Care for patients with advanced cancer in the last weeks of life in Brazil

ABSTRACT

Despite all advances in the treatment of neoplasms and substantial increases in fiveyear survival rates, most patients still die due to their diseases. Late diagnosis in some circumstances and resistance mechanisms throughout treatment still cause most patients to require palliative care integrated with cancer treatment, since diagnosis. Most palliative care interventions can and should be carried out by the oncologist, with reference to the multidisciplinary team specialized in palliative care in the most critical moments of clinical evolution. It is important that the oncologist develops their skills in this scenario and knows how to recognize the moment of referral. The following text outlines the basic skills that are expected of oncologists, such as recognition of the prognosis, identification and correct assessment of symptoms, definition of the time to stop antineoplastic therapy, how to communicate these aspects to patients and family, how to involve psychosocial and spiritual issues and, finally, how to stay within the limits established by modern bioethics. This work consists of brief recommendations for oncologists working in Brazil.

RESUMO

Apesar de todos os avanços no tratamento das neoplasias e aumentos substanciais nas taxas de sobrevida em cinco anos, a maioria dos pacientes ainda morre em decorrência de suas doenças. Diagnósticos tardios em algumas circunstâncias e mecanismos de resistência ao longo do tratamento ainda fazem com que a maioria dos pacientes necessite de cuidados paliativos integrados ao tratamento oncológico, desde o diagnóstico. A maioria das intervenções em cuidados paliativos pode e deve ser realizada pelo oncologista, tendo como referência a equipa multidisciplinar especializada em cuidados paliativos nos momentos mais críticos da evolução clínica. É importante que o oncologista desenvolva suas habilidades nesse cenário e saiba reconhecer o momento do encaminhamento. O texto a seguir descreve as habilidades básicas que são esperadas dos oncologistas, como reconhecimento do prognóstico, identificação e avaliação correta dos sintomas, definição do momento de interromper a terapia antineoplásica, como comunicar esses aspectos aos pacientes e familiares, como envolver questões psicossociais e espirituais e, por fim, como se manter dentro dos limites estabelecidos pela bioética moderna. Este trabalho consiste em breves recomendações para oncologistas atuantes no Brasil.

Headings:

Terminal care - Death - Palliative care - Palliative medicine

Descritores:

Cuidados terminais - Morte - Cuidado paliativo - Medicina paliativa

Publication History

Received: 13 October 2021

Accepted: 26 November 2021

Article published online:
27 January 2022

• REFERENCES

• 1 Hui D, Santos R, Reedy D, Nascimento MSA, Zhukovsky DS, Paiva CE. et al. Acute symptomatic complications among patients with advanced cancer admitted to acute palliative care units: a prospective observational study. Palliat Med 2015; Oct; 29 (09) 826-833 https://doi.org/10.1177/0269216315583031
• 2 Bruera E, Hui D. Integrating supportive and palliative care in the trajectory of cancer: establishing goals and models of care. J Clin Oncol 2010; 28 (25) 4013-4017 https://doi.org/10.1200/JCO.2010.29.5618
• 3 World Health Organization (WHO). Definition of palliative care. Geneva: WHO;; 2019
