Family support is an important part of your cancer care, and when a recommended chemo or radiation regimen is one that you can have close to home, many oncologists will suggest having it done at a cancer center close to your family and support network.   Chemo and radiation can require frequent trips to the hospital (sometimes as many as 3-5 appointments per week).  In addition these treatments can sometimes be tiring.  Family and friend support can be helpful and sometimes critical.  This includes everything from rides to the hospital to verbal encouragement.  When getting a second opinion at a major cancer center far away from home, ask the oncologist if the recommended chemo or radiation regimen is the same or similar to what you can get closer to home.  Most importantly, consider the importance of your support network.

• Lay media does a poor job of keeping a balanced perspective when reporting cancer information
• Study found that 95% reported exclusively on aggressive and expensive treatments such as chemotherapy, while only 13% mentioned that these treatments can fail
• Less than a third put their article in a balanced perspective by including a description of the adverse side effects and cost of cancer treatments; Only 8% mentioned the possibility that people die of their cancer
• Researcher from the study concludes, media “…play to this fear (of dying) by reassuring us that there are treatments that work, and that there are cures that are effective. That is, they tell us what we want to hear”
• That is why we are working to empower patients with accurate and straight-forward information on our site and our companion site www.patientresource.net

How well does the media do in reporting to you about the “hope” of cancer advances, while keeping a perspective that this is still a life-threatening disease that kills over a half million people each year?

Not very well, according to a study published in the Annals of Internal Medicine in March, 2010 by Drs  Fishman, Ten and Casarett from the University of Pennsylvania. They examined over 400 articles published in the lay press (i.e.: a public audience, not a medical journal) and found that a whopping 95% reported exclusively on aggressive and expensive  treatments –such as chemotherapy, bone marrow transplantation and radiation therapy—while only 13% mentioned that these treatments can fail. Moreover, less than a third put their article in a balanced perspective by including a description of the adverse side effects and cost of cancer treatments.

Please understand that I am not against the reporting of promising advances and the progress we are making, but I do think the media can do a better job. For example, I was recently interviewed on a new drug advance for melanoma, and was quoted (appropriately) that this was “ a single, not a home run”, meaning that is one of the first survival advances in the treatment of advanced melanoma, but probably won’t be used as a single agent to increase cure rates of melanoma. It was not reported that the drug can have serious side effects and that some patients died as a result of the treatment! On the one hand, if you are a patient for whom all other treatments have failed and you are facing the prospects of dying in the coming months, then getting a powerful drug with serious, sometimes life-threatening side effects may be your only choice. Or, if you have had potentially curative surgery but still have a risk of relapsing later on, you might have some pause about taking a drug that may interrupt or halt your present quality of life or even shorten your life. Doctors and cancer patients make these kinds of decisions every day based upon estimating the probability of success or failures among groups of patients. However, at the level of an individual patient, we don’t have a crystal ball! Some patients do better than expected and other do worse. We all have to make our best decision about the whether the benefits of a particular treatment outweigh the potential risks and complications and then accept the outcome as we go forward.

I’ll quote from a blog by Dr Casarett, one of the researchers on this study. “Of course, it’s not such a terrible thing if we can’t find what we need about cancer in newspapers and magazines. These are just one source of information that’s available to us. If we don’t find what we are looking for in one of these articles, we can look somewhere else. That’s why the real problem with these articles is not the information that’s missing from them, but rather the biased picture that they give of what it’s like to have cancer…..The most worrisome thing we found in these articles, though, was the way they carefully avoid mentioning death and dying. In fact, only 8% mentioned the possibility that people die of their cancer….So these articles play to this fear (of dying) by reassuring us that there are treatments that work, and that there are cures that are effective. That is, they tell us what we want to hear.” The full blog story can be found at www.huffingtonpost.com/david-casarett-md/cancer-news-offers-reader_b_499540.html.

Of course, this desire–indeed our passion– is to inform and educate cancer patients so they can learn about what they need to know, not just the things we want to hear. That is why we started Patient Resource Cancer Guides and its website www.patientresource.net and www.mycanceradvisor.com, so that cancer patients could learn about all aspects of the cancer journey, including the more difficult issues of pain management, treatment options and their complications, and the process of death and dying. We hope that empowering patients with accurate and straight-forward information will make a difference in their lives and the lives of their loved ones.

