Journal of Palliative Care 6:4/2000 33-38.
M Mant, J Crandall London, Ontario

Ø With increased numbers of palliative care patients in the community, there is increased opportunity for crisis.
Ø An open question survey was completed to increase awareness of difficulties encountered in responding to a patient/family in crisis in the home.
Ø Survey competed on community visiting nurses (13), case managers (6) and palliative outreach clinicians (5, from local hospital programs).
Ø 35 surveys distributed, 24 returned (68%). We are never aware of the type of questions asked.
Ø Literature review found little on the impact of palliative crisis on pt and family.
Ø The authors discuss crisis intervention, and the potential impact of unsuccessful crisis resolution on grief and bereavement (Rando).

Findings:
Ø Mix of part time, rural/urban responses, with 17/24 stating "frequently" or "very frequently" (q1month) experience crisis (q 1-3 months).
Ø Typical types of crisis were reported, primarily pain, confusion, sudden deterioration.
Ø Discusses impact on patient (fear, anxiety, restlessness, loss of control)
Ø Sites impact on family (anxiety, fear, upset, helpless, overwhelmed)
Ø Impact on caregiver (helpless/powerless, frustration, ) listed.
Ø In 10/24 cases the physicians were noted to be called and 12 resulted in admissions.
Ø The authors identified the following needs: earlier referrals, accessible meds and beds, 24 hour outreach team knowlegable caregivers (pain & symptom control and of the needs of palliative patients),timeand back-up, and a formal meeting time to discuss interventions and debrief, and ask the question if these issues were addressed could there be less visits to emergency and reduced requests for hospital based beds.
Ø The authors encouraged the community to track relevent statistics (time per nursing visit, hrs of services, # deaths at home)to identify and address barriers to community palliative care services.

Comments
Although little information is provided about the survey, nor would the survey be considered generalizable, the authors discuss and review palliative care crisis in the community from several views, reminding us to proactively prepare for potential crisis to decrease the impact on patient, family, staff and the palliative care services.

Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. (downloadable pdf file)

Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ et al. Lancet 2005; 366: 643-48.

Prepared by: Winnie Leung

Received during: Journal Rounds on the Tertiary Palliative Care Unit, Dec 14, 2006

Abstract

Background: The standard treatment of spinal cord compression caused by metastatic cancer is corticosteroids and radiotherapy. The role of surgery has not been established. We assessed the efficacy of direct decompressive surgery.
Methods: In this randomized, multi-institutional, non-blinded trial, we randomly assigned patients with spinal cord compression caused by metastatic cancer to either surgery followed by radiotherapy (n=50) or radiotherapy alone (n=51). Radiotherapy for both treatment groups was given in ten 3 Gy fractions. The primary endpoint was the ability to walk. Secondary endpoints were urinary continence, muscle strength and functional status, the need for corticosteroids and opioid analgesics, and survival time. All analyses were by intention to treat.
Findings: After an interim analysis the study was stopped because the criterion of a predetermined early stopping rule was met. Thus, 123 patients were assessed for eligibility before the study closed and 101 were randomized. Significantly more patients in the surgery group (42/50, 84%) than in the radiotherapy group (29/51, 57%) were able to walk after treatment (odds ratio 6.2 [95% CI 2.0-19.8] p=0.001). Patients treated with surgery also retained the ability to walk significantly longer than did those with radiotherapy alone (median 122 days vs 13 days, p=0.003). 32 patients entered the study unable to walk; significantly more patients in the surgery group regained the ability to walk than patients in the radiation group (10/16 [62%] vs 3/16 [19%], p=0.01). The need for corticosteroids and opioid analgesics was significantly reduced in the surgical group.
Interpretation: Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.

Comments

Strengths/uniqueness:
This is a well-designed study. The groups were equal and represented the main cancers that cause cord compression from metastases. More recent studies have shown benefit with direct decompressive surgery, but this is the first study to use a randomized design. The surgery + radiotherapy group had a NNT=4 for the primary outcome of ability to walk.

Weaknesses:
It is unusual that it took 10 years to recruit the study patients, and the authors did not specify how the patients were recruited. Multiple groups were excluded, which may introduce selection bias. There is no information about baseline co-morbidities of the study patients; co-morbidities may influence their ability to walk.

Relevance to Palliative Care:
The findings of this trial may confer improved quality of life and independence in the palliative population. Surgery in palliative patients is often limited by their general condition.