• 4 Hui D, Hannon BL, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: team-based, timely, and targeted palliative care. Cancer J Clin 2018; Sep; 68 (05) 356-376 https://doi.org/10.3322/caac.21490
• 5 Temel JS, Jackson VA, Billings JA, Dahlin C, Block SD, Ostler BP. et al. Phase II study: Integrated palliative care in newly diagnosed advanced non-small-cell lung cancer patients. J Clin Oncol 2007; 25 (17) 2377-2382 https://doi.org/10.1200/JCO.2006.09.2627
• 6 Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A. et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014; May; 383 (9930) 1721-1730 https://doi.org/10.1016/S0140-6736(13)62416-2
• 7 Gaertner J, Siemens W, Meepohl JJ, Antes G, Meffert C, Xander C. et al. Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis. BMJ 2017; Jun; 357: j2925 https://doi.org/10.1136/bmj.j2925
• 8 Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J. et al. Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis. JAMA 2016; Nov; 316 (20) 2104-2114 https://doi.org/10.1001/jama.2016.16840
• 9 Haun MW, Estel S, Rücker G, Friedrich HC, Villalobos M, Thomas M. et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 2017; Jun; 6 (06) CD011129
• 10 Hui D, Bruera E. Models of palliative care delivery for patients with cancer. J Clin Oncol 2020; 38 (09) 852-865 https://doi.org/10.1200/JCO.18.02123
• 11 Bickel KE, McNiff K, Buss MK, Kamal A, Lupu D, Abernethy AP. et al. Defining high-quality palliative care in oncology practice: an American Society of Clinical Oncology/ American Academy of Hospice and Palliative Medicine guidance statement. J Oncol Pract 2016; 12 (09) e828-e38 https://doi.org/10.1200/JOP.2016.010686
• 12 Hui D, Paiva CE, Del Fabbro E, Steer C, Naberhuis J, Van de Wetering M. et al. Prognostication in advanced cancer: update and directions for future research. Support Care Cancer 2019; Mar; 27 (06) 1973-1984 https://doi.org/10.1007/s00520-019-04727-y
• 13 Hui D, Li MO, Paiva CE. The importance of prognosti-cation: impact of prognostic predictions, disclosures, awareness, and acceptance on patient outcomes. Curr Treat Options Oncol 2021; Jan; 22 (02) 1-14 https://doi.org/10.1007/s11864-020-00810-3
• 14 Weeks JC, Cook F, O'Day SJ, Peterson LM, Wenger N, Reding D. et al. Relationship between cancer patients' predictions of prognosis and their treatment preferences. JAMA 1998; Jun; 279 (21) 1709-1714 https://doi.org/10.1001/jama.279.21.1709
• 15 Sborov K, Giaretta S, Koong A, Aggarwal S, Aslakson R, Gensheimer MF. et al. Impact of accuracy of survival predictions on quality of end-of-life care among patients with metastatic cancer who receive radiation therapy. J Oncol Pract 2019; 15 (03) e262-e70 https://doi.org/10.1200/JOP.18.00516
• 16 Hui D. Prognostication of survival in patients with advanced cancer: predicting the unpredictable?. Cancer Control 2015; Oct; 22 (04) 489-497 https://doi.org/10.1177/107327481502200415
• 17 Reid VL, McDonald R, Nwosu AC, Mason SR, Probert SR, Ellershaw JE. et al. A systematically structured review of biomarkers of dying in cancer patients in the last months of life; an exploration of the biology of dying. PLoS One 2017; Apr; 12 (04) e0175123 https://doi.org/10.1371/journal.pone.0175123
• 18 Morita T, Tsunoda J, Inoue S, Chihara S. The pallia-tive prognostic index: a scoring system for survival prediction of terminally ill cancer patients. Support Care Cancer 1999; Apr; 7 (03) 128-133 https://doi.org/10.1007/s005200050242