The abstract of the publication cited above is:

Fishman J, Ten Have T, Casarett D. Arch Intern Med. 2010 Mar 22;170(6):515-8.

Cancer and the media: how does the news report on treatment and outcomes?

BACKGROUND: Cancer receives a great deal of news media attention. Although approximately half of all US patients with cancer die of their illness or of related complications, it is unknown whether reports in the news media reflect this reality. METHODS: To determine how cancer news coverage reports about cancer care and outcomes, we conducted a content analysis of US cancer news reporting in 8 large-readership newspapers and 5 national magazines. Trained coders determined the proportion of articles reporting about cancer survival, cancer death and dying, aggressive cancer treatment, cancer treatment failure, adverse events of cancer treatment, and end-of-life palliative or hospice care. RESULTS: Of 436 articles about cancer, 140 (32.1%; 95% confidence interval [CI], 28%-37%) focused on survival and only 33 (7.6 %; 5%-10%) focused on death and dying (P < .001, chi(2) test). Only 57 articles (13.1%; 10%-17%) reported that aggressive cancer treatments can fail, and 131 (30.0%; 26%-35%) reported that aggressive treatments can result in adverse events. Although most articles (249 of 436 [57.1%]; 95% CI, 52%-62%) discussed aggressive treatments exclusively, almost none (2 of 436; [0.5%]; 0%-2%) discussed end-of-life palliative or hospice care exclusively (P < .001, chi(2) test), and only a few (11 of 436 [2.5%]; 1%-6%) discussed aggressive treatment and end-of-life care. CONCLUSIONS: News reports about cancer frequently discuss aggressive treatment and survival but rarely discuss treatment failure, adverse events, end-of-life care, or death. These portrayals of cancer care in the news media may give patients an inappropriately optimistic view of cancer treatment, outcomes, and prognosis.

Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, 19104, USA. fishman1@mail.med.upenn.edu

Blog Highlights:

• This video provides patients with the chance to see what actually

• happens during the course of radiation treatment
• On a daily bases there is no pain or discomfort with the treatment
• Treatment course can extend anywhere from 2-8 weeks
• Side effects are highly dependent on the region of the body being treated and the total dose

Radiation treatments are used in the majority of patients with cancer, and yet most patients have little idea of what to expect. This video is helpful in showing what happens during the course of a single radiation treatment. Some take home messages include that the technology has become relatively sophisticated, that the treatment has to be precisely delivered to one defined area of the body, and that on a daily bases there is no pain or discomfort with the treatment.

Prior to this patient’s treatments, a series of events had already taken place. You can see in the video that the patient’s head is immobilized by plastic mask that is fastened onto the table. The purpose of this and other forms of immobilization is to assure that the carefully planned treatment is able to be reproduced each day when the patient comes for their daily treatment. Treatment course can extend anywhere from 2-8 weeks and the ability of the treatment to hit its target is highly dependent on the ability to precisely reproduce the position of the patient each day. Also prior to the treatment, a CAT scan of the patient while he was immobilized in his mask was obtained. This information is transferred to treatment planning computers and the doctor outlines the targeted region and the normal tissues to avoid. Working with his team, the doctor then helps determine the optimal angle of beam entrance and exit and the shape and intensity of each field. In the video, four fields were used: one from the front, one from the back and one from each side. These four beams will have a mutual intersection point at the targeted region where the addition from each beam will result in a selectively high dose to this region. Within the treatment head of the machine are a collimation system that can shape the beam edges into almost any shape which further adds to the precision of the dose delivery.

Radiation treatments are a scary endeavor for any patient and the treatment can cause some side effects that are highly dependent on the region of the body being treated and the total dose. What I liked about the video is that it provides patients with the chance to see what actually happens within the treatment room. In doing so, I hope you were left with the impression that it’s not that bad and when it is warranted it can provide a great service to cancer patients.

Blog Highlights:

• There is some evidence, although somewhat controversial, that acupuncture can be effective in reducing frequency of hot flashes
• A small, 12-week study concluded “Acupuncture appears to be equivalent to drug therapy…”
• A large, 4-week study did not demonstrate a statistically significant reduction of hot flashes
• However, the 4-week study concluded: “We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.”

