REVIEW ARTICLE
Palliative care in terminal cancer: characterization, pain management and ethical aspects
Cuidados paliativos en cáncer terminal: caracterización, manejo del dolor y aspectos éticos
Adriel Herrero Díaz 1*, http://orcid.org/0000-0002-4016-6553
Diana Rosa González Tamayo 2, https://orcid.org/0009-0002-2316-9565
Dionis Ruiz Reyes 3, https://orcid.org/0000-0003-3061-1892
1 University of Medical Sciences of Villa Clara. Faculty of Medical Sciences of Sagua la Grande. Villa Clara, Cuba.
2 Arnaldo Milian Castro University Clinical Surgical Hospital. Neurosurgery Service. Villa Clara, Cuba.
3 University of Medical Sciences of Villa Clara. Faculty of Medicine. Villa Clara, Cuba.
* Corresponding author: adriel.hd02@gmail.com
Received: 25/08/2023
Accepted: 25/12/2023
How to cite this article: Herrero-Díaz A; González-Tamayo DR; Ruiz-Reyes D. Palliative care in terminal cancer: characterization, pain management and ethical aspects. Med. Es. [Internet]. 2024 [cited access date]; 4(1). Available in: https://revmedest.sld.cu/index.php/medest/article/view/257
ABSTRACT
Introduction: when Cancer patients reach the terminal phase of the disease, require palliative care. These procedures consist of the active and total care of diseases that have no response to curative treatment, in order to achieve the best possible quality of life by controlling the physical-psychic symptoms and the spiritual and social needs of patients.
Objective: to characterize palliative care in terminal cancer patients, to establish an updated bibliographical base that becomes future consultations on this topic.
Method: a bibliographic review was carried out in relation to the subject, with a total of 24 bibliographies. Scientific articles in English and Spanish were used, available in databases such as: Scielo, PubMed, Elsevier and in the Google Scholar search engine.
Development: palliative care in end-stage cancer patients is aimed at reducing pain and temporarily improving the manifestations of this disease. They are applied when it is certain that the prognosis is not positive and the outcome will be death. They encompass a series of guidelines and procedures necessary to face the end of the patient's life, complying with the rules of Bioethics. This care is necessary in a high percentage of terminal cancer patients.
Conclusions: palliative care responds to the need to ensure that patients in terminal stages of various diseases, and in particular cancer, find an integrated way to obtain the best care according to their symptoms. This care is the best resource for terminal cancer patients.
Key words: Patients;Palliative Care; Pain; Life Quality
RESUMEN
Introducción: los pacientes oncológicos cuando llegan a la fase terminal de la enfermedad, requieren de los cuidados paliativos. Estos procederes consisten en el cuidado activo y total de las enfermedades que no tienen respuesta al tratamiento curativo, con el objeto de conseguir la mejor calidad de vida posible controlando los síntomas físico-psíquicos y las necesidades espirituales y sociales de los pacientes.
Objetivo: caracterizar los cuidados paliativos en los pacientes oncológicos terminales.
Método: se realizó una revisión bibliográfica con relación al tema contando con un total de 24 bibliografías. Se utilizaron artículos científicos en inglés y español, disponibles en bases de datos como: Scielo, PubMed, Elsevier y en el motor de búsqueda de Google Académico.
Desarrollo: Los cuidados paliativos en pacientes oncológicos en etapa terminal van encaminados a la reducción del dolor y la mejora temporal de las manifestaciones de esta dolencia. Son aplicados cuando se tiene la certeza de que el pronóstico no es positivo y el desenlace será la muerte. Engloban una serie de directrices y procederes necesarios para afrontar el final de la vida del paciente, cumpliendo con las normas de la Bioética. Estos cuidados son necesarios en un elevado porcentaje de los enfermos oncológicos terminales.
Conclusiones: los cuidados paliativos responden a la necesidad de lograr que los pacientes en etapas terminales de varias enfermedades, y en particular del cáncer encuentren la manera integrada de obtener los mejores cuidados acorde a su sintomatología. Estos cuidados constituyen el mejor recurso para los pacientes oncológicos terminales.
Palabras Clave: Calidad de Vida; Cuidados Paliativos; Dolor; Pacientes
INTRODUCTION
Cancer is defined as a group of diseases characterized by the uncontrolled growth of cells, which form tumors and have the capacity to invade other tissues. (1) This process, known as metastasis, is responsible for approximately 90% of cancer deaths, making it one of the major global health challenges. (1,2)
Around 18.1 million new cases are diagnosed annually, with approximately 9.6 million deaths, making cancer the second leading cause of death globally. (3) It is estimated that by 2040 these figures will increase by 60%, reaching 21.7 million new diagnoses and 13.1 million deaths annually. (8)
When cancer reaches an advanced, irreversible, and incurable stage, the focus of healthcare must shift from cure to alleviating suffering and improving quality of life. (2,3) It is in this context that palliative care (PC) emerges as a comprehensive care modality for patients with terminal illnesses whose life expectancy is limited and for whom curative treatment is no longer viable (1-3).
