Survival of cancer patients under treatment with the palliative care team in a Brazilian hospital in São Paulo

Abstract

Introduction

The Karnofsky Performance Status Scale is a relevant functional evaluation instrument that can be used to determine which patients should be followed by multidisciplinary palliative care teams.

Objective

To analyze the clinical outcomes of patients with performance status lower than 70%, according to the Karnofsky Scale, who received care from a palliative care team compared to those who did not receive care from a palliative care team.

Methods

In this retrospective cohort, follow-up of cancer patients by the palliative care team for 10 days was considered the exposure factor, while the dependent variable was patient survival. Data were extracted from medical records and descriptive and survival curve analyses were conducted.

Results

Among 581 participants in the sample, 42.5% had metastasis, and the most prevalent medical diagnosis was gastrointestinal cancer (29.1%). Fifty-one (8.7%) were followed by the palliative care team. The mortality rate during the 10 days in the sample was 10.8%, and the rate was higher (15.7%) among patients followed by the palliative care team.

Conclusion

Patients with a performance status below 70% who were followed by the palliative care team had poorer clinical conditions and a shorter survival than those who were not followed up by the team.

INTRODUCTION

Palliative care is an approach to patient care with key objectives of alleviating suffering and improving the quality of life of individuals and their families (Chaves [2011], cited in Cabianca et al., 2017). Palliative care is defined by the World Health Organization (WHO) as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (World Health Organization [WHO] & World Palliative Care Alliance, 2020). Despite its negative or passive connotation, a palliative care approach and treatment should be eminently active and supported by early, dynamic, and active therapeutic approaches that respect personal limits, especially for patients with advanced cancer who present with severe physical, emotional, and psychological symptoms (INCA, 2016, cited in Lima et al., 2018). The closeness between the care team and these patients provides benefits, such as bonding and therapeutic listening, which can have positive effects on physical symptoms, such as pain and fatigue (Quintana et al., 2006), and fostering better perception among health professionals regarding their role in providing comfort and support to patients dealing with a difficult phase of life (Mendes et al., 2009).

Patients with advanced cancer may face numerous decisions about personal matters and healthcare. These decisions often depend on a patient’s life expectancy and clinical condition (Hui, 2015) and, in turn, are closely associated with functional capacity. Functionality is considered a criterion for prognostic evaluation that has a direct relationship with suffering and is an important aspect in the clinical decision-making of both health professionals and patients (ANCP, 2012).

The Karnofsky Performance Status Scale was developed as an instrument to assess clinical decline related to the ability to perform certain basic activities by cancer patients (ANCP, 2012). A score of less than 70% is an early indication for palliative care; a score of less than or equal to 50% suggests a terminal stage of illness (ANCP, 2012). Therefore, it is a relevant functional evaluation instrument that can help to determine which patients should be followed by multidisciplinary palliative care teams. Early referral to the palliative care team has several benefits, such as better quality of life, lower rates of depression, and less aggressive care at the end of life (Temel et al., 2010).

The early initiation of palliative care for patients with impaired functionality can have positive impacts on healthcare and contribute to individualization and improvement in the quality of care and optimization of resources and labour for priority demands. Given these benefits, knowing the clinical outcomes of patients who received this care approach is essential to the discussion, and choice, of appropriate treatments. Thus, this study analyzed the survival of patients admitted to an oncology unit with performance status below 70% according to the Karnofsky Performance scale and compared clinical outcomes of those who were followed by the palliative care team with those who were not followed by the palliative care team. A fundamental step toward achieving more humanized and effective social, psychological, and clinical care is awareness of professionals about the importance of the early introduction of palliative care for cancer patients with greatly impaired functionality.

METHOD

This study used a retrospective cohort design in which the follow-up of cancer patients with low functionality by the palliative care team for 10 days was considered the exposure factor, and the survival of these patients was considered the dependent variable. Data on the sociodemographic profile, presence of metastasis, comorbidities, intensive care unit (ICU) admission, and functionality classification were collected from electronic medical records.

