Patients with life-limiting advanced lung cancer often experience intense grief and loss.

Addressing patients’ physical symptoms — drug side effects, trouble breathing, pain, fatigue — alongside their psychological and spiritual distress — depression, anxiety, fear of death — is critical to restoring their dignity and improving their quality of life, say palliative care experts.

Palliative care aims “to anticipate, prevent, and reduce suffering, promote adaptive coping, and support the best possible quality of life…regardless of the stage of the disease or the need for other therapies,” commented Andreas Charalambous, RN, PhD, assistant professor (acting) of oncology and palliative care at the Cyprus University of Technology in Limassol, Cyprus.

He was speaking at the 2021 World Conference on Lung Cancer, where he chaired a special session entitled, “Grief and Loss in Palliative Care,” on September 10.  

Research shows that the use of palliative care is associated with improved quality of life and lower costs of care for patients with cancer. But a 2015 Palliative Care Survey by the National Comprehensive Cancer Network found that although the majority of leading US cancer centers have inpatient palliative care services, most reported insufficient capacity to meet the demand, and that home-based palliative care services and inpatient units were much less common.

Charalambous emphasized the importance of enhancing the use and quality of palliative care services for patients with advanced lung cancer.

During the session, experts discussed an array of strategies geared towards relieving physical symptoms as well as psychological and spiritual stressors.  

Physical Activity: Establishing What‘s Possible

Grief and loss are “natural and normal” reactions to advanced cancer, commented Celia Marston, MPallCare, clinical lead for occupational therapy at Peter MacCallum Cancer Centre in Melbourne, Australia.

Patients experience feelings of loss around their independence, relationships, physical and cognitive functioning, which in turn impacts their sense of identity, daily routines, and plans for the future.

According to Marston, the rapid physical decline patients experience in the last 3 months of life is particularly “distressing,” which is why helping patients continue to perform everyday tasks is so critical. 

In clinical practice, this means providing patients palliative rehabilitation focused on maintaining at least a degree of their normal physical activity, which allows them “to adjust and contend with that decline,” Marston said. It also requires understanding what is important to patients and supporting those requests.

According to Marston, optimizing patient function can help maintain or slow that rate of physical decline, or sometimes improve it. But even partial activity can be “equally if not more important” than full participation in an activity. Patients “want to be active, they want to test what they can and can’t do” and establish what is possible, she said.

Nonpharmacological Approaches to Symptom Control

Addressing strategies to relieve physical symptoms in patients with lung cancer, Alex Molassiotis, RN, PhD, chair professor of nursing at Hong Kong Polytechnic University, explored the role nonpharmacological interventions can play.

Molassiotis highlighted the 2021 American Society of Clinical Oncology guidelines for the Management of Dyspnea in Advanced Cancer, which discuss a range of nonpharmacological strategies to manage respiratory distress, in particular. These include supplemental oxygen and noninvasive ventilation as well as breathing techniques, posture, relaxation, meditation, physical and music therapy, and acupressure or reflexology.

In a 2015 randomized controlled feasibility trial, Molassiotis explored the effectiveness of one such strategy — inspiratory muscle training — in patients with lung cancer and reported improvements in the respiratory symptom cluster of breathlessness, cough, and fatigue. A 2020 trial of breathing retraining and psychosocial support for managing dyspnea in patients with lung cancer or mesothelioma also showed the intervention improved average dyspnea, control over dyspnea, and anxiety.

However, Molassiotis cautioned, many other nonpharmacological interventions have only “limited” evidence of effectiveness, and a “stronger evidence base” is required.

Physicians should nevertheless talk to patients about their respiratory symptoms and discuss the available options, taking into account the “major impact” these symptoms have on their quality of life.

Integrating Psychological Strategies

More than 40% of patients with advanced nonsmall cell lung cancer experience moderate to severe death anxiety, and about one in four patients with any stage of lung cancer experience significant depression and demoralization, research shows.

During the session, Gary Rodin, MD, of the Princess Margaret Cancer Centre in Toronto, Ontario, Canada, stressed the “need to intervene” and outlined approaches relevant to different stages of the disease journey.