• 19 Maltoni M, Nanni O, Pirovano M, Scarpi E, Indelli M, Martini C. et al. Successful validation of the palliative prognostic score in terminally ill cancer patients. J Pain Symptom Manag 1999; Apr; 17 (04) 240-247 https://doi.org/10.1016/S0885-3924(98)00146-8
• 20 Hui D, Park M, Liu D, Paiva CE, Suh SY, Morita T. et al. Clinician prediction of survival versus the palliative prognostic score: which approach is more accurate?. Eur J Cancer 2016; Sep; 64: 89-95 https://doi.org/10.1016/j.ejca.2016.05.009
• 21 Hui D, Ross J, Park M, Dev R, Vidal M, Liu D. et al. Predicting survival in patients with advanced cancer in the last weeks of life: How accurate are prognostic models compared to clinicians' estimates?. Palliative Med 2020; Jan; 34 (01) 126-133
• 22 Hui D, Maxwell JP, Paiva CE. Dealing with prognos-tic uncertainty: the role of prognostic models and websites for patients with advanced cancer. Curr Opin Support Palliat Care 2019; Dec; 13 (04) 360-368 https://doi.org/10.1097/SPC.0000000000000459
• 23 Avati A, Jung K, Harman S, Downing L, Ng A, Shah NH. Improving palliative care with deep learning. BMC Medical Inform Decis Mak 2018; 18 (04) 55-64 https://doi.org/10.1186/s12911-018-0677-8
• 24 Morita T, Ichiki T, Tsunoda J, Inoue S, Chihara S. A. prospective study on the dying process in terminally ill cancer patients. Am J Hosp Palliat Med 1998; Jul; 15 (04) 217-222 https://doi.org/10.1177/104990919801500407
• 25 Kehl KA, Kowalkowski JA. A systematic review of the prevalence of signs of impending death and symptoms in the last 2 weeks of life. Am J Hosp Palliat Med 2013; 30 (06) 601-616 https://doi.org/10.1177/1049909112468222
• 26 Hui D, Santos R, Chisholm G, Bansal S, Silva TB, Kil-gore K. et al. Clinical signs of impending death in cancer patients. Oncologist 2014; Apr; 19 (06) 681-687 https://doi.org/10.1634/theoncologist.2013-0457
• 27 Hui D, Santos R, Chisholm G, Bansal S, Crovador CS, Bruera E. Bedside clinical signs associated with impending death in patients with advanced cancer: preliminary findings of a prospective, longitudinal cohort study. Cancer 2015; 121 (06) 960-967 https://doi.org/10.1002/cncr.29048
• 28 Hui D, Hess K, Santos R, Chisholm G, Bruera E. A. diag-nostic model for impending death in cancer patients: preliminary report. Cancer 2015; Jul; 121 (21) 3914-3921 https://doi.org/10.1002/cncr.29602
• 29 Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. et al. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 2003; 21 (06) 1133-1138 https://doi.org/10.1200/JCO.2003.03.059
• 30 Cherny NI, Catane R, Kosmidis P. Members of the ESMO Taskforce on Supportive and Palliative Care. ESMO takes a stand on supportive and palliative care. Ann Oncol 2003; Sep; 14 (09) 1335-1337 https://doi.org/10.1093/annonc/mdg379
• 31 Peppercorn JM, Smith TJ, Helft PR, DeBono DJ, Berry SR, Wollins DS. et al. American society of clinical oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol 2011; 29 (06) 75560 https://doi.org/10.1200/JCO.2010.33.1744
• 32 Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC. et al. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 2004; 22 (02) 31521 https://doi.org/10.1200/JCO.2004.08.136
• 33 Zdenkowski N, Cavenagh J, Ku YC, Bisquera A, Bonaventura A. Administration of chemotherapy with palliative intent in the last 30 days of life: the balance between palliation and chemotherapy. Intern Med J 2013; Jul; 43 (11) 1191-1198 https://doi.org/10.1111/imj.12245
• 34 Levy CR, Ely W, Kate P, Ruth EA, Donald PL, Randall CJ. Quality of dying and death in two medical ICUs: perceptions of family and clinicians. Chest 2005; May; 127 (05) 1775-1783 https://doi.org/10.1378/chest.127.5.1775