Overall, 623 patients were admitted to the oncology unit from June to November 2017. The unit is in a 560-room hospital that provides services involving high technology and care at the primary, secondary, and tertiary levels in the metropolitan region of the city of São Paulo, Brazil. The study was conducted based on 581 patients admitted to an oncology unit with a cancer diagnosis who met the study criteria. The inclusion criteria were patients older than 18 years and hospitalized in the cancer unit during the study period. Patients hospitalized without a defined cancer diagnosis and with a hospital stay of ≤ 24 hours were excluded.

The outcome variable was the survival of the cancer patients during the 10-day study interval. The independent variables were age, presence of metastases, Charlson index, admission to the intensive care unit (ICU), and follow-up by the care team.

The data collection procedure followed three stages: identification of patients admitted to the cancer unit according to the inclusion and exclusion criteria of the study; review of the patients’ electronic medical records to gather information on the disease evolution and the medical and nursing physical examination on the date of admission; and classification of the patients’ functionality on the date of admission based on the Karnofsky Scale. These steps were carried out by one of the researchers between February and June 2019 after approval of the study by the Ethics and Research Committee where the study was conducted. The study fulfilled the recommendations of the Regulatory Guidelines and Norms for Research Involving Human Beings of resolution No. 466/2012 of the National Health Council (Conselho Nacional de Saúde).

Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) software, version 21.0. The variables were determined to be parametric or nonparametric by the Kolmogorov-Smirnov test. They were expressed as measures of central tendency (mean and median) and measures of dispersion (standard deviation and interquartile ranges). Categorical variables were expressed as the absolute and relative frequencies and were analyzed by Pearson’s chi-squared test. The Kaplan-Meier procedure with the log-rank test was used to analyse survival. The analysis considered sub-groups classified according to follow-up by the palliative care team (with or without follow-up). The survival curve did not include patients who had functionality greater than 70% and were followed by the palliative care team. These patients comprised only 0.5% of the sample. A p value ≤ 0.05 was considered significant, and 95% confidence intervals were computed.

RESULTS

Among the 581 participants in this study, the most prevalent medical diagnosis was gastrointestinal cancer (169, 29.1%), followed by haematological cancer (69, 11.9%) and breast cancer (62, 10.7%). A total of 247 (42.5%) had metastasis. The median age of the participants was 66 years (53–75). The 60–69-year age group was the largest, with 152 patients (26.3%). The sample included more males than females (302 men [52%], 279 women [48%]). Overall, the mortality rate was 10.8% (60), but was higher among patients followed by the palliative care team (Table 2 and Figure 2).

Table 2.

Reason for hospitalization for patients followed and not followed by the palliative care team. São Paulo, 2019.

Reasons for hospitalization	Patients followed by the palliative care team (n = 51)	Patients NOT followed by the palliative care team (n = 530)
Symptom control	13 (25.5%)	189 (35.7%)
Intestinal subocclusion	3 (4.9%)	17 (3.2%)
Disease progression	19 (38%)	51 (9.7%)
Pain	7 (13.8%)	41 (7.7%)
Infection	4 (7.9%)	55 (10.3%)
Chemotherapy cycle	1 (2%)	94 (17,7%)
Others (biliary obstruction, neurological worsening, dyspnea, sleep deprivation, constipation)	4 (7,9%)	83 (15,7%)

Figure 2.

Life expectancy (days) of cancer patients by functionality and follow-up with the palliative care team. Sao Paulo, 2019.

In total, 51 (8.7%) of the patients were followed by the palliative care team. The median age of patients followed by the palliative care team was 56 (40–75.5) years and was 66 (54–75) years among those who were not followed by the palliative care team.

