Illness Understanding, Prognostic Awareness, and End-of-Life Care in Patients With GI Cancer and Malignant Bowel Obstruction With Drainage Percutaneous Endoscopic Gastrostomy

Abstract

PURPOSE: Malignant bowel obstruction (MBO) is common in advanced GI cancer, and MBO management, including drainage percutaneous endoscopic gastrostomy (dPEG), is palliative. How patients understand the goals of dPEG and its impact on disease is inadequately understood in the literature. Therefore, we analyzed these issues in patients with GI cancer. METHODS: Demographics, clinical variables, and patient outcomes were abstracted from the medical record. Illness understanding and future expectations were retrieved from palliative care notes. We described additional treatment and outcomes after dPEG and estimated overall survival (OS). RESULTS: From January 2015 to June 2017, 125 admitted patients with metastatic GI cancer underwent dPEG for MBO. Cancers were most commonly colorectal (34%) and pancreatic/ampullary (25%). During the dPEG admission, 32% (40 of 125) of patients had a palliative care consultation, and 22% (28 of 125) were asked about illness understanding and future expectations. All (28 of 28) reported good understanding of the advanced nature of their disease, but few were accurate about prognosis given their stage IV disease (10 of 28). Of the 117 (94%) discharged, 13% (15 of 117) received additional chemotherapy, which rarely prevented progression; half (63 of 117) had a do-not-resuscitate order; and most (101 of 117) were enrolled in hospice at death. Median time to death was 37 days (95% CI, 29 to 45 days); 6-month OS was 3.7% (95% CI, 1.2% to 8.4%). CONCLUSION: dPEGs are placed close to end of life in patients with advanced GI cancer. A minority of patients receive additional chemotherapy post-dPEG. Many have adequate disease understanding, but chemotherapy benefit is low, and future expectations vary. This may be an opportunity for improved communication regarding palliative procedures in advanced cancer.

Inoperable malignant bowel obstruction: palliative interventions outcomes – mixed-methods systematic review

“…Online supplemental file 4 provides summary descriptions of the included quantitative studies. There were 6 prospective,27–32 35 retrospective cohort studies,7 8 33–67 1 mixed-method study68 and 2 RCTs 69 70. Sample sizes ranged from 7 to 629.…”

“…Sample sizes ranged from 7 to 629. Studies were globally represented; 1 study from Australasia,50 5 from Asia,31 40 60 69 70 17 from Europe27–30 32 35 39 42 44–47 54 64 67 68 and 21 from North America 7 8 33 34 36–38 43 49 52 53 55–59 61–63 65 66…”

“…Thirteen studies reported median survivals between 13 and 63 days, range from 1 to 1226 days 7 27 49 50 53 54 56 59–63 67. Five studies reported mean survivals between 53 and 135 days, range from 5 to 2772 days 28 52 57 58 65.…”

“…Twenty/51 (39%)50 to 83% (20/24)64 of patients with PVG were discharged home. Hospice enrolment rates varied from 5/53 (9.4%)63 to 95/117 (81%) 56. A further retrospective cohort study67 reported 116/158) (81.6% of patients discharged, though discharge location unknown).…”