Hot flashes can be a debilitating condition for cancer patients who are being treated with chemotherapy or hormone therapy. This includes women with breast cancer and men with prostate cancer. I have written about this condition previously, including a listing of various medications that can be taken to reduce the frequency and intensity of hot flashes. (for more information, read Study May Help Cool Hot Flashes for Cancer Patients).

There is some evidence, although somewhat controversial, that acupuncture can be effective in women…and in men…who suffer from hot flashes. In a scientific study conducted at Henry Ford Hospital and published in the Journal of Clinical Oncology (February 1, 2010; vol. 28:pages 634-40; abstract listed below), 50 breast cancer patients volunteered for a  randomized controlled trial that tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine (Effexor), a commonly used drug for hot flashes. The investigators concluded that: “Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.”

However, the evidence for acupuncture is not compelling. For example a slightly larger study from Memorial Sloan Kettering Cancer Center in 2007 did not convincingly demonstrate that acupuncture worked (J Clin Oncol. 2007 Dec 10; volume25:page 5584). They concluded: “Hot flash frequency in breast cancer patients was reduced following acupuncture. However, when compared with sham acupuncture, the reduction by the acupuncture regimen as provided in the current study did not reach statistical significance. We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.” This is an important point, since the positive Detroit trial administered acupuncture for 12 weeks while the New York trial was only 4 weeks in duration. FYI, sham acupuncture is a commonly used control group using techniques that are not intended to stimulate known acupuncture points.

While the evidence about the value of acupuncture treatments for refractory hot flashes are still preliminary, there seems to be enough potential value for this to be considered as an adjunct to conventional treatments for hot flashes, as described in previous blogs (for more information, read Study May Help Cool Hot Flashes for Cancer Patients). More research on this subject is needed.

Please read the abstracts below for more information. An interesting small study about acupuncture for hot flashes was recently reported in men with prostate cancer who were receiving hormone therapy (abstract listed below).

Acupuncture for Hot Flashes in Patients With Prostate Cancer.

Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, Donovan D, Katovic N, Reeder C, Eilers K.

Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, Oregon.

Urology. 2010 May 20. [Epub ahead of print]

Abstract

OBJECTIVES: To determine the effect of acupuncture on hot flash frequency and intensity, quality of life, and sleep quality in patients undergoing hormonal therapy for prostate cancer. Hot flashes are a common adverse effect of hormonal therapy for prostate cancer. METHODS: Men who had a hot flash score >4 who were receiving androgen deprivation therapy for prostate cancer underwent acupuncture with electrostimulation biweekly for 4 weeks, then weekly for 6 weeks, using a predefined treatment plan. The primary endpoint was a 50% reduction in the hot flash score after 4 weeks of therapy, calculated from the patients’ daily hot flash diaries. The hot flash-related quality of life and sleep quality and biomarkers potentially related to hot flashes, including serotonin, calcitonin gene-related peptide, and urinary 5-hydroxyindoleacetic acid, were examined. RESULTS: A total of 25 men were enrolled from September 2003 to April 2007. Of these, 22 were eligible and evaluable. After 4 weeks, 9 (41%, 95% confidence interval 21%-64%) of 22 patients had had a >50% reduction in the hot flash score. Of the 22 patients, 12 (55%, 95% confidence interval 32%-76%) met this response definition at any point during the therapy course. No patient had a significant increase in hot flash score during therapy. A reduced hot flash score was associated with improvement in the hot flash-related quality of life and sleep quality. CONCLUSIONS: Multiple placebo-controlled trials have demonstrated a 25% response rate to placebo treatment for hot flashes. Of the 22 patients, 41% had responded by week 4 and 55% overall in the present pilot study, providing evidence of a potentially meaningful benefit. Additional studies of acupuncture for hot flashes in this population are warranted. Copyright © 2010 Elsevier Inc. All rights reserved.

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Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial.

Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, Nunez R, Peterson E, Jakary S, Levine RA.

Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI 48202, USA. ewalker1@hfhs.org

J Clin Oncol. 2010 Feb 1;28(4):634-40. Epub 2009 Dec 28.

Abstract

PURPOSE: Vasomotor symptoms are common adverse effects of antiestrogen hormone treatment in conventional breast cancer care. Hormone replacement therapy is contraindicated in patients with breast cancer. Venlafaxine (Effexor), the therapy of choice for these symptoms, has numerous adverse effects. Recent studies suggest acupuncture may be effective in reducing vasomotor symptoms in menopausal women. This randomized controlled trial tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine (Effexor). PATIENTS AND METHODS: Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health outcomes were measured for up to 1 year post-treatment. RESULTS: Both groups exhibited significant decreases in hot flashes, depressive symptoms, and other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups, indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being. CONCLUSION: Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.