PC has its roots in the pioneering work of Cicely Saunders, who in the mid-20th century spearheaded a movement focused on the holistic care of the terminally ill, addressing not only physical pain but also the psychological, social, and spiritual dimensions of suffering (4,5). Her revolutionary approach, based on the preventive and progressive administration of analgesia and personalized care, laid the foundation for modern palliative care models (5,6).
Despite conceptual and clinical advances, the effective implementation of PC continues to present significant challenges. The World Health Organization (WHO) estimates that approximately 80% of cancer patients in advanced stages require this care (7,10); however, access to and quality of this care are unequal globally and regionally. In the Americas, for example, approximately 4 million new cases of cancer are diagnosed annually, with 1.4 million deaths, figures that are projected to increase (9). In Cuba, 27,817 new cases and 15,450 deaths were reported in 2022, with a significant burden in provinces such as Villa Clara (11).
This epidemiological reality, coupled with the complex physical, emotional, and ethical needs of terminally ill cancer patients, highlights the need to deepen our understanding and optimize palliative care in this vulnerable group.
Despite the recognized importance of palliative care in the management of terminally ill cancer patients, gaps remain in the comprehensive characterization of its components, the adaptation of interventions to the clinical and sociocultural context, and the systematization of evidence-based approaches that guarantee quality, dignified care in accordance with bioethical principles.
Based on the above, the objective is to characterize palliative care in terminally ill cancer patients, with emphasis on its foundations, symptom management—especially of pain—, nutritional considerations, and ethical aspects, in order to provide an updated bibliographic base to guide clinical practice and future research in this field.
METHODS
A narrative literature review was conducted to characterize palliative care for terminally ill cancer patients. The search period extended from September 1, 2022, to October 31, 2023.
The Scopus, SciELO, Dialnet, EBSCO, and PubMed/Medline databases were searched using a combination of descriptors and keywords related to the topic. The descriptors used, adapted from each database's thesaurus, included: "Quality of Life," "Palliative Care," "Pain," "Cancer Patients," and "Terminal Neoplasms," combined with Boolean operators (AND, OR).
Original articles and systematic reviews in Spanish, English, or Portuguese, published between 2018 and 2023, with open access and peer review, were included. No geographical restrictions were applied. The studies had to address clinical, psychosocial, ethical, or symptom management aspects related to palliative care in advanced or terminal cancer. Editorials, letters to the editor, single case studies, and non-scientific literature were excluded.
The initial search yielded 42 potentially relevant references. After reviewing titles and abstracts, the full texts were critically appraised. The final selection of 24 articles was based on the criteria of thematic relevance, methodological quality, timeliness, and open access availability. The filtering and selection process was carried out independently by the authors, who resolved discrepancies through consensus.
The extracted information was organized narratively and thematically, structuring the content into coherent sections that address: historical and conceptual foundations, epidemiology, pain management, nutritional interventions, and ethical considerations. Priority was given to integrating recent evidence and identifying trends and consensus in the current scientific literature.
DEVELOPMENT
Palliative care (PC) is a comprehensive care model that, in more than 90% of terminally ill patients, alleviates physical, psychosocial, and spiritual problems. Its objective is neither to hasten nor postpone death, but to function as a genuine support system for both the patient and their family, facilitating a dignified transition between life and death (2,12).
In 1990, the World Health Organization (WHO) defined PC as the active and total care of illnesses that do not respond to curative treatment, including terminal cancer (7). This therapeutic approach seeks to improve the quality of life of patients and their families by preventing and relieving suffering through meticulous assessment and treatment of pain and other physical, psychological, and spiritual symptoms. It is important to emphasize that many of these interventions should be implemented from earlier stages of the illness, combined with active palliative treatments (13).
Needs of Cancer Patients in Advanced Stages
In patients with advanced cancer, prolonging life through aggressive treatments can be counterproductive, generating additional complications that affect the quality of their remaining time. This reality has led to intense bioethical, academic, and legal debates surrounding palliative care since its inception in the 1970s. Comprehensive pain and symptom management is therefore a central objective, aimed at enabling patients to live their final days with fulfillment and dignity (14-16).
