The World Health Organization (WHO) defines palliative care as the prevention and relief of suffering through early identification, accurate assessment and management of the disease and its somatic, psychosocial and spiritual components for those with fatal illnesses and their families to improve their quality of life overall.
Palliative care is more concerned with bringing patients’ distressing symptoms under control, improving their quality of life, and giving psychological support and caring for their dignity of life. It is clear that palliative care is not an attempt to delay death, nor does it deliberately accelerate the process of death. At the same time, the patient’s family is also the target of palliative care concern.
After breast cancer reaches the end stage, patients often have symptoms corresponding to metastasis and typically also present with anorexia and cachexia (i.e., the body is extremely depleted and thin due to the tumor). The doctor will treat the patient and family according to their expectations and requirements for palliative care.
Anorexia-cachexia syndrome
Patients with end-stage breast cancer often have anorexia and malnutrition, also known as anorexia-malignant syndrome, mainly due to tumor-induced metabolic dysfunction, immune suppression, increased fat and protein catabolism, and other factors such as tumor treatment and psychological effects. Patients in this condition often show significant weight loss, muscle atrophy, anorexia, weakness, abnormal taste, anemia, hypoproteinemia, edema, decubitus ulcers and mental depression.
For treatment, the physician will primarily consider correcting metabolic abnormalities and providing appropriate nutritional support, usually with nutrients and energy based on laboratory tests and daily metabolic levels, usually enteral nutrition, or sometimes intravenous nutrition via infusion. In addition, steroid corticosteroids, progesterone, and gastrodynamic drugs may be given as adjunctive therapy. At the same time, psychological support is given to the patient and family.
Fatigue
Fatigue is a common and serious symptom of end-stage breast cancer. Many patients may experience fatigue early in the disease, and it may be exacerbated by treatment, which can manifest as lack of energy, malaise, drowsiness, and mental retardation, or it may exacerbate other symptoms, such as pain, depression, and sleep disturbances.
Malnutrition, cachexia, drugs and radiation therapy, pain, mood and sleep disorders, water-electrolyte disturbances, hypoxia, metabolic disorders, low blood count, heart, liver, and kidney failure, endocrine disorders, and infections can all be causes of fatigue. The doctor will first identify the cause and treat it accordingly, such as pain relief, anti-infection, protection of heart, liver and kidney function, correction of malnutrition, and may also consider adding some hormones (e.g. dexamethasone, progesterone megestrol, methacholine) and psychostimulants (e.g. methylphenidate).
Coma
Coma implies severe impairment of brain function. Depending on whether there is a response to pain and the presence or absence of pupillary and corneal reflexes, physicians will classify the degree of coma in end-stage patients as light or deep coma.
Common causes of coma in oncology patients include:
- Brain metastases
- Malignant tumor invasion of the central nervous system
- High fever
- Infection
- Metabolic disorders
- Electrolyte disorders
- Brain hemorrhage
Cancer patients in coma are most often a sign of advanced disease, and physicians will manage the principle of moderation in their treatment. They usually take care to keep the airway open, give oxygen when there is hypoxia or difficulty breathing, use appropriate antibiotics if there is an infection, and use other medications as necessary. The patient is in a deep coma and is usually not in much pain, so if the family agrees or requests it, no further treatment can be given.
After cancer reaches its end stage, patients are generally unable to tolerate any intensity of antitumor therapy, so palliative care will focus on pain reduction and supplementation, with the principle that death is neither deliberately accelerated nor delayed. The entire process of palliative care also requires close collaboration between the patient’s family and the patient and medical staff in order to maximize the patient’s quality of life at the end stage.