PMID: 20038728 [PubMed - indexed for MEDLINE]

• Day before surgery can be an intimidating and confusing time
• Patients who do well the day before surgery describe being active with others
• Contrary to popular opinion, the days before surgery should be an active time with good hearty meals
• Exercising beforehand can set back atrophy by not allowing it to get a head start
• Remember the details of your instructions before surgery

The day before surgery can be an intimidating and confusing time. Anxiety about the outcome of the operation and long-term survival can be alleviated by knowing facts about surgery and tips patients have found useful in preparing.

First, stay active and eat well right up until the night before surgery. Unless you’re having colon surgery which often requires a bowel prep and an extra day of a restricted diet before surgery, go ahead and beef up! Contrary to popular opinion, the days before surgery should be an active time with good hearty meals. I tell many patients to treat themselves to a delicious meal in the days leading up to surgery and, depending on the operation, even the night before surgery. You won’t be eating much after the operation for a couple days at least, so to minimize the period of going without nutrition, its good to get some good calories in the system. Nutrition is also known to strengthen your immune system, which sometimes needs to work well during your recovery.

Along the same lines, stay fit. Go ahead and go to the gym and get some good exercise before surgery. The days after surgery are like being an astronaut in that your muscles get weak from lack of use (called atrophy). Exercising beforehand can set back atrophy by not allowing it to get a head start.

Here are some more facts that are good to ease fears. The data on surgery demonstrate that the operation itself is very standardized. In my field of pancreas surgery for example, nearly every experienced pancreas surgeon in the world performs essentially the same operation with minimal variation. Many patients are also worried about general anesthesia, perhaps based on scary movies or public legends of the olden days, but general anesthesia today has a major complication rate of only about 1 in 100,000. Anesthesia is very safe in the modern era, and its safety profile in medicine is among the best of any medical intervention.

Patients who do well the day before surgery describe being active with others. As a general note on patients that I see who are depressed and anxious, the more someone has a community, the less likely they are to experience depression or anxiety. Movies, performances, getting together with friends, and family gatherings are some of the activities patients find helpful in making the day before surgery a pleasant experience. Often times patients describe a great experience surrounding themselves with positive friends—people who are optimistic and enjoy life.

Finally, remember the details of your instructions before surgery: Nothing to eat or drink by mouth 8 hours before your scheduled surgery time, and bring your most recent CAT scan with you if your surgeon does not already have it.



Blog Highlights:

• It is important for the caregiver, for family members, and friends of a dying cancer patient to understand some of the basics about the physical act of dying
• Study finds that patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life
• Listed below are references on the internet that caregivers and families can go to about the death and dying process

Death is not an easy subject. As a consequence, there is too little discussion about it…even among loved ones. The videos shown above are a succinct and informative series for caregivers and loved ones in a family facing the emotionally difficult experience of watching someone go through the dying process. I know first-hand what this is like as both of my parents died from agonizing and mean-spirited cancers.

Death is a huge subject, and one that engages strong emotions. Every individual, and every family unit, faces this in different ways, for the human spirit and the sum of our life experiences are so unique!

It is important for the caregiver, for family members, and friends of a dying cancer patient to understand some of the basics about the physical act of dying and the issues associated with this process.  Hopefully, the four videos shown here will open up a dialogue and help in some small way to understand these issues.

Should a dying patient be shielded from their terminal state? In my opinion, no. That doesn’t mean that caregivers and patients should give up hope, but that they should be realistic in their expectations and be able to communicate the reality of the dying process in a loving and forthright manner. Knowing about the certainty of dying can oftentimes bring out intimate discussions with loved ones, including confronting fears about dying, that might otherwise not happen.

In a publication in the Journal of Clinical Oncology (April 10, 2010) on the topic: “Experiences and Attitudes of Patients with Terminal Cancer and their Family Caregivers toward the Disclosure of Terminal Illness”, the authors found that most patients with terminal cancer and their family caregivers preferred disclosure about their status. Patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life. Patients who were informed had a better quality of life and fewer symptoms and a lower rate of emotional distress than patients who came to their own conclusion that they were dying based on their worsening condition.

