Little is known about quality of life (QOL), depression, and end-of-life (EOL) outcomes among hospitalized patients with advanced cancer.
Objective:
To assess whether the surprise question identifies inpatients with advanced cancer likely to have unmet palliative care needs.
Design:
Prospective cohort study and long-term follow-up.
Setting/Subjects:
From 2008 to 2010, we enrolled 150 inpatients at Duke University with stage III/IV solid tumors or lymphoma/acute leukemia and whose physician would not be surprised if they died in less than one year.
Measurements:
We assessed QOL (FACT-G), mood (brief CES-D), and EOL outcomes.
Results:
Mean FACT-G score was quite low (66.9; SD 11). Forty-five patients (30%) had a brief CES-D score of ≥4 indicating a high likelihood of depression. In multivariate analyses, better QOL was associated with less depression (OR 0.91, p < 0.0001), controlling for tumor type, education, and spiritual well-being. Physicians correctly estimated death within one year in 101 (69%) cases, yet only 37 patients (25%) used hospice, and 4 (2.7%) received a palliative care consult; 89 (60.5%) had a do-not-resuscitate order, and 63 (43%) died in the hospital.
Conclusions:
The surprise question identifies inpatients with advanced solid or hematologic cancers having poor QOL and frequent depressive symptoms. Although physicians expected death within a year, EOL quality outcomes were poor. Hospitalized patients with advanced cancer may benefit from palliative care interventions to improve mood, QOL, and EOL care, and the surprise question is a practical method to identify those with unmet needs.
Get full access to this article
View all access options for this article.
References
1.
MovsasB, MoughanJ, SarnaL, et al.: Quality of life supersedes the classic prognosticators for long-term survival in locally advanced non-small-cell lung cancer: An analysis of RTOG 9801. J Clin Oncol, 2009; 27:5816–5822.
2.
PirlWF, TemelJS, BillingsA, et al.: Depression after diagnosis of advanced non-small cell lung cancer and survival: A pilot study. Psychosomatics, 2008; 49:218–224.
3.
MontazeriA, MilroyR, HoleD, et al.: Quality of life in lung cancer patients: As an important prognostic factor. Lung Cancer, 2001; 31:233–240.
4.
KressJP, ChristensonJ, PohlmanAS, et al.: Outcomes of critically ill cancer patients in a university hospital setting. Am J Respir Crit Care Med, 1999; 160:1957–1961.
5.
KrebberAM, BuffartLM, KleijnG, et al.: Prevalence of depression in cancer patients: A meta-analysis of diagnostic interviews and self-report instruments. Psychooncology, 2014; 23:121–130.
6.
MitchellAJ, ChanM, BhattiH, et al.: Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. Lancet Oncol, 2011; 12:160–174.
7.
KoropchakCM, PollakKI, ArnoldRM, et al.: Studying communication in oncologist-patient encounters: The SCOPE Trial. Palliat Med, 2006; 20:813–819.
8.
MoroniM, ZocchiD, BolognesiD, et al.: The ‘surprise’ question in advanced cancer patients: A prospective study among general practitioners. Palliat Med, 2014; 28:959–964.
9.
MossAH, LunneyJR, CulpS, et al.: Prognostic significance of the “surprise” question in cancer patients. J Palliat Med, 2010; 13:837–840.
10.
WrightAA, KeatingNL, BalboniTA, et al.: Place of death: Correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health. J Clin Oncol, 2010; 28:4457–4464.
11.
WrightAA, ZhangB, RayA, et al.: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 2008; 300:1665–1673.
12.
TemelJS, GreerJA, MuzikanskyA, et al.: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med, 2010; 363:733–742.
13.
LeBlancTW: In the sandbox: Palliative care and hematologic malignancies. J Community Support Oncol, 2014; 12:44–45.
14.
LeBlancTW: Palliative care and hematologic malignancies: Old dog, new tricks?. J Oncol Pract, 2014; 10:e404–e407.
15.
PearceMJ, CoanAD, HerndonJE2nd, et al.: Unmet spiritual care needs impact emotional and spiritual well-being in advanced cancer patients. Support Care Cancer, 2012; 20:2269–2276.
16.
KarnofskyD, BurchenalJ: The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeodC (ed): Symposium on the Evaluation of Chemotherapeutic Agents. New York: Columbia University Press, 1949, pp. 191–205.
17.
CharlsonME, PompeiP, AlesKL, et al.: A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis, 1987; 40:373–383.
18.
CellaDF, TulskyDS, GrayG, et al.: The Functional Assessment of Cancer Therapy scale: Development and validation of the general measure. J Clin Oncol, 1993; 11:570–579.
19.
CellaD, HahnEA, DineenK: Meaningful change in cancer-specific quality of life scores: Differences between improvement and worsening. Qual Life Res, 2002; 11:207–221.
20.
YostKJ, CellaD, ChawlaA, et al.: Minimally important differences were estimated for the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) instrument using a combination of distribution- and anchor-based approaches. J Clin Epidemiol, 2005; 58:1241–1251.
21.
YostKJ, EtonDT: Combining distribution- and anchor-based approaches to determine minimally important differences: The FACIT experience. Eval Health Prof, 2005; 28:172–191.
22.
RingashJ, O'SullivanB, BezjakA, et al.: Interpreting clinically significant changes in patient-reported outcomes. Cancer, 2007; 110:196–202.
23.
BruckerPS, YostK, CashyJ, et al.: General population and cancer patient norms for the Functional Assessment of Cancer Therapy-General (FACT-G). Eval Health Prof, 2005; 28:192–211.