At the onset, he said, Emotion and Symptom-Focused Engagement (EASE) can help relieve patients’ physical symptoms and traumatic stress. Those with more advanced disease can receive Meaning-Centered Psychotherapy, or Managing Cancer and Living Meaningfully (CALM), which Rodin and his colleague Sarah Hales, MD, PhD, developed. And patients at the end of life may benefit from Dignity Therapy, a short form of psychotherapy focused on helping patients find comfort and meaning in their final days.  

Rodin focused on the role of CALM for those with advanced disease. CALM encompasses three to six sessions of a semi-structured intervention given over several months. The intervention focuses on four domains: 1. Symptom management and communication with healthcare providers; 2. Changes in oneself and relationships with others; 3. Spirituality, or finding a sense of meaning and purpose; and 4. Approaches to sustain hope and face mortality.

Rodin led a 2018 randomized trial comparing CALM with usual care, which showed the intervention was associated with significant reductions in depression symptoms and death anxiety in patients with advanced cancer at 3 and 6 months, as well as better patient communication and preparedness for the end of life. Patients reported that the intervention gave them “complete freedom” to communicate about themselves, their condition, and their life.

Evidence-based psychological interventions “should be offered as standard of care” to patients with lung cancer, Rodin said.

Enhancing Patient-Doctor Communication

Having conversations early on about the goals of cancer care is particularly critical, according to Rachelle E. Bernacki, MD, director of quality initiatives, psychosocial oncology, and palliative care at the Dana-Farber Cancer Institute.

These conversations between physicians, patients, and family members give patients and loved ones time to make informed decisions, improve patients’ quality of care and satisfaction, and increase the likelihood of using hospice care, Bernacki explained.

But the reality is that these conversations don’t happen often enough. Less than one third of patients with end-stage diagnoses reported having an end-of-life discussion with their physician, and when the topic does arise, it is typically a few weeks before a patient passes away.

Moreover, these conversations “often fail to address key elements of quality discussions,” Bernacki commented.

Part of the problem is that many doctors lack the necessary training, face time constraints, or are uncertain about when or how to initiate these conversations.  

Although challenging, patients want to have these discussions. Nine of 10 Americans believe doctors should talk about end-of-life issues with their patients, and 75% of older patients want to know their prognosis so they can prepare for the future, make informed medical decisions, and optimize the time they have left.

Bernacki highlighted a framework that can help clinicians have productive end-of-life conversations with patients. The Serious Illness Conversation Guide, developed by Ariadne Labs and the Dana-Farber Cancer Institute, outlines key steps, which include scheduling the conversation, delivering a prognosis, and exploring what matters to the patient. The guide also explores how to communicate effectively with patients, such as asking permission and clarifying questions as well as engaging in active listening.

Above all, Bernacki stressed that physicians should “listen more than talk” and avoid providing premature assurance when addressing the prognosis. “Many fears will arise that cannot be fixed, but talking about them makes them more bearable for the patient,” she said.

Physicians Experience Grief Too

Patients with advanced lung cancer are not the only ones who face loss and distress. More than half of physicians treating terminally ill patients can experience burnout, according to Sonia Oyola, MD, assistant professor of family medicine at the University of Chicago Medicine, Illinois.

In her presentation, Oyola highlighted strategies physicians can use to manage their grief.

The first step is simply acknowledging feelings of loss. But every physician will have a “unique way of grieving and caring for themselves,” she said.

In general, the literature supports several approaches for managing grief: engaging in death talks and self-attunement or personal awareness training as well as providing end-of-life education in medical schools.

On the personal awareness front, Oyola highlighted a narrative medicine exercise where physicians write about the patient and reflect on what moved or touched them, what surprised them, and what inspired them.

Pursuing this kind of exercise allows physicians to reflect on their experiences in a way “we often do not have the opportunity to do” and could prevent some of the “devastating consequences in our practices, such as burnout,” Oyola said.

No funding declared. Molassiotis has reported a relationship with Helsinn. No other relevant financial relationships declared.

IASLC 2021 World Conference on Lung Cancer. Session ES07. Presented September 10, 2021.

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