• 35 Luhm MV. Factors influencing oncologists' use of chemotherapy in patients at the end of life: a qualitative study [thesis]. Michigan: University of Michigan Library;; 2011
• 36 Behl D, Jatoi A. What do oncologists say about chemotherapy at the very end of life? Results from a semiqualitative survey. J Palliat Med 2010; Jul; 13 (07) 831-835 https://doi.org/10.1089/jpm.2009.0414
• 37 Clarke G, Johnston S, Corrie P, Kuhn I, Barclay S. Withdrawal of anticancer therapy in advanced disease: a systematic literature review. BMC Cancer 2015; Nov; 15 (01) 1-9 https://doi.org/10.1186/s12885-015-1862-0
• 38 Elkin EB, Kim SHM, Casper ES, Kissane DW, Schrag D. Desire for information and involvement in treatment decisions: elderly cancer patients' preferences and their physicians' perceptions. J Clin Oncol 2007; 25 (33) 5275-5280 https://doi.org/10.1200/JCO.2007.11.1922
• 39 White DB, Braddock CH, Bereknyei S, Curtis JR. Toward shared decision making at the end of life in intensive care units: opportunities for improvement. Arch Intern Med 2007; Mar; 167 (05) 461-467 https://doi.org/10.1001/archinte.167.5.461
• 40 Thompson BT, Cox PN, Antonelli M, Carlet JM, Cas-sell J, Hill NS. et al. Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care Med 2004; Aug; 32 (08) 1781-1784 https://doi.org/10.1097/01.CCM.0000126895.66850.14
• 41 Buiting HM, Rurup ML, Wijsbek H, Van Zuylen L. Understanding provision of chemotherapy to patients with end stage cancer: qualitative interview study. BMJ 2011; Apr; 342: d1933 https://doi.org/10.1136/bmj.d1933
• 42 Schulman-Green DJ, Naik AD, Bradley EH, McCorkle R, Bogardus ST. Goal setting as a shared decision making strategy among clinicians and their older patients. Patient Educ Couns 2006; Oct; 63 (1-2): 145-151 https://doi.org/10.1016/j.pec.2005.09.010
• 43 Gilligan T, Coyle N, Frankel RM, Berry DL, Bohlke K, Epstein RM. et al. Patient-clinician communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol 2017; 35 (31) 3618-3632 https://doi.org/10.1200/JCO.2017.75.2311
• 44 Cain CL, Surbone A, Elk R, Kagawa-Singer M. Culture and palliative care: preferences, communication, meaning, and mutual decision making. J Pain Symptom Manag 2018; May; 55 (05) 1408-1419 https://doi.org/10.1016/j.jpainsymman.2018.01.007
• 45 Weston WW, Brown JB, Stewart MA. Patient-centred interviewing part I: understanding patients' experiences. Can Fam Physician 1989; Jan; 35: 147-151
• 46 Brooks LA, Manias E, Bloomer MJ. Culturally sensitive communication in healthcare: a concept analysis. Collegian 2019; Jun; 26 (03) 383-391 https://doi.org/10.1016/j.colegn.2018.09.007
• 47 Rodin G, Zimmermann C, Mayer C, Howell D, Katz M, Sussman J. et al. Clinician-patient communication: evidence-based recommendations to guide practice in cancer. Curr Oncol 2009; Dec; 16 (06) 42-49 https://doi.org/10.3747/co.v16i6.432
• 48 Correa R, Ridley J, Zimmermann C. Communication in advanced illness. In: Oneschuk D, Hagen N, MacDonald N. eds. Palliative medicine. 3rd . Oxford: Oxford University Press;; 2012. https://doi.org/10.1093/acprof:oso/9780199694143.003.0010
• 49 Cassie A, Zimmermann C. Structure and process: Communication. In: McKean S, Brotman D, Dressler D, Ginsberg J, Ross J. eds. The principles and practice of hospital medicine. 2nd . Boston: McGraw-Hill;; 2017
• 50 Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000; Aug; 5 (04) 302-311 https://doi.org/10.1634/theoncologist.5-4-302