Care at the end of life focuses on making patients comfortable. They can still have goals of maximizing their quality of life and receive medicines and treatments to control pain and other symptoms. Some patients choose to die at home. Others enter a hospital or a hospice. When my parents were dying of cancer, I found that the Hospice Program in our area was an invaluable resource to help us mange through this difficult time.

The goal of palliative or end-of-life care is to improve the patient’s and the family’s quality of life by preventing and relieving suffering. This includes treating physical symptoms such as pain, and dealing with emotional, social, and spiritual concerns. Below are two more informative videos, and I have listed references available on the Internet for caregivers and families about the death and dying process. Also listed are helpful websites, specifically for caregivers. Finally, I have copied (below) an excerpt from the National Cancer Institute that has some helpful information.

Physical Contact Can Be A Simple Way to Bring Comfort to Your Dying Loved One:

Changes In A Dying Loved One’s Eating Habits Can Be Discomforting to Caregivers:

FOR ADDITIONAL INFORMATION:

American Society of Clinical Oncology: http://www.cancer.net/patient/Coping/End-of-Life+Care

American Cancer Society: http://www.cancer.org/Treatment/NearingtheEndofLife/NearingtheEndofLife/index

Cancer Care: http://www.cancercare.org/get_help/special_progs/caregivers.php

Caregivers: http://www.caregivers4cancer.com/

Mayo Clinic: http://www.mayoclinic.com/health/cancer/CA00048

National Cancer Institute on end-of-life issues: http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/patient

National Cancer Institute on Care giving: http://www.cancer.gov/cancertopics/caring-for-the-caregiver

SUMMARY FROM THE NATIONAL CANCER INSTITUTE (see website for details)

The following information can help answer some of the questions that many patients, their family members, and caregivers have about the end of life.”

1. How long is the patient expected to live?

Patients and their family members often want to know how long a person is expected to live. This is a hard question to answer. Factors such as where the cancer is located and whether the patient has other illnesses can affect what will happen. Although doctors may be able to make an estimate based on what they know about the patient, they might be hesitant to do so. Doctors may be concerned about over- or under-estimating the patient’s life span. They also might be fearful of instilling false hope or destroying a person’s hope.

2. When caring for the patient at home, when should the caregiver call for professional help?

When caring for a patient at home, there may be times when the caregiver needs assistance from the patient’s health care team. A caregiver can contact the patient’s doctor or nurse for help in any of the following situations:
• The patient is in pain that is not relieved by the prescribed dose of pain medication;
• The patient shows discomfort, such as grimacing or moaning;
• The patient is having trouble breathing and seems upset;
• The patient is unable to urinate or empty the bowels;
• The patient has fallen;
• The patient is very depressed or talking about committing suicide;
• The caregiver has difficulty giving medication to the patient;
• The caregiver is overwhelmed by caring for the patient, or is too grieved or afraid to be with the patient; or
• At any time the caregiver does not know how to handle a situation.

3. What are some ways that caregivers can provide emotional comfort to the patient?

Everyone has different needs, but some emotions are common to most dying patients. These include fear of abandonment and fear of being a burden. They also have concerns about loss of dignity and loss of control. Some ways caregivers can provide comfort are as follows:
• Keep the person company—talk, watch movies, read, or just be with the person.
• Allow the person to express fears and concerns about dying, such as leaving family and friends behind. Be prepared to listen.
• Be willing to reminisce about the person’s life.
• Avoid withholding difficult information. Most patients prefer to be included in discussions about issues that concern them.
• Reassure the patient that you will honor advance directives, such as living wills.
• Ask if there is anything you can do.
• Respect the person’s need for privacy.

4. What are the signs that death is approaching? What can the caregiver do to make the patient comfortable?

Certain signs and symptoms can help a caregiver anticipate when death is near. They are described below, along with suggestions for managing them. It is important to remember that not every patient experiences each of the signs and symptoms. In addition, the presence of one or more of these symptoms does not necessarily indicate that the patient is close to death. A member of the patient’s health care team can give family members and caregivers more information about what to expect.

• Drowsiness, increased sleep, and/or unresponsiveness (caused by changes in the patient’s metabolism).