Pain in Cancer Patients at the End of Life
Terminal cancer pain is a predictable and, to a large extent, preventable symptom, the intensity of which increases with disease progression. Despite therapeutic advances in the last decade, its prevalence remains unacceptably high. While Sacristán (17) indicates that up to 30% of patients experience pain at the time of diagnosis, a figure that rises to 60-80% in terminal stages, Vallejo (18) reports that in advanced stages the prevalence ranges between 80% and 90%. Up to 75% of patients with advanced cancer report pain upon hospital admission, and between 70% and 80% experience it in the last four weeks of life.
Pain relief is an ethical and healthcare imperative and has been recognized as a fundamental human right according to the Montreal Declaration of the International Association for the Study of Pain (IASP) in 2010. This symptom significantly impacts quality of life and physical autonomy, being present in 60% to 100% of patients in advanced stages, and carries a considerable emotional and spiritual burden (18,19).
However, barriers to its optimal management persist. Alonso Díaz et al. (20) highlight the reluctance of patients and their families to use strong opioids, due to social stigma or the association of morphine with imminent death. There is also an unfounded fear that analgesia may hasten death, which limits its appropriate administration.
The pharmacological management of cancer pain encompasses a broad spectrum, ranging from common analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) to opioids and specialized adjuvants. Anticonvulsants such as gabapentin, pregabalin, and carbamazepine are used for neuropathic pain, while bisphosphonates are indicated for pain from bone metastases (20-22). Corticosteroids, due to their potent anti-inflammatory effect, and antidepressants such as tricyclics or dual-action antidepressants also play a significant role in symptom management (21,22).
In addition to pharmacological approaches, there are invasive and non-pharmacological interventions that can be effective, such as nerve blocks, radiotherapy, physical therapy, and psychological support (21,22).
In conclusion, the management of advanced cancer pain, especially when it is refractory, represents a significant clinical and ethical challenge. The authors agree on the need to promote research in this field in order to develop innovative therapeutic strategies and improve the quality of care for this vulnerable group of patients.
Invasive treatment of severe terminal cancer pain
The use of invasive techniques is reserved for cases of severe pain that do not respond to optimized conventional pharmacological management, when intolerable side effects occur, or when other routes of administration are not feasible. Pharmacological advances in the last decade have significantly reduced the need for these interventions, although they remain a valuable option in selected situations (18-22).
Among the available techniques, neuromodulation stands out, using spinal administration (via epidural or intrathecal route) of analgesic drugs. Morphine is the only drug approved for this route, although other opioids such as fentanyl, sufentanil, methadone, or meperidine can also be used. The selection of adjuvants (local anesthetics, alpha-2 agonists) depends on the type of pain: in visceral or somatic pain, opioids are usually combined with local anesthetics, while in neuropathic pain, local anesthetics predominate along with alpha-2 agonists (18, 21, 22).
Another alternative is spinal cord stimulation, considered a fourth-line therapeutic option for refractory neuropathic or vascular pain. Likewise, in cases of refractory cancer pain, injections of local anesthetics or neurolytic agents have been used in specific nerves or ganglia, a procedure known as nerve block. However, the development of implantable controlled-release drug delivery systems and more advanced neurosurgical techniques has significantly reduced the use of neurolytic methods, which are currently employed in less than 10–15% of cases (18, 22).
Neurosurgical techniques have also experienced a decrease in their application, although they remain an option to consider in the management of refractory pain. Contraindications for these procedures include: very limited life expectancy, coagulation disorders, impaired sphincter function, and severe pulmonary dysfunction ipsilateral to the pain (18, 22).
Nutritional Considerations in Palliative Care
Nutrition transcends the biological realm and possesses a profound social, cultural, and emotional dimension; therefore, its management in palliative care must be approached with sensitivity and clinical judgment (23).
As Pereira (23) points out, when food intake no longer contributes to improving the illness or quality of life, pressuring terminally ill patients can be useless and even counterproductive. Artificial nutrition is a medical intervention that must be prescribed with a solid scientific basis, ensuring that its benefits clearly outweigh the risks, and always within an ethical framework that respects the patient's autonomy and dignity.
The nutritionist plays a fundamental role within the interdisciplinary palliative care team, contributing to improving quality of life through nutritional strategies adapted to each clinical situation (24). Muscogiuri (24) recommends prioritizing the patient's tolerance and enjoyment, even allowing low or nutritionally inadequate intakes if this leads to greater well-being. In this phase, the goal is not to maintain optimal nutritional status, but rather to provide comfort. Therefore, artificial nutrition may be disproportionate and cause more harm than good.
