Journal of Palliative Medicine

Published by Mary Ann Liebert
Online ISSN: 1557-7740
Theoretical model modified from the Revised Stress and Coping Model. 5 
We examined the efficacy of an innovative family-based intervention designed to decrease caregiving stress and increase family communication among individuals with chronic, life-limiting illnesses and their family caregivers in a randomized, contact control group design. The intervention group received three home visits in which the interventionist actively worked with the family to construct a personal Legacy, usually a scrapbook with photographs or audiotaped stories. Control group families received three supportive telephone calls. Of the 42 families that entered the project, 31 families completed follow-up assessments within 9 to 10 weeks (14 control; 17 intervention; 72% African American) for a retention rate of 74%. Intervention caregivers showed reduced caregiving stress in comparison with control group caregivers, who showed increases in stress. Intervention patients reported decreased breathing difficulty and increased religious meaning. Caregivers and patients reported greater social interaction on the part of the patient. All participants in the intervention group initiated a Legacy activity and reported that Legacy improved family communication. Legacy interventions hold promise and are simple to implement.
The current health care system cannot reliably meet the needs of patients with eventually fatal chronic illnesses near the end-of-life. Enduring change requires improved public policy, in part because most paid care for serious illness at the end of life now relies on federal programs. This project reviews the legislation proposed in the 107th Congress (2001-2002) related to improving end-of-life care. We searched THOMAS, the search engine of the Library of Congress, to identify all bills relating to end-of-life care introduced in either house of the U.S. Congress during the 2001/2002 legislative period. Using explicit criteria intended to find any that received serious attention and incorporating recommendations of political consultants, the initial 563 bills narrowed to 22. We summarize their status as of October 24, 2002. The 22 bills identified dealt with the following topics: demonstration or research projects (9), palliative care or hospice (8), caregivers (7), chronic illness generally (5), care coordination (2), and long-term health care (3). Dementia, graduate medical education, nursing, and pain appeared in 1 bill each. Congress enacted only 1 of the bills. Only 7 bills had more than 10% of either house as sponsors. While Medicare reform and health care costs are prominent topics among policymakers, Congress is considering essentially no fundamental changes that would remedy the problems associated with health care for the elderly who are seriously ill near the end-of-life. The mismatch between the urgency of policy reform and the lack of vehicles and momentum to achieve reform calls for consensus and leadership from those concerned with hospice and palliative care.
Palliative chemotherapy is often administered to terminally ill cancer patients to relieve symptoms. Yet, unnecessary use of chemotherapy can worsen patients' quality of life due to treatment-related toxicities. Thus, accurate prediction of survival in terminally ill patients can help clinicians decide on the most appropriate palliative care for these patients. However, studies have shown that clinicians often make imprecise predictions of survival in cancer patients. Hence, the purpose of this study was to create a clinical decision support tool to predict survival in cancer patients beyond 120 days after palliative chemotherapy. Data were obtained from a retrospective study of 400 randomly selected terminally ill cancer patients in the National Cancer Centre Singapore (NCCS) from 2008 to 2009. After removing patients with missing data, there were 325 patients remaining for model development. Three classification algorithms, naive Bayes (NB), neural network (NN), and support vector machine (SVM) were used to create the models. A final model with the best prediction performance was then selected to develop the tool. The NN model had the best prediction performance. The accuracy, specificity, sensitivity, and area under the curve (AUC) of this model were 78%, 82%, 74%, and 0.857, respectively. Five patient attributes (albumin level, alanine transaminase level (ATL), absolute neutrophil count, Eastern Cooperative Oncology Group (ECOG) status, and number of metastatic sites) were included in the model. A decision support tool to predict survival in cancer patients beyond 120 days after palliative chemotherapy was created. With further validation, this tool coupled with the professional judgment of clinicians can help improve patient care.
Steroids are recommended for use in bone pain, but the choice of dose, duration, and specific drug is largely empiric. Steroid toxicities are a concern, and the duration of treatment should be minimized to reduce the risk of adverse events.
