Members of the ESMO Guidelines Committee, Tomasz Dzierżanowski (Poland) and Philip Larkin (Switzerland), introduce ESMO’s latest clinical practice guideline – the first such document that targets both oncologists and palliative care providers by focusing on patient comfort and specifically their physical, psychosocial, and spiritual issues.
There is a raft of clinical practice guidelines (CPGs) released every year by international and local organisations concerning numerous symptoms and clinical settings in cancer. Nevertheless, in August 2021, for the first time, the European Society of Clinical Oncology (ESMO) published new guidelines on the end-of-life care of cancer patients. Although there is a body of evidence for optimal management of many symptoms during early stages, or in the course of cancer treatment, it remains scarce when referring to the last weeks or days of life.
The ESMO end-of-life (EoL) Clinical Practice Guidelines is the first such document targeting both oncologists and palliative care providers by focusing on patient comfort and specifically their physical, psychosocial, and spiritual issues. The novelty of these recommendations comes down to several aspects. First, recommendations on managing selected symptoms at the end of life are dispersed across dozens of CPGs. Thus, there was a need to collate these pieces of evidence into one comprehensive document, revise, verify, and formulate a complex and streamlined approach to care for the dying patient. Further, these new CPGs reference the most up-to-date detailed clinical practice guidelines on pain, dyspnoea, and several other symptoms critical in the last days of life.
Second, these ESMO EoL care guidelines provide statements on several complex symptoms and procedures in the last days of life, such as considering judicious assessment with regards to hydration and nutrition, how to approach this in the last days of life, and the appropriate insertion of lines and catheters. Furthermore, the complexity of ‘diagnosing’ the last weeks of life and in recognizing them, how to convey decisions about stopping systemic anticancer treatments and discontinuation of prophylactic anticoagulation, etc.
Third and of utmost importance, these guidelines emphasise the essential need for communication with the patient and the family defined as the unit of care at EoL. Effective communication and shared decision-making are essential at EoL – poor communication remains an Achilles’ heel of oncology despite an unprecedented improvement in medical technology. How to communicate with the patients who are parents of young children? – this is an example of critical communication aspects raised in this relatively short document.
For the first time, ESMO has recommended the management of spiritual distress as a key element of routine oncological care. Tools to screen the spiritual needs of the patients and suitable interventions, such as referral to spiritual care professionals, mindfulness, art, narrative, and music therapy, meaning-oriented therapy, or dignity therapy are also evidenced.
The last innovation, but often new for many clinicians, is the recommendation to screen and recognise psychosocial distress among caregivers and family members in the pre-death phase to assess and appropriately address bereavement needs as routine referral for bereavement support is not always indicated or warranted.
The decision to cease life-saving treatment is not easy for the oncologist. It incurs both legal consequences and moral dilemmas. Therefore, the ESMO clinical practice guidelines on EoL care as a synthesis of the state of knowledge, and the best practices of care in the last days of a cancer patient’s life, may help those complicated and challenging decisions in the oncology setting.
‘Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines’ by GB Crawford, T Dzierżanowski, K Hauser, P Larkin, AI Luque-Blanco, I Murphy, CM Puchalski, CI Ripamonti, on behalf of the ESMO Guidelines Committee, is published in ESMO Open, Vol. 6, issue 4. Published online 17 August 2021. https://doi.org/10.1016/j.esmoop.2021.100225
You may also be interested in New ESMO recommendations for palliative and supportive care during the COVID-19 pandemic by Nathan Cherny, Anna KL Reyners and Elisabeth DeVries published on the EAPC blog, 24 April 2020.
More about the authors
Tomasz Dzierżanowski, MD, PhD, is Assistant Professor, Laboratory of Palliative Medicine, Department of Social Medicine and Public Health Medical University of Warsaw, Poland and Medical Director, Caritas Diecezji Warszawsko-Praskiej. He is also Vice-President of the Polish Society of Palliative Medicine and Deputy Editor-in-Chief of Medycyna Paliatywna/Palliative Medicine. Contact Tomasz by email.
Prof Philip Larkin, PhD, MSc, BSc, is Chair of Palliative Care Nursing, Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Switzerland. He also directs the Master of Science in Advanced Nursing Practice at the Institute for Higher Education and Research in Healthcare (IUFRS), University of Lausanne.
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