The classification of functionality based on the Karnofsky scale for the whole sample showed a median score of 70% (60–80%). A majority of patients, 469 (80.7%), had a score greater than five on the Charlson comorbidity index. Among the 51 patients followed by the palliative care team, 48 (94.1%) had functionality lower than 70%, 40 (78.4%) had metastasis, and 47 (92.2%) had a Charlson index score ≥ 5. Among those not followed by the palliative care team, 207 (39.1%) had metastasis, 422 (79.6%) had a Charlson score ≥ 5, and 305 (57.5%) had functionality lower than 70% (Table 1). Thirty-five (6%) of these patients who were not followed by the palliative care team and four (7.8%) in the group followed by the palliative care team were referred to the ICU for further treatment. The median period of patient follow-up by the palliative care team was five days (2–9), with a maximum hospital stay of 10 days.

Table 1.

Sociodemographic and clinical characteristics of study participants. Sao Paulo, 2019.

Follow-up by the palliative care team		No		Yes
		n (530)	%	n (51)	%
Metastasis	No	323	60.9	11	21.6
	Yes	207	39.1	40	78.4
Charlson comorbidity index	< 5	108	20.4	4	7.8
	≥ 5	422	79.6	47	92.2
ICU	No	499	94.2	47	92.2
	Yes	31	5.8	4	7.8
Categorized age	< 60 Years old	190	35.8	29	56.9
	≥ 60 Years old	340	64.2	22	43.1
Functionality	> 70	225	42.5	3	5.9
	≤ 70	305	57.5	48	94.1
Death (10 days)	No	514	97.0	43	84.3
	Yes	16	3,0	8	15.7
Gender	Female	249	46.9	30	58.8
	Male	281	53.1	21	41.2
Type of cancer	Solid tumour	418	78.8	47	92.1
	Haematological cancer	112	21.2	04	7.9
Length of hospital stay (days)		05(03–08)		05(03–10)
Age		66 (54–75)		56 (40–75.5)

The most frequent reasons for patient hospitalization were symptom control, administration of chemotherapy, and infection (Table 2). The presence of metastasis, the presence of comorbidities, lower functionality, and a higher mortality rate were associated with the group followed by the palliative care team (Table 3). The presence of metastases was higher and functionality was lower in the patients followed by the palliative care team. While the presence of comorbidities was observed with patients in the conventional treatment group, survival in this group had a longer life span. The life expectancy of patients followed with the palliative care team was lower (p = 0.009; Figure 1), especially among those with functionality below 70% (p = 0.001; Figure 2). Patients with functionality less than 70% and who were not in the group followed by the palliative care team had a longer survival period.

Table 3.

Association between clinical variables and being followed by the palliative care team. São Paulo, 2019.

Follow-up by the palliative care team		No		Yes		p*
		n	%	n	%	.
Presence of metastasis	No	323	60.9%	11	21.6%	0.000
	Yes	207	39.1%	40	78.4%
Charlson comorbidity index (points)	< 5	108	20.4%	4	7.8%	0.030
	≥ 5	422	79.6%	47	92.2%
Stay in the ICU (days)	No	499	94.2%	47	92.2%	0.568
	Yes	31	5.8%	4	7.8%
Functionality **	> 70	225	42.5%	3	5.9%	0.000
	≤ 70	305	57.5%	48	94.1%
Death (10 days)	No	514	97.0%	43	84.3%	0.000
	Yes	16	3.0%	8	15.7%

^*Chi-squared test.

^**Karnofsky Performance Status Scale, ICU-Intensive Care Unit

Figure 1.

Life expectancy (days) of cancer patients being followed by the palliative care team. São Paulo, 2019.