When designing nutritional interventions in palliative care, it is essential to differentiate between terminally ill patients, in whom symptom relief takes precedence over prolonging survival, and those who can still benefit from more active nutritional support. Decision-making must be guided by well-defined ethical principles that balance clinical benefit with respect for autonomy and quality of life (23,24).
In summary, the authors emphasize the fundamental importance of palliative care in supporting terminally ill cancer patients. Palliative medicine, with its comprehensive and humanized approach, has the capacity to offer conditions that allow the remaining time of life to be lived with the greatest possible dignity, comfort, and satisfaction, both for the patient and their family and loved ones.
CONCLUSIONS
Palliative care addresses the need to ensure that patients in the terminal stages of various illnesses, particularly cancer, receive integrated care tailored to their specific symptoms. This care for terminally ill cancer patients involves a broad range of specialists, representing their most valuable resource. It is crucial to guarantee the necessary conditions, along with medications and procedures to manage pain. This care must adhere to the principles of bioethics, which should guide all healthcare professionals.
BIBLIOGRAPHIC REFERENCES
1. Organización Mundial de Salud (OMS) [Internet]. Cáncer. Ginebra, Suiza: OMS; 2020 [Internet]. [cited 20/08/2023]. Available in: https://www.who.int/es/news-room/fact-sheets/detail/cancer
2. Souza MC dos S, Jaramillo RG, Borges M da S. Conforto de pacientes em cuidados paliativos: revisão integrativa. EnfermGlob [Internet]. 2021 [cited 20/08/2023];20(1):420–65. Available in: https://scielo.isciii.es/pdf/eg/v20n61/1695-6141-eg-20-61-420.
3. Fhon JRS, Silva LM, Rodrigues RAP, Acosta MEC. Percepción de las enfermeras sobre cuidados paliativos: experiencia con pacientes oncológicos. Rev. iberoam. educ. Invest. enferm. [Internet] 2018 [cited 20/08/2023]; 8(3): 28-36. Available in: https://www.enfermeria21.com/revistas/aladefe/articulo/284/percepcion-de-las-enfermeras-sobre-cuidados-paliativos-experiencia-con-pacientes-oncologicos/
4. Moreira Miranda Â. O Trabalho de Cuidados Paliativos: Uma sociohistória a partir de Cicely Saunders e Elisabeth Kübler-Ross [Internet] [Tesis]. [Universidad de Brasilia]; 2020 [cited 20/08/2023]. p. 18–9. Available in: https://repositorio.unb.br/bitstream/10482/39670/1/2020_%c3%82ngeloMoreiraMiranda.pdf
5. Vidal M. A., Torres L. M. In memoriam Cicely Saunders, fundadora de los Cuidados Paliativos. Rev. Soc. Esp. Dolor [Internet]. 2006 [cited 20/08/2023]; 13(3): 143-144. Available in: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1134-80462006000300001&lng=es.
6. Montes de Oca Lomeli GA. Historia de los Cuidados Paliativos [Internet]. Rev. digit. univ. [Internet]. 2006 [cited 20/08/2023]. Available in: https://www.ru.tic.unam.mx/bitstream/handle/123456789/1064/abr_art23.pdf?sequence=1&isAllowed=y
7. Organización Mundial de la Salud (OMS). Cuidados paliativos. Ginebra, Suiza: OMS; 2020 [Internet] [cited 20/08/2023]. Available in: https://www.who.int/cancer/palliative/es/
8. Parra-Soto S, Petermann-Rocha F, Martínez-Sanguinetti MA, Leiva-Ordeñez AM, Troncoso-Pantoja C, Ulloa N et al. Cáncer en Chile y en el mundo: una mirada actual y su futuro escenario epidemiológico. Rev. méd. Chile [Internet]. 2020 [cited 20/08/2023]; 148(10): 1489-1495. Available in: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872020001001489&lng=es
9. Organización Panamericana de la Salud (OPS). Cáncer. Washington DC, Estados Unidos: OPS; 2020. [Internet] [cited 20/08/2023]. Available in: https://www.paho.org/es/temas/cancer
10. World Health Organization (WHO). Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey [Internet]. WHO; 2020 [cited 20/08/2023]. Available in: https://www.who.int/publications/i/item/9789240002319
11. MINSAP. Dirección de registros Médicos y estadísticas de Salud. Anuario Estadístico de Salud de Cuba [internet]. La Habana: ECIMED; 2021 [cited 20/08/2023]. Available in: https://files.sld.cu/dne/files/2022/10/Anuario-Estadistico-de-Salud-2021.-Ed-2022.pdf
