The aim of this study is to endorse that advanced solid cancer in-patients experience the best possible quality of life from palliative care in resource limited health care environment. Regarding to complex mechanisms and clinical presentations of suffering symptoms, including its physical, psychological, and spiritual aspects, multidisciplinary team approach is required for providing the effective palliative care. Moreover, the discordance between patients-reported and physician-documented symptoms was reported (5). One study shown that compared 58 questionaries completed by advanced cancer patients and their paired physician completed in medical records. The results showed that pain assessment was high concordance (96%), but psychological and other aspects were discordance, which is associated with poor QoL, and distress (5–6).
In our limited resource condition, interprofessional team approach for this study was co-working in palliative care between specialist palliative care nurses, and medical oncologists. In fact, mood disorders are major contributors to morbidity in patients with advanced cancer (7). We considered using Thai-Hospital Anxiety and Depression Scale (Thai-HADS), and Thai-Functional Assessment of Cancer Therapy-General (Thai FACT-G) scale as main measurement. The Thai-Hospital Anxiety and Depression Scale (Thai-HADS) is the most reliability and validity for mood assessment in palliative care setting. Moreover, the Thai-Functional Assessment of Cancer Therapy-General (Thai FACT-G) is the best tool for comprehensive quality of life assessments, including its physical, social, emotional, and functional well-beings (2). Furthermore, palliative care assessment for hospitalized advanced cancer patients in the Netherland evaluated the quality of life by using EQ5D scores, which the questionnaires provide a simple, generic questionnaire for use in clinical and economic appraisal and population health surveys (8).
The team approach from our study explored the effect of having specialist palliative care nurses and medical oncologists in the palliative care team, which advanced cancer in-patients with team-based approach significantly improved anxiety-, and depressive subscale at day 7 of hospitalization, and clinical meaningfully improved quality of life in social well-being subscale. Our study results were similar to previous studies. For example, one randomized controlled trial showed improvement of depressive subscale significantly in advanced non-small cell lung cancer patients who were assessed palliative care by multidisciplinary team approach (p-value = 0.01) (2). In addition, the ENABLE trial shown that cancer patients who were received palliative care by specialist palliative care team had lower incidence of depression than patients who were received assessment by physicians (p-value = 0.02) regarding to focusing on coping skills and psychosocial concerns from specialist palliative care professionals (8). Another randomized controlled trial demonstrated that early palliative care by specialist palliative care team significantly improved depressive symptoms in advanced stage cancer patients (p-value = 0.01), and depressive symptom was associated with mortality (10). Additionally, Interestingly, one study demonstrated a positive correlation between quality of life of advanced cancer patients and their survival (11–14). Therefore, we hypothesize that improvement of mood and quality of life from palliative care in advanced cancer patients may prolong their survival. Further study should be explored.
There are a few studies focusing on readmissions for cancer patients. However, the re-admission rate is a crucial balancing measure to indicate a quality of palliative care and continuity of care, and healthcare resource allocation (15). Our study found that readmission rate was significantly reduced in patients who were received palliative care by team-based approach significantly. However, the median length of stay for patients who were assessed by our team-based approach were longer than patients who were assessed by medical oncologist team, which the median duration of hospital stay were 14 days (7-127 days), and 11 days (7-45days), respectively. Regarding to non-randomized study design, our provocative results would seem to conflict with existing theories that readmission rate is indication of quality issue related to shortened length of stay. In addition, patients who were assessed by our team-based approach with longer in length of hospital stay might indicate a relatively unstable condition.
Only approximately 10% on each group died during their admission for receiving palliative care, while the population-based cohort study from Taiwan shown that the majority of hospitalized cancer patients for palliative care (59%) died during their first admission (16). This result may indicate that an early palliative care is associated with reduction of mortality rate during admission. Moreover, this study demonstrated that poor communication with patients and their family, inadequate outpatient follow-up and care coordination may attribute to increase readmission rate and mortality (16).
This study had several limitations. First, the study design was non-randomization, therefore selection bias could be occurred due to an error in the procedure used to select target populations. Moreover, it could potentially occur self-selection bias because it is likely that their motivation for participation into interprofessional collaborative team group. Second, generalizability as this study was conducted in an institution. Third, there was short-term follow up of this study. Fourth, there was not ideally multidisciplinary team-based approach regarding limited resource in human reason. Fifth, we did not distinguish subclassification of advanced stage to terminal stage of disease. To address the limitations, the randomization method eliminates the selection bias, and balances the groups with respect to many confounding variables. Furthermore, multicenter study and longer follow up time are required.