DISCUSSION

The profiles of patients who benefit most from palliative care and the appropriate times for referral to the palliative care team have been studied (Ferrell et al., 2017; Hui, Hannon et al., 2018). The existing recommendations support the referral of people with advanced cancer, progressive chronic diseases, or significant cognitive impairment to palliative care at the time of diagnosis (Kelley & Morrison, 2015). Modern cancer therapy has changed the landscape of cancer treatment and survival, and cancer is currently considered a chronic disease. For those diagnosed with more advanced disease, this change in cancer diagnosis and therapy may result in survival for many years, with a variety of physical and psychological symptoms associated with living with a life-limiting multisystem disease. Strong evidence indicates that early integration of palliative care can improve quality of life and increase survival for those who receive such usual care (Yates, 2017). Our study allows an exploration of the characteristics of patients followed by the palliative care team in our setting and selected indicators of quality end-of-life care.

As seen in our results, functionality, metastases, and comorbidities are associated with follow-up by the palliative care team during the patients’ hospitalization period. This result is similar to results found in patient samples from other studies (Hui et al., 2014) and suggests that individuals who are more compromised are the ones referred to palliative care teams. This prompts a discussion of how health professionals change the care offered to these people. We also found that, among patients followed by the palliative care team, the median age was less than 60 years, which may have occurred because younger patients tend to experience greater suffering and more intense symptoms (Yates et al., 2015). Suffering and symptom management are the main indications for follow-up by teams specialized in palliative care. In our situation, among the patients who were followed by the team, the main reason for the support of the palliative care team was symptom control.

Another important aspect to consider in explaining the referral pattern is that access to much-needed palliative care remains severely limited in inpatient settings in developing countries due to a gap in medical education and a lack of professionals specializing in this type of care (Chow & Dahlin, 2018). These factors can lead to delayed implementation of this resource. Professionals specializing in palliative care are in high demand due to the increasing number of patients living with cancer, new treatments, and increased survival among cancer patients because of innovative treatments. One of the recommendations by the World Medical Organization regarding the quality of cancer care is accessibility to evidence-based care (Chow & Dahlin, 2018). In this context, attention to palliative care planning and the management of cancer effects (Chow et al., 2018) are important steps in the process. This facilitates achieving a sustainable and high-quality care model that includes a palliative care perspective, with nurses being the essential professional for its implementation (Chow & Dahlin, 2018).

In our study, the median age was lower among the patients who were followed by the palliative care team. These patients also had more metastasis and lower functionality. The prevalence of symptoms, such as pain, sleep deprivation, lack of energy, nausea, dyspnea, and constipation, has been reported as higher among young patients, despite having a Karnofsky score greater than 60% (Yates et al., 2015). In our study, the most prevalent reason for hospitalization was symptom control, especially among those who were being followed by the palliative care team. Therefore, we have inferred that, in our setting, palliative care is mostly implemented for patients with greater suffering and symptoms that are difficult to manage, which may explain why younger patients and those with more comorbidities and less functionality were more often referred to the palliative care team.

Early palliative care can have a favourable impact on the aggressiveness of end-of-life care, with a decrease in the administration of chemotherapy, the number of hospitalizations, visits to the emergency department, and admissions to the ICU (Colombet et al., 2019) in the last 30 days of life. These indicators assist in monitoring the quality of end-of-life care for patients and can contribute to a shared vision of adequate end-of-life goals and the promotion of improved actions for the education of health professionals (Colombet et al., 2019). The introduction of palliative care in a period more than 30 days prior to death has resulted in patients receiving less intense unnecessary care (Colombet et al., 2019). In a meta-analysis conducted to evaluate the impact of palliative care on quality of life and survival of patients, survival was found to be greater among patients who were followed by the palliative care team for a period of six to eighteen months. In the early stages, there was no impact of palliative care on survival (Rogers et al., 2020). Although palliative care can extend the duration of survival for some patients, its main objective is to improve the quality of life for the family and patient at the end of life (Rogers et al., 2020). Hence survival is a challenging indicator of quality care in this population. Our results show that patients followed by the palliative care team had a shorter survival than those who were not under follow-up; and among the patients followed, survival was lower for those with worse functionality. These observations reflect the nature of the referrals made to the palliative care team. These patients already had low functionality and advanced disease. Influencing the quality of life of these patients is challenging given palliative care was initiated close to the last days of the patients’ lives.