• 51 Von Blanckenburg P, Hofmann M, Rief W, Seifart U, Seifart C. Assessing patients' preferences for breaking Bad News according to the SPIKES-Protocol: the MABBAN scale. Patient Educ Couns 2020; Aug; 103 (08) 1623-1629 https://doi.org/10.1016/j.pec.2020.02.036
• 52 Cameron RA, Mazer BL, DeLuca JM, Mohile SG, Epstein RM. In search of compassion: a new taxonomy of compassionate physician behaviours. Health Expect 2013; Dec; 18 (05) 1672-1685 https://doi.org/10.1111/hex.12160
• 53 Smith RC, Hoppe RB. The patient's story: integrating the patient-and physician-centered approaches to interviewing. Ann Intern Med 1991; Sep; 115 (06) 470-477 https://doi.org/10.7326/0003-4819-115-6-470
• 54 Houska A, Louĉka M. Patients' autonomy at the end of life: a critical review. J Pain Symptom Manag 2019; Apr; 57 (04) 835-845 https://doi.org/10.1016/j.jpainsymman.2018.12.339
• 55 Uchida M, Sugie C, Yoshimura M, Suzuki E, Shibamoto Y, Hiraoka M. et al. Factors associated with a preference for disclosure of life expectancy information from physicians: a cross-sectional survey of cancer patients undergoing radiation therapy. Support Care Cancer 2019; Mar; 27 (12) 4487-4495 https://doi.org/10.1007/s00520-019-04716-1
• 56 Bernacki RE, Block SD. Communication about seri-ous illness care goals: a review and synthesis of best practices. JAMA Intern Med 2014; Dec; 174 (12) 19942003 https://doi.org/10.1001/jamainternmed.2014.5271
• 57 Berntsen GKR, Gammon D, Steinsbekk A, Salamon-sen A, Foss N, Ruland C. et al. How do we deal with multiple goals for care within an individual patient trajectory? A document content analysis of health service research papers on goals for care. BMJ Open 2015; 5 (12) e009403 https://doi.org/10.1136/bmjopen-2015-009403
• 58 Temel JS, Greer JA, El-Jawahri A, Pirl WF, Park ER, Jackson VA. et al. Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial. J Clin Oncol 2017; 35 (08) 834 https://doi.org/10.1200/JCO.2016.70.5046
• 59 Dadalto L, Tupinambás U, Greco DB. Advanced directive: a Brazilian model. Rev Bioét 2013; Dec; 21 (03) 463-476 https://doi.org/10.1590/S1983-80422013000300011
• 60 Hudson P, Quinn K, O'Hanlon B, Aranda S. Family meetings in palliative care: multidisciplinary clinical practice guidelines. BMC Palliat Care 2008; Aug; 7 (01) 1-12 https://doi.org/10.1186/1472-684X-7-12
• 61 Sanderson CR, Cahill PJ, Philips JL, Johnson A, Lobb EA. Patient-centered family meetings in palliative care: a quality improvement project to explore a new model of family meetings with patients and families at the end of life. Ann Palliat Med 2017; 6 (Suppl 2): S195-S205 https://doi.org/10.21037/apm.2017.08.11
• 62 Chapman L, Ellershaw J. Care in the last hours and days of life. Medicine 2020; Jan; 48 (01) 52-56 https://doi.org/10.1016/j.mpmed.2019.10.006
• 63 Anderson RJ, Bloch S, Armstrong M, Stone PC, Low JTS. Communication between healthcare professionals and relatives of patients approaching the endof-life: a systematic review of qualitative evidence. Palliat Med 2019; Jun; 33 (08) 926-941 https://doi.org/10.1177/0269216319852007
• 64 Pereira-Salgado A, Mader P, O'Callaghan C, Boyd L, Staples M. Religious leaders' perceptions of advance care planning: a secondary analysis of interviews with Buddhist, Christian, Hindu, Islamic, Jewish, Sikh and Bahá'í leaders. BMC Palliat Care 2017; Dec; 16 (01) 1-10 https://doi.org/10.1186/s12904-017-0239-3