Low-dose ketamine (at subanesthetic doses) can be considered for use in the palliative care setting for pain refractory to opioids and adjuvant analgesics.
For many patients, NM represents a preterminal diagnosis and no antineoplastic therapy is warranted. Establishing the diagnoses in such patients may be important to help prognosticate and to anticipate future neurologic problems (e.g., seizures, headache, radicular pain). The decision whether or not to begin antineoplastic treatment should be made in consultation with a medical, radiation, or neuro-oncologist.
Objective: Shortened quality-of-life (QOL) tools are advantageous in palliative care patients. Development of such tools begins with the identification of issues relevant to a population. The purpose of this study was to identify the most important items of the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) to create an abbreviated questionnaire for future palliative care trials. Methods: A convenience sample of patients and health care professionals (HCPs) assessed the relevance of each item of the FACIT-Pal and whether they would include the item in a final questionnaire. Patients and HCPs identified their top 10 most important issues and were asked whether items were inappropriate, upsetting, or irrelevant; a shortened questionnaire was generated from this input. Results: Sixty patients and 56 HCPs participated. The median score in the Karnofsky Performance Scale (KPS) of patients was 70, and the majority of HCPs were radiation oncologists. The 46-item questionnaire was shortened to 14 questions, retaining several items from the Functional Assessment of Cancer Therapy-General (FACT-G) as well as issues pertaining specifically to palliative care patients. Items within the emotional, physical, and functional well-being subscales were retained along with those for various symptoms including constipation, nausea, dyspnea, and sleep. No new content beyond what is covered by the FACIT-Pal was identified consistently by either HCPs or patients. Similarly, no item was consistently rated as being inappropriate, upsetting, or irrelevant in the 14-item questionnaire. Conclusion: The FACIT-Pal-14, a shortened 14-item questionnaire has been generated for the palliative care population. Future studies should complete psychometric validation of this instrument for the assessment of QOL in palliative care patients.
To determine if physician prediction of survival duration (PSD) is accurate for patients with metastatic breast or prostate cancer. Radiation Therapy Oncology Group 9714 (RTOG 9714) was a randomized comparison of radiotherapy schedules for treatment of bone metastases. The treating physician assigned a baseline Karnofsky Performance Score (KPS) and predicted survival duration at study entry. Patients completed the Functional Assessment of Cancer Therapy (FACT). These three were compared to actual survival time. Eight hundred ninety-eight patients were eligible and analyzable. Actual median survival was 9.3 months. The median PSD was 12 months. PSD, KPS, and FACT were all moderately correlated with actual survival. Patients with higher KPS had a longer survival time (882 patients, Spearman's rho = 0.259, p < 0.0001). The median survival of the 618 expired patients is 6.5 months (PSD was 12 months). The PSD was within 1 month of actual survival in 61 (10%), with 177 (29%) patients surviving more than 1 month longer than predicted and 375 (61%) surviving more than 1 month less than predicted. A univariate analysis of actual overall survival was performed, dividing the PSD into 4 groups. For predicted survivals of 6 months or less, less than 6 to less than 12 months, 12 months, and more than 12 months, median actual survivals were 7.0, 7.2, 9.7. and 13.5 months (p < 0.0001). KPS, FACT scores, and PSD all are correlated with actual survival. Physicians on this study were able to predict which patients would have longer survival times, although prediction of survival was optimistic compared to actual survival by an average of 3 months.
COPD is a heterogeneous disease without a simple prognostic trajectory. For ambulatory patients, their age, degree of dyspnea, weight loss (BMI), functional status, and FEV1 are relevant prognostic factors for predicting 1-3 year survival. For hospitalized patients, the same factors are relevant; in addition, the need for prolonged or recurrent mechanical ventilation is predictive of shorter prognosis.
The lidocaine patch 5% is a safe and modestly effective topical analgesic for postherpetic neuralgia. Controlled trials are needed to determine its efficacy in the treatment of neuropathic and non-neuropathic painful conditions other than PHN.
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Diane E Meier
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Eduardo Bruera
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Janet Bull
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Harvey Max Chochinov
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