24.
LewinsohnPM, SeeleyJR, RobertsRE, et al.: Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychol Aging, 1997; 12:277–287.
25.
HannD, WinterK, JacobsenP: Measurement of depressive symptoms in cancer patients: Evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). J Psychosom Res, 1999; 46:437–443.
26.
ZauszniewskiJA, GrahamGC: Comparison of short scales to measure depressive symptoms in elders with diabetes. West J Nurs Res, 2009; 31:219–234.
27.
ShroutPE, YagerTJ: Reliability and validity of screening scales: Effect of reducing scale length. J Clin Epidemiol, 1989; 42:69–78.
28.
FavaGA, PilowskyI, PierfedericiA, et al.: Depressive symptoms and abnormal illness behavior in general hospital patients. Gen Hosp Psychiatry, 1982; 4:171–178.
29.
ClementJP, FrayE, PaycinS, et al.: Detection of depression in elderly hospitalized patients in emergency wards in France using the CES-D and the mini-GDS: Preliminary experiences. Int J Geriatr Psychiatry, 1999; 14:373–378.
30.
KoenigHG: Depression in hospitalized older patients with congestive heart failure. Gen Hosp Psychiatry, 1998; 20:29–43.
31.
Lesman-LeegteI, JaarsmaT, SandermanR, et al.: Depressive symptoms are prominent among elderly hospitalised heart failure patients. Eur J Heart Fail, 2006; 8:634–640.
32.
SchroeversMJ, SandermanR, van SonderenE, et al.: The evaluation of the Center for Epidemiologic Studies Depression (CES-D) scale: Depressed and Positive Affect in cancer patients and healthy reference subjects. Qual Life Res, 2000; 9:1015–1029.
33.
PetermanAH, FitchettG, BradyMJ, et al.: Measuring spiritual well-being in people with cancer: The functional assessment of chronic illness therapy—Spiritual Well-being Scale (FACIT-Sp). Ann Behav Med, 2002; 24:49–58.
34.
LeBlancTW, NippRD, RushingCN, et al.: Correlation between the international consensus definition of the Cancer Anorexia-Cachexia Syndrome (CACS) and patient-centered outcomes in advanced non-small cell lung cancer. J Pain Symptom Manage, 2015; 49:680–689.
35.
RiedelRF, SlusserK, PowerS, et al.: Improvements in patient and health system outcomes using an integrated oncology and palliative medicine approach on a solid tumor inpatient service. J Oncol Pract, 2017; 13:e738–e748.
36.
MeropolNJ, EglestonBL, BuzagloJS, et al.: Cancer patient preferences for quality and length of life. Cancer, 2008; 113:3459–3466.
37.
HerrmannC, Brand-DriehorstS, KaminskyB, et al.: Diagnostic groups and depressed mood as predictors of 22-month mortality in medical inpatients. Psychosom Med, 1998; 60:570–577.
38.
BakitasM, LyonsKD, HegelMT, et al.: The project ENABLE II randomized controlled trial to improve palliative care for rural patients with advanced cancer: Baseline findings, methodological challenges, and solutions. Palliat Support Care, 2009; 7:75–86.
39.
ZimmermannC, SwamiN, KrzyzanowskaM, et al.: Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet, 2014; 383:1721–1730.
40.
LeBlancTW, O'DonnellJD, Crowley-MatokaM, et al.: Perceptions of palliative care among hematologic malignancy specialists: A mixed-methods study. J Oncol Pract, 2015; 11:e230–e238.
41.
LeBlancTW: Addressing end-of-life quality gaps in hematologic cancers: The importance of early concurrent palliative care. JAMA Intern Med, 2016; 176:265–266.
42.
OdejideOO, Salas CoronadoDY, WattsCD, et al.: End-of-life care for blood cancers: A series of focus groups with hematologic oncologists. J Oncol Pract, 2014; 10:e396–e403.
43.
OdejideOO, CroninAM, CondronN, et al.: Timeliness of end-of-life discussions for blood cancers: A national survey of hematologic oncologists. JAMA Intern Med, 2016; 176:263–265.
44.
SchenkerY, Crowley-MatokaM, DohanD, et al.: Oncologist factors that influence referrals to subspecialty palliative care clinics. J Oncol Pract, 2014; 10:e37–e44.
45.
BakitasMA, TostesonTD, LiZ, et al.: Early versus delayed initiation of concurrent palliative oncology care: Patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol, 2015; 33:1438–1445.
46.
El-JawahriA, LeBlancT, VanDusenH, et al.: Effect of inpatient palliative care on quality of life 2 weeks after hematopoietic stem cell transplantation: A randomized clinical trial. JAMA, 2016; 316:2094–2103.
47.
El-JawahriA, TraegerL, GreerJA, et al.: Effect of inpatient palliative care during hematopoietic stem-cell transplant on psychological distress 6 months after transplant: Results of a randomized clinical trial. J Clin Oncol, 2017; 35:3714–3721.
48.
BrueraE, RussellN, SweeneyC, et al.: Place of death and its predictors for local patients registered at a comprehensive cancer center. J Clin Oncol, 2002; 20:2127–2133.
49.
HigginsonIJ, Sen-GuptaGJ: Place of care in advanced cancer: A qualitative systematic literature review of patient preferences. J Palliat Med, 2000; 3:287–300.
50.
ChristakisNA, LamontEB: Extent and determinants of error in doctors' prognoses in terminally ill patients: Prospective cohort study. BMJ, 2000; 320:469–472.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
