End of Life Care
Clinical Outline
= Primers in Thyroidology
= Journal Club Presentation
= Case-based Discussion (inc. roundtables)
= Grand Rounds Lectureship
Management Recommendations
1. End of Life Planning & Counseling
Due to the aggressive nature of ATC, it is advisable that early discussions be undertaken that include the following:
- Naming a surrogate who can make decisions if the patient is unable to do so.
- Establish a resuscitation status and details regarding end-of-life management decisions.1
- Toward that end, POLST or MOST documents should be established to define the level of treatment that ranges from full to limited to palliative care treatment only.
- These documents should be readily accessible for use by medical care teams that may become involved in the patient’s care in the event that they require hospitalization at a new location and at a time when the patient is not able to fully articulate their wishes.
- Specific circumstances where a decision to adhere to a Do Not Resuscitate directive are suspended should be clearly discussed and readily available for the clinical team.
In light of the speed at which ATC can progress, it is imperative that a discussion of goals of care should be conducted soon after establishing a definitive diagnosis of ATC. Patients and their surrogates must be made aware of the potential risks and benefits of various treatment options and an understanding of how those treatments may impact a patient’s life. It is imperative that discussions include end of life options that include the incorporation of palliative and hospice care.1
2. Palliative Care
The treatment team should include palliative care expertise at every stage of patient management to help with pain and symptom control, as well as addressing psychosocial and spiritual issues.1,2
The treatment team should engage hospice care for ATC patients who decline therapies against their tumor intending to prolong life, yet who still require symptom and pain relief spanning the remainder of their illness.1,2
In the situation where patients with ATC decline therapy or when their disease has progressed despite efforts to prolong life, a hospice care team can be extremely helpful for symptom management and pain relief.1,2
At all stages of palliative care and hospice care in ATC patients, practitioners should be aware of family systems, and how they affect patient decision-making.1
Family systems can be vital to the decision making that is required for patients with ATC and must be familiar to all members of the care team including palliative and hospice care.1
An understanding of the role and focus of palliative and hospice care is critical for the care team and the patient and their loved ones to understand. A palliative care team can and should be engaged in the patient management at all steps in the process in order to address and mitigate the suffering of patients and their families secondary to the disease and the treatments that are instituted. The introduction of a palliative care team can be done at any time following the diagnosis of ATC. Issues related to the psychosocial and spiritual impact of this disease can be best managed by palliative care specialists. Alternatively, the primary focus of hospice care is the administration of measures to alleviate pain and suffering for patients who are not undergoing therapies intended to prolong life.1,2
3. Hospice Care
In addition to discussing the potential risks and benefits of various treatment options, clinicians initiating treatment conversations with patients with anaplastic thyroid cancer should consider addressing the following:
- Goals of care.
- The role of caregiver and family members in decision making.
- The role of palliative care to help with symptom control at every stage of treatment.
- End-of-life options, including and when indicated, hospice as initial management.
- Obtaining and documenting patients’ advance directives.
The burden of disease, treatment, and response to therapy may rapidly impact patients’ preferences about treatment and goals of care. As such, clinicians should include these issues during the care process.1–3
- Given the historically dire prognosis of ATC, especially if stage IVC, hospice should always be presented among care options for patients who decline therapies intended to prolong life yet require symptom and pain relief spanning the remainder of their illness.
- Hospice care should be coordinated by the patient’s clinicians, and all discussion should include a palliative care service or expert, as well as pastoral care to plan an appropriate treatment regimen.
- Practitioners should be aware of family systems and how they affect patient decision-making with hospice care.
- Multiple brain lesions not amenable to stereotactic radiotherapy or whole-brain radiation therapy should be referred to hospice care.
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References
- 1.Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. Published online January 2016:1-133. doi:10.1089/thy.2015.0020
- 2.Haddad RI, Nasr C, Bischoff L, et al. NCCN Guidelines Insights: Thyroid Carcinoma, Version 2.2018. J Natl Compr Canc Netw. Published online December 2018:1429-1440. doi:10.6004/jnccn.2018.0089
- 3.Ito Y, Onoda N, Okamoto T. The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer. Endocr J. Published online 2020:669-717. doi:10.1507/endocrj.ej20-0025
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