• 65 Lichtenthal WG, Roberts KE, Catarozoli C, Schofield E, Holland JM, Fogarty JJ. et al. Regret and unfinished business in parents bereaved by cancer: a mixed methods study. Palliat Med 2020; Feb; 34 (03) 367-377 https://doi.org/10.1177/0269216319900301
• 66 Patterson P, McDonald FEJ, Kelly-Dalgety E, Lavorgna B, Jones BL, Sidis AE. et al. Development and evaluation of the Good Grief program for young people bereaved by familial cancer. BMC Palliat Care 2021; Apr; 20 (01) 1-15 https://doi.org/10.1186/s12904-021-00752-z
• 67 Cowan JD, Palmer TW. Practical guide to palliative sedation. Curr Oncol Rep 2002; Jun; 3 (03) 242-249 https://doi.org/10.1007/s11912-002-0022-2
• 68 Chater S, Viola R, Paterson J, Jarvis V. Sedation for intractable distress in the dying-a survey of experts. Palliat Med 1998; Jun; 12 (04) 255-269 https://doi.org/10.1191/026921698671831786
• 69 Cherny NI, Portenoy RK. Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. J Palliat Care 1994; Jun; 10 (02) 31-38 https://doi.org/10.1177/082585979401000207
• 70 Braun TC, Hagen NA, Clark T. Development of a clinical practice guideline for palliative sedation. J Palliat Care 2004; Jun; 6 (03) 345-350 https://doi.org/10.1089/109662103322144655
• 71 Rousseau PC. Palliative sedation. Am J Hosp Palliat Med 2002; Sep; 19 (05) 295-297 https://doi.org/10.1177/104990910201900501
• 72 Teunissen SCCM, Wesker W, Kruitwagen C, Haes HCJM, Voest EE, Graeef A. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manag 2007; Jul; 34 (01) 94-104 https://doi.org/10.1016/j.jpainsymman.2006.10.015
• 73 Coradazzi AL. Diretivas antecipadas de vontade: bem mais que uma lista de desejos finais 2018. Slow Medicine [Internet]. 2018 ;[access in 2022 Jan 27]. Available from: https://www.slowmedicine.com.br/diretivas-antecipadas-de-vontade-bem-mais-que-uma-lista-de-desejos-finais/
• 74 Zwingmann J, Vaile WF, Schmier JW, Bernhard J, Keller M. Effects of patient-centered communication on anxiety, negative affect, and trust in the physician in delivering a cancer diagnosis: a randomized, experimental study. Cancer 2017; Apr; 123 (16) 3167-3175 https://doi.org/10.1002/cncr.30694
• 75 Pitman A, Suleman S, Hyde N, Hodgkiss A. Depression and anxiety in patients with cancer. BMJ 2018; Apr; 361: k1415 https://doi.org/10.1136/bmj.k1415
• 76 Kushner R. Coping with breast cancer: what health professionals can do to help. Breast Cancer 2021; 21-33
• 77 Cordova MJ, Riba MB, Spiegel D. Post-traumatic stress disorder and cancer. Lancet Psychiatr 2017; Apr; 4 (04) 330-338 https://doi.org/10.1016/S2215-0366(17)30014-7
• 78 Hellstadius Y, Malmström M, Lagergren P, Sundbom M, Wikman A. Reflecting a crisis reaction: Narratives from patients with oesophageal cancer about the first 6 months after diagnosis and surgery. Nurs Open 2019; Aug; 6 (04) 1471-1480 https://doi.org/10.1002/nop2.348
• 79 Harmon J. Tell cancer to take a hike: post traumatic growth on the trail to recovery. Leisure/Loisir 2019; Jan; 44 (04) 459-478 https://doi.org/10.1080/14927713.2019.1697349
• 80 Leong-Abdullah MFI, Hami R, Appalanaido GK, Azman N, Shariff NM, Sharif SS. Diagnosis of cancer is not a death sentence: Examining posttraumatic growth and its associated factors in cancer patients. J Psychosocial Oncol 2019; Mar; 37 (05) 636-651 https://doi.org/10.1080/07347332.2019.1574946
• 81 McDonald JC, Manoir JM, Kevork N, Le LW, Zimmermann C. Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers. Support Care Cancer 2017; 25 (02) 523-531 https://doi.org/10.1007/s00520-016-3433-6
