End-of-Life Issues

Author Credentials 

Julie L. Goldman, MD
Professor
Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders
University of Louisville School of Medicine
Louisville, KY
julie.goldman@louisville.edu

Module Summary

End of life issues surrounding head and neck cancer can be complex and overwhelming for both patient and physician; it is incumbent upon the physician to be aware of the impact of the diagnosis on multiple aspects of the patient’s life. Developing skills in having difficult conversations and engaging in shared decision making are paramount, as well as being aware of and anticipating issues related to physical and psychosocial functioning and offering varied options for palliation. Multidisciplinary care, including integrative and complementary medicine, should be the goal. 

Module Learning Objectives 
  1. Recognize the importance of providing accurate information to the patient with a terminal prognosis and be aware of frameworks for having difficult conversations.
  2. Assess the patient nearing the end of life in regard to pain management, quality of life, social functioning and activities of daily living and offer appropriate surgical and nonsurgical palliative options for each domain. 
  3. Explain the role of integrative and complementary medicine in treating patients at the end of life.
     

Patient Evaluation

Learning Objectives 

Be able to evaluate and generally predict prognosis in advanced cancers of the head and neck and engage the patient and family in a shared decision-making process regarding treatment.

References 
  1. Buckman R. Communication skills in palliative care: a practical guide. Neurol Clin. 2001 Nov;19(4):989-1004.
  2. Beers E, Lee Nilsen M, Johnson J. The role of patients: shared decision-making. Otolaryngol Clin North Am. 2017 Aug;50(4):689-708.

Measurement of Functional Status

Learning Objectives 

Be familiar with commonly used scales of global, physical, psychosocial functioning.

References 
  1. Malloy KM, Pou AM. Survivorship: Morbidity, mortality, malignancy. Otolaryngol Clin North Am. 2017 Aug;50(4):853-866.

Treatment

Learning Objectives 

Be able to describe and recommend appropriate surgical, chemotherapeutic, or radiation therapy palliation options for patients.

References 
  1. Rainone F. Palliative medicine and end of life care. In: Eisele D, Smith R, editors. Complications in head and neck surgery. 2nd ed. Philadelphia PA: Mosby Elsevier; 2008:207-14.

Medical Therapies

Learning Objectives 
  1. Be aware of integrative/complementary medicine strategies including medical marijuana.
References 
  1. Gonzalez D. Integration of palliative and curative care strategies. In: Flint P, Haughey B, Lund V, Niparko J, Robbins T, Thomas J, Lesperance M, editors. Cummings otolaryngology-head and neck surgery. 6th ed. Philadelphia PA: Elsevier Saunders; 2015:1158-64.

Pharmacology

Learning Objectives 

Know appropriate use of pain control regimens for chronic cancer pain, including opioids, nonnarcotic medications such as NSAIDs, tricyclics and anti-epileptic drugs.

References 
  1. Rainone F. Palliative medicine and end of life care. In: Eisele D, Smith R, editors. Complications in head and neck surgery. 2nd ed. Philadelphia PA: Mosby Elsevier; 2008:207-14.

Surgical Therapies

Learning Objectives 

Be aware of nontraditional procedures for symptom alleviation including acupuncture.

References 
  1. Gonzalez D. Integration of palliative and curative care strategies. In: Flint P, Haughey B, Lund V, Niparko J, Robbins T, Thomas J, Lesperance M, editors. Cummings otolaryngology-head and neck surgery. 6th ed. Philadelphia PA: Elsevier Saunders; 2015:1158-64.
     

Rehabilitation

Learning Objectives 

Recognize the prevalence of dysphagia and difficulties swallowing and feeding orally in advanced H&N cancer and know appropriate referral and rehabilitation options.

References 
  1. Gonzalez D. Integration of palliative and curative care strategies. In: Flint P, Haughey B, Lund V, Niparko J, Robbins T, Thomas J, Lesperance M, editors. Cummings otolaryngology-head and neck surgery. 6th ed. Philadelphia PA: Elsevier Saunders; 2015:1158-64.
  2. Rainone F. Palliative medicine and end of life care. In: Eisele D, Smith R, editors. Complications in head and neck surgery. 2nd ed. Philadelphia PA: Mosby Elsevier; 2008:207-14.

Case Studies

An 80 year old male patient, 2 years s/p total laryngectomy and neck dissection for a T3 N1 SCCa of the R pyriform sinus, presents for evaluation of dysphagia and weight loss. He became a widower 6 months ago and “hasn’t felt like eating”. Physical exam and imaging show unresectable recurrence involving the prevertebral fascia. What are the goals of treatment for this patient? What factors should be considered in the treatment alternatives offered? Should the patient’s financial/insurance status influence the options offered?

References 
  1. Liao K, Blumenthal-Barby J, Sikora A. Factors influencing head and neck surgical oncologists’ treatment goals. Otolaryngol Head Neck Surg. 2017 Jan:156 (1):46-51.

Review

Review Questions 

1. What is the overarching goal of palliative care?
2. What treatment related symptoms are best relieved by medical marijuana?
3. What are 2 commonly used scales to evaluate dysphagia?
4. Name 3 options for the palliative treatment of xerostomia.
5. Describe 4 strategies for ameliorating side effects of opioid medications.
6. Compare and contrast the CLASS and SPIKES methods for breaking bad news to patients.
7. What are some common barriers to communicating realistic risk/benefit information to patients?

References 
  1. Kuo T, Lin C, Jiang R, Yen T, Wang C, Liang K. End-of-life care for head and neck cancer patients: a population-based study. Support Care Cancer. 2017 May;25(5):1529-36.
  2. Long BB, Shuman A. Could good care mean withholding information from patients? AMA J Ethics. 2016 Jan 1;18(1):6-11.
  3. Mulvey C, Smith T, Gourin C. Use of inpatient palliative care services in patients with metastatic incurable head and neck cancer. Head Neck. 2016 Mar;38(3):355-63.
Resources 

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  1. Annual Meeting Webcast (AMW):