Some experts indicate that the best time to start follow-up by the palliative care team is within three months of the diagnosis of advanced and/or metastatic cancer, when the patient’s prognosis is for life expectancy less than one year and a low performance on the Karnofsky Performance Status Scale. For these patients, a life-expectancy prognosis of more than 24 months could be too early for referral; the ideal time is when the prognosis is six to 24 months of life (Hui, Mori, et al., 2018). The longer time period allows for interventions to relieve suffering and improve quality of life to be implemented and have time for being effective.

Although the association between ICU admission and follow-up was not significant in our study, it is noteworthy that there were patients who were being followed by the palliative care team who were referred for treatment to this service. Routinely this would mean these patients would undergo aggressive procedures and artificial life support treatments. Decisions for end-of-life care also frequently take place in ICUs, aiming to implement measures that prioritize comfort (Jensen et al., 2020). In Brazil, the prevalence of ICU admission of patients with haematological cancer in the last 30 days of life was 56%, and among these, 71% received chemotherapy (Soares, 2019). Even in developed countries, the proportion of advanced cancer patients who die in hospitals in the last months of life is still high. In the USA, approximately 40.3% of cancer patients are referred to the ICU in the last 180 days of life (Bekelman et al., 2016).

Prognosis is important for determining the care that will be provided, as well as choosing how to communicate with patients, their families, and health professionals who provide care throughout the disease, from the day of the prognosis until the time of death. There are survival estimates for each Karnofsky performance level. In a study, patients with advanced cancer were assessed by physicians using three different instruments, including the Karnofsky Scale and the average survival was lower as each performance level became more severe (Jang et al., 2014). In line with our findings, the same study found that patients referred for follow-up to a palliative care team had worse functionality, more advanced disease, and a higher mortality rate. This demonstrates that patient referrals to palliative care was late and the patients were in worse clinical condition (Jang et al., 2014).

This debate about the most appropriate timing for referral to palliative care needs to be broadened so that the practice of referring people to palliative care is guided by evidence and brings benefits to the quality of life remaining (Jang et al., 2014). Early referral has a positive impact on end-of-life care (Hui et al., 2014), especially in the last 30 days of life, in the form of lower rates of emergency care and hospitalizations (Hui et al., 2014). In a Brazilian hospital, among patients with advanced cancer, during the last 60 days of life, 62% were seen in the emergency department, and 33% were admitted to the ICU; in the last 30 days of life, 51% underwent diagnostic tests, 24% received blood transfusions, 29% received chemotherapy, and only 1% were cared for at home (Soares et al., 2019). These findings support the importance of early inclusion of patients who have low functionality in follow-up by the palliative care team so that patients and families can have a better quality of care, with less suffering and less use of unnecessary therapeutic measures.

There is a need for prospective studies that can address the early introduction of palliative care and identify criteria that contribute to the quality of end-of-life care. More than survival ought to be measured as a reflection of quality of care. Since palliative care provided by specialized professionals is a scarce resource in Brazil, evaluation of patients using criteria and validated instruments can assist in the development of guidelines and public policies to improve care for patients at the end of their lives. Further studies exploring palliative treatment are recommended, which may improve the quality of care by analyzing how resources can be better used and how individual differences can be addressed in treatment.

LIMITATIONS

One limitation of this research is that it was not possible to assess the quality of life of patients, especially those who were followed by the palliative care team, since it was a retrospective study.

CONCLUSION

The patients with a performance status below 70% followed by the palliative care team had shorter survival than those who were not followed by the team, and their clinical conditions were worse. These findings demonstrate that the patients were referred for follow-up to the palliative care team at a time when the disease was already very advanced, and the patients debilitated with a number of symptoms and suffering. This finding leads to consideration of the shortage of professionals and services specialized in palliative care and the education of health professionals regarding this subject.