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Impact of a Palliative Care Consultation Team on Cancer-Related Symptoms in Advanced Cancer Patients Referred to an Outpatient Supportive Care Clinic
Abstract
Context:
Patients with advanced cancer may develop severe physical and psychosocial symptoms. There are limited data on the impact of an outpatient palliative consultation (PC) team on cancer-related symptoms.
Objectives:
To study the impact of the PC on symptoms in patients with advanced cancer receiving outpatient palliative care.
Methods:
Four hundred six consecutive patients referred to a supportive care outpatient center (OPC) from January 2006 to June 2007 with complete Edmonton Symptom Assessment Scale (0-10 scale) at the initial and follow-up visits were reviewed. Patient characteristics, change of symptoms at follow-up visit, and response rate were analyzed. Using logistic regression models, the predictors of improvement of pain and fatigue were assessed.
Results:
Median age was 59 years; 53% were female. Median interval between visits was 15 days. Mean scores at baseline and follow-up visits were fatigue 6.8 and 5.3 (P<0.0001), pain 5.3 and 4.1 (P<0.0001), depression 3.2 and 2.5 (P<0.0001), anxiety 3.7 and 2.8 (P<0.0001), dyspnea 2.7 and 2.5 (P=0.05), sleep 5 and 4 (P<0.0001), and well-being 5.2 and 4.4 (P<0.0001). Dyspnea (odds ratio and P-value, 0.90, 0.03), nausea (0.92, 0.06), and depression (0.91, 0.04) were associated with improvement in fatigue; drowsiness (1.10, 0.04), and feeling of well-being (0.87, 0.02) were associated with improvement in pain.
Conclusion:
The initial consult by PC achieved significant symptom improvement in patients receiving treatment in the OPC. Further prospective studies are needed.
... The pretreatment of a cancer patient with antidepressants reduces symptoms of depression induced by interferon alfa. Other nonpharmacological psychosocial interventions can also be applied to reduce depressive symptoms in cancer patients, such as relaxation techniques, individual and group psychotherapy (42), and palliative care counseling (43). ...
... They are classified into two types: pharmacological and non-pharmacological interventions. The pharmacological interventions include antidepressants (43,45), such as Mianserin, low-dose fluoxetine, paroxetine, and amitriptyline (35), second-and third-generation tricyclic antidepressants (44), and selective serotonin reuptake inhibitors, such as citalopram or escitalopram (45). ...
... The international non-pharmacological interventions used for depression rehabilitation in cancer patients include the following: palliative rehabilitation programs with a holistic approach of care to improve the management of depression in cancer patients that focus on three factors (inflammation, exercise, and self-efficacy) (29); structured group support interventions, such as palliative care in depression rehabilitation clinics (33,45); programs of interdisciplinary palliative oncology rehabilitation (focusing on nutrition, psychological care, and the management of symptoms of depression in cancer patients as social support) (9, 34); social support (46); other psychological interventions, such as cognitive and behavioral techniques (44); psychosocial interventions (CBT family therapy, palliative care by multidisciplinary team