Prevalence of Ethical Issues in Patients with Advanced Cancer: Secondary Analysis of Pooled Data from the Development and Validation Cohorts of the PALCOM Scale for Complexity of Palliative Care Needs

Introduction: The life experience of patients with advanced cancer and limited life expectancy is unique and profoundly complex, often leading to moral discrepancies among the various individuals involved in decision-making. There is no data in the literature on the prevalence of ethical issues in the end-of-life care of patients with ad-vanced cancer. Objectives: The primary objective of this study is to identify the overall and specific prevalence of ethical issues in the end-of-life care process for patients with advanced cancer. Method: We conducted a secondary analysis of pooled data from the prospective development and validation cohorts of the PALCOM scale for the complexity of palliative care needs. This was done to determine the overall and specific prevalence of ethical issues, describe their evolution over a 6-month follow-up period, and their association with the level of palliative care complexity. Results: A total of 607 patients with advanced cancer and a life expectancy of ≤ 6 months were included. The absence of significant differences in clinical data and the frequencies of the PALCOM scale domains between the development and validation cohorts, conducted in different settings and times, confirmed the reliability of the pooled data sample. Systematic application of the PALCOM scale identified 126 patients (20.7%) who experienced at least one ethical issue. A total of 204 ethical issues (1.6 per patient) were recorded, related to: proportionality of healthcare intervention (15.6%); information (13.0%); research (2.9%); desire to hasten death (1.8%); palliative sedation (0.15%). The monthly probability of presenting an ethical issue was significantly higher at the baseline visit (24.0%) compared to the rest of the 6-month follow-up period (14-17%) (p< 0.001) The prevalence of ethical issues was significantly higher in patients with greater palliative care complexity according to the PALCOM scale: 4.5% in low complexity; 19.5% in medium complexity; 30.8% in high complexity (p< 0.001). Conclusions: The prevalence of ethical issues in patients with advanced cancer is high. Most of these issues are directly or indirectly related to the preservation of patient autonomy in the decision-making process. The presence of ethical issues is significantly associated with greater complexity of palliative care needs. In this context, it is crucial for healthcare professionals to strengthen both communication skills and basic competencies to effectively identify, assess, and manage these ethical issues.