in increased venous pressure and decreased cardiac output. The most common cause is a malignancy present in the mediastinal area (small cell lung cancer)
      • Symptoms: dyspnea (most common), facial and neck swelling, magenta or bluish discoloration of the skin, upper extremity swelling, cough, dilated collateral chest wall veins.
  4. Confusion: Supportive care and reorientating the patient may help to reduce confusion, but confusion often persists, especially with high doses of opioids.
  5. Bowel/ bladder dysfunction: This is common because of dehydration and opioid use. Stool softeners, laxatives, and encouraging fluid intake may help. If the patient is still able to eat, adding yogurt, fiber, and prune juice to the diet may be helpful.

 

Factors supporting hospice referral:

  1. Disease with distant metastases at presentation

OR

2. Progression from an earlier stage of the disease to metastatic disease with either:

  • The continued decline despite therapy (like palliative chemo or radiation)

OR

  • The patient refuses further disease-related therapy

Certain cancers with poor prognoses, such as small cell lung cancer, brain cancer, and pancreatic cancer, maybe hospice eligible without fulfilling the other criteria in this section.

 

***Poor performance status – a decline in functional status is the most important prognostic indicator and is a measure of how much a patient can do independently.

In the cancer population, performance status is typically measured by ECOG, PPS, or Karnofsky Index.

 

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