12. Buigues Mengual F, Torres Pérez J, Mas Sesé G, Femenía Pérez M, Baydal Cardona R. Paciente terminal. Guía de actuación clínica en A.P. España [Internet]. 2018 [cited 20/08/2023]. Available in: http://www.san.gva.es/documents/246911/251004/guiasap027terminal.pdf
13. World Health Organization (WHO). Cancer Pain Relief and Palliative Care. Genève, Switzerland: World Health Organization; 1990. [Internet] [cited 21/08/2023] Available in: https://apps.who.int/iris/bitstream/handle/10665/39524/WHO_TRS_804.pdf?sequence=1&isAllowed=y
14. Murillo MT, Moreno MV, Maganto VV, Pascual DR. Cuidados continuos. Una necesidad del paciente oncológico. Psicooncologia (Pozuelo de Alarcon) [Internet]. 2017 [cited 21/08/2023]; 1(1):155–64. Available in: https://dialnet.unirioja.es/servlet/articulo?codigo=1705538
15. Pessini L, Siqueira JE de. Reflexões sobre cuidados a pacientes críticos em final de vida. Rev Bioét [Internet]. 2019 [cited 21/08/2023];27(1):29–37. Available in: https://www.scielo.br/j/bioet/a/ZR5CdVSMkp4jwzF6GtYHcrb/?lang=es
16. Betancourt Betancourt G, Rivero Castillo J, Betancort Reyes G. La adecuación del esfuerzo terapéutico en la Atención Primaria de Salud. Rev Cubana Med Gen Integr [Internet]. 2018 [cited 21/08/2023]; 34 (2):4 Available in: http://www.revmgi.sld.cu/index.php/mgi/article/view/394
17. Sacristán Rodea A, Ferrari Sanjuan M. Tratamientos al final de la vida: cuidados paliativos, sedación terminal, eutanasia y suicidio medicamente asistido (SMA). RIECS[Internet]. 2021 [cited 21/08/2023] 30;6(2):94–105. Available in: https://www.riecs.es/index.php/riecs/article/view/293/384
18. Vallejo Martínez M, Baque Hidalgo JE. Alimentación y cuidados paliativos en el paciente oncológico terminal. Rev Nutr Clin Metab [Internet]. 2021 [cited 21/08/2023];4(2):71–7. Available in: https://revistanutricionclinicametabolismo.org/index.php/nutricionclinicametabolismo/article/view/274
19. Domínguez Cruz M. Consideraciones éticas para el cuidado de pacientes con dolor por cáncer en la comunidad. Rev Cubana Med Gen Integr [Internet]. 2019 [cited 21/08/2023]; 35(4): e1106. Available in: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864-21252019000400014&lng=es
20. Alonso Díaz T, Llantá Abreu M del C, Ropero Toirac R, Bazán Milian B, Navarrete Dávalos C, et al. Atención integral al paciente oncológico con dolor. Rev cuba oncol [Internet]. 2021 [cited 22/08/2023]; 19(1):10-13. Available in: http://revoncologia.sld.cu/index.php/onc/article/view/90/51
21. Díaz Juvier YL, Hernández Ortega Y, Hernández Rodríguez LA, Cuevas Pérez OL, Fernández Ruiz DR. Tratamiento del dolor en el paciente oncológico. Medisur [Internet]. 2019 [cited 22/08/2023]; 17(4): 552-561. Available in: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1727-897X2019000400552&lng=es
22. González González S. Dolor en el paciente oncológico y terminal. NPunto [Internet]. 2021 [cited 22/08/2023]; 4(43):79–106. Available in: https://dialnet.unirioja.es/servlet/articulo?codigo=8215378
23. Pereira dos Santos Duarte EC, Rodrigues de Sousa R, Feijó Figueiredo MC, Pereira Freire JA. Assistência nutricional para os cuidados palliativos de pacientes oncológicos: uma revisão integrativa. Rev Bras Ciênc Saúde [Internet]. 2020 [cited 22/08/2023]; 18(64):5. Available in: https://seer.uscs.edu.br/index.php/revista_ciencias_saude/article/view/6585
24. Muscogiuri G, Barrea L, Carignano M de LÁ, Ceriani F. Recomendaciones nutricionales en cuidados paliativos para pacientes con enfermedades avanzadas y al final de la vida. Rev Nutr Clin Metab [Internet]. 2021 [cited 22/08/2023]; 4(2):59–70. Available in: https://revistanutricionclinicametabolismo.org/index.php/nutricionclinicametabolismo/article/view/272
AUTHORSHIP STATEMENT
AHD: Conceptualization, Editing, Research, Methodology, Resources, Writing.
DRGT: Research, Drafting, Review.
DRR: Drafting, Review.
FUNDING
The authors received no funding for the literature review.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.