The caregiver and family members can plan visits and activities for times when the patient is alert. It is important to speak directly to the patient and talk as if the person can hear, even if there is no response. Most patients are still able to hear after they are no longer able to speak. Patients should not be shaken if they do not respond.

• Confusion about time, place, and/or identity of loved ones; restlessness; visions of people and places that are not present; pulling at bed linens or clothing (caused in part by changes in the patient’s metabolism). Gently remind the patient of the time, date, and people who are with them. If the patient is agitated, do not attempt to restrain the patient. Be calm and reassuring. Speaking calmly may help to re-orient the patient.

• Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased blood flow, and mental preparation for dying).

Speak to the patient directly. Let the patient know you are there for them. The patient may be aware and able to hear, but unable to respond. Professionals advise that giving the patient permission to “let go” can be helpful.

• Decreased need for food and fluids, and loss of appetite (caused by the body’s need to conserve energy and its decreasing ability to use food and fluids properly).

Allow the patient to choose if and when to eat or drink. Ice chips, water, or juice may be refreshing if the patient can swallow. Keep the patient’s mouth and lips moist with products such as glycerin swabs and lip balm.

• Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area).

Keep the patient as clean, dry, and comfortable as possible. Place disposable pads on the bed beneath the patient and remove them when they become soiled.

• Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or decreased fluid intake).

Caregivers can consult a member of the patient’s health care team about the need to insert a catheter to avoid blockage. A member of the health care team can teach the caregiver how to take care of the catheter if one is needed.

• Skin becomes cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities).

Blankets can be used to warm the patient. Although the skin may be cool, patients are usually not aware of feeling cold. Caregivers should avoid warming the patient with electric blankets or heating pads, which can cause burns.

• Rattling or gurgling sounds while breathing, which may be loud; breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs).

Breathing may be easier if the patient’s body is turned to the side and pillows are placed beneath the head and behind the back. Although labored breathing can sound very distressing to the caregiver, gurgling and rattling sounds do not cause discomfort to the patient. An external source of oxygen may benefit some patients. If the patient is able to swallow, ice chips also may help. In addition, a cool mist humidifier may help make the patient’s breathing more comfortable.

• Turning the head toward a light source (caused by decreasing vision).

Leave soft, indirect lights on in the room.

• Increased difficulty controlling pain (caused by progression of the disease).

It is important to provide pain medications as the patient’s doctor has prescribed. The caregiver should contact the doctor if the prescribed dose does not seem adequate. With the help of the health care team, caregivers can also explore methods such as massage and relaxation techniques to help with pain.

• Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms are additional signs that the end of life is near.

5. What are the signs that the patient has died?

• There is no breathing or pulse.
• The eyes do not move or blink, and the pupils are dilated (enlarged). The eyelids may be slightly open.
• The jaw is relaxed and the mouth is slightly open.
• The body releases the bowel and bladder contents.
• The patient does not respond to being touched or spoken to.

The time at the end of life is different for each person. Each individual has unique needs for information and support. The patient’s and family’s questions and concerns about the end of life should be discussed with the health care team as they arise.

Here are some hints to keep in mind to help you get the nutrition you need while you are undergoing cancer treatments. Be sure to review this list with your health-care professional before following any of these suggestions.

1) Try eating small meals and snacks all day instead of three large meals.

2) When you are hungry, eat more than usual.

3) Eat meals and snacks with sufficient protein and calories to help you keep up your strength.

4) You may find that your appetite is better in the morning, so eat more then. You may want to eat your main meal early in the day rather than at night.

5) Keep ready-to-eat snacks handy to nibble on during the day, such as cheese, crackers, ice cream, muffins, yogurt, granola bars and nuts.

6) If you are not interested in eating and can eat only one or two things, consume a liquid or powdered commercial meal replacement product, such as instant breakfast, for extra calories and protein.

7) On days when you don’t feel like eating, drink plenty of fluids, especially water. Other healthy liquids include fruit juices, sports drinks, broth and milk.

Because cancer treatments can weaken your body’s immune system, your body may not be able to protect you against infections at times, and so you may be told to avoid some foods that can expose you to bacteria, such as raw and undercooked meat, fish, poultry, eggs and tofu.

Once your treatment is complete, most of your eating-related side effects should disappear. Rather than staying on a high-calorie, high-protein diet, you should return to a conventional healthy diet when you start feeling better.