• 82 Henson KE, Brock R, Charnock J, Wickramasinghe B, Will O, Pitman A. et al. Risk of suicide after cancer diagnosis in England. JAMA Psychiatr 2019; Jan; 76 (01) 51-60 https://doi.org/10.1001/jamapsychiatry.2018.3181
• 83 Tsaras K, Papathanasiou IV, Mitsi D, Veneti A, Keleso M, Zyga S. et al. Assessment of depression and anxiety in breast cancer patients: prevalence and associated factors. Asian Pac J Cancer Prev 2018; 19 (06) 1661 https://doi.org/10.22034/APJCP.2018.19.6.1661
• 84 Kuhnt S, Friedrich M, Schulte T, Cella D, Hinz A. Screening properties of the diagnostic criteria for cancer-related fatigue. Oncol Res Treat 2019; 42 (09) 440-447 https://doi.org/10.1159/000501128
• 85 Jean CY, Syrjala KL. Anxiety and depression in cancer survivors. Med Clin 2017; Nov; 101 (06) 1099-1113 https://doi.org/10.1016/j.mcna.2017.06.0
• 86 McCanney J, Winckworth-Preksnar K, Schatz AA, Nardi EA, Dwyer AJ, Lieu C. et al. Addressing survivorship in cancer care. J Natl Compr Cancer Netw 2018; Jul; 16 (07) 801-806 https://doi.org/10.6004/jnccn.2018.7054
• 87 Flink DM, Kondapalli LA, Kellar-Guenther Y. Priorities in fertility decisions for reproductive-aged cancer patients: fertility attitudes and cancer treatment study. J Adolesc Young Adult Oncol 2017; Feb; 6 (03) 435-443 https://doi.org/10.1089/jayao.2016.0072
• 88 Albers LF, Van Belzen MA, Van Batenburg C, Engelen V, Putter V, Pelger RCM. et al. Discussing sexuality in cancer care: towards personalized information for cancer patients and survivors. Support Care Cancer 2020; Jan; 28 (09) 4227-4233 https://doi.org/10.1007/s00520-019-05257-3
• 89 Shapiro CL. Cancer survivorship. N Engl J Med 2018; Dec; 379 (25) 2438-2450 https://doi.org/10.1056/NEJMra1712502
• 90 Candy B, Jones L, Drake R, Laurent B, King M. Interventions for supporting informal caregivers of patients in the terminal phase of a disease. Cochrane Database Syst Rev 2011; 6: CD007617 https://doi.org/10.1002/14651858.CD007617.pub2
• 91 Thomas C, Morris SM, Harman JC. Companions through cancer: the care given by informal carers in cancer contexts. Soc Sci Med 2002; Feb; 54 (04) 529-544 https://doi.org/10.1016/S0277-9536(01)00048-X
• 92 Alam S, Hannon B, Zimmermann C. Palliative care for family caregivers. J Clin Oncol 2020; 38 (09) 926-936 https://doi.org/10.1200/JCO.19.00018
• 93 World Health Organization (WHO). National cancer control programmes: policies and managerial guidelines. Geneva: WHO;; 2002
• 94 Thomas K, Hudson P, Trauer T, Remedios C, Clarke D. Risk factors for developing prolonged grief during bereavement in family carers of cancer patients in palliative care: a longitudinal study. J Pain Symptom Manag 2014; Mar; 47 (03) 531-541 https://doi.org/10.1016/j.jpainsymman.2013.05.022
• 95 Samar MA, Rumbold B, Rowting D, Bolleter A, Breen LJ. Bereavement support for family caregivers: the gap between guidelines and practice in palliative care. PLoS One 2017; Oct; 12 (10) e0184750 https://doi.org/10.1371/journal.pone.0184750
• 96 Dans M, Kutner JS, Agarwal R, Baker JN, Bauman JR, Beck AC. et al. NCCN guidelines insighnts: palliative care (version 2.2010). J Natl Compr Canc Netw [Internet] 2021; Jul;[cited 2021 May 20]; 19 (07) 780-788 Available from: https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
• 97 Worldwide Palliative Care Alliance (WPCA). Global atlas of palliative care at end of life [Internet]. London: WPCA;; 2014. ;[access in 2021 May 21]. https://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf
• 98 Esperandio MRG, Leget C. Spirituality in pallia-tive care in Brazil: an integrative literature review. Rever 2020; Sep; 20 (02) 29-45 https://doi.org/10.23925/1677-1222.2020vol20i2a3
• 99 Nuzum D, Murphy M. The comfort of nurses and physicians addressing spirituality in palliative care. J Pain Symptom Manag 2018; Dec; 56 (06) e141 https://doi.org/10.1016/j.jpainsymman.2018.10.447
• 100 Rego F, Nunes R. The interface between psychology and spirituality. Palliat Care 2019; Aug; 24 (03) 279-287 https://doi.org/10.1177/1359105316664138
• 101 Long CO. Cultural and spiritual considerations in palli-ative care. J Pediatr Hematol Oncol 2011; 33: S96-S101 https://doi.org/10.1097/MPH.0b013e318230daf3
• 102 Richardson P. Spirituality, religion and palliative care. Ann Palliat Med 2014; Jul; 3 (03) 150-159 https://doi.org/10.3978/j.issn.2224-5820.2014.07.05
• 103 Steinhauser KE, Balboni TA. State of the science of spirituality and palliative care research: research landscape and future directions. J Pain Symptom Manag 2017; Sep; 54 (03) 426-427 https://doi.org/10.1016/j.jpainsymman.2017.02.020
• 104 Benites AC, Rodin G, Leite ACAB, Nascimento LC, Santos MA. The experience of spirituality in family caregivers of adult and elderly cancer patients receiving palliative care: a meta-synthesis. Eur J Cancer Care 2021; Feb; 30 (04) e13424 https://doi.org/10.1111/ecc.13424
• 105 Steinhorn DM, Din J, Johnson A. Healing, spirituality and integrative medicine. Ann Palliat Med 2017; 6 (03) 237-247 https://doi.org/10.21037/apm.2017.05.01
• 106 Childress JF. The place of autonomy in bioethics. Hastings Center Rep 1990; Jan/Feb; 20 (01) 12-17 https://doi.org/10.2307/3562967
• 107 Gómez-Vírseda C, Maeseneer Y, Gastmans C. Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities. BMC Med Ethics 2020; 21 (01) 50 https://doi.org/10.1186/s12910-020-00495-1
• 108 Conselho Federal de Medicina (CFM). Resolução CFM n° 1995, de 31 de agosto de 2012. Diário Oficial da União, Brasília (DF) 2012; ago; 31 Seção 1 269-270
• 109 Conselho Federal de Medicina (CFM). Resolução CFM N° 2.217, de 27 de setembro de 2018. Diário Oficial da União; Brasília (DF): 1. set; 2018. Seção I 179-182
• 110 The Economist - Intelligence Unit. 2015 Quality of death index. The Economist [Internet]. 2015 ;[access in 2021 May 24]. Available from: https://eiuperspectives.economist.com/healthcare/2015-quality-death-index/white-paper/2015-quality-death-index?redirect=TRUE
• 111 Santos CE, Campos LS, Barros NB, Serafim JA, Klug D, Cruz RP. Palliative care in Brasil: present and future. Rev Assoc Med Bras 2019; Jun; 65 (06) 796 https://doi.org/10.1590/1806-9282.65.6.796
• 112 Academia Nacional de Cuidados Paliativos (ANCP). [Internet]. Sao Paulo: ANCP; ANO; ;[access in 2022 Jan 27]. Available from: https://api-wordpress.paliativo.org.br/wp-content/uploads/2020/11/10-VIII_congresso_brasileiro_de_cuidados_paliativos_resumos.pdf
• 113 Cheng MJ, King LM, Alesi ER, Smith TJ. Doing palliative care in the oncology office. J Oncol Pract 2013; 9 (02) 84 https://doi.org/10.1200/JOP.2013.000885
• 114 Hui D, Finlay E, Buss MK, Prommer EE, Bruera E. Palliative oncologists: specialists in the science and art of patient care. J Clin Oncol 2015; 33 (20) 2314 https://doi.org/10.1200/JCO.2014.60.3274
• 115 Jackson VA, Mack J, Matsuyama R, Lakoma MD, Sul-livan AM, Arnold RM. et al. A qualitative study of oncologists' approaches to end-of-life care. J Palliat Med 2008; Aug; 11 (06) 893-906 https://doi.org/10.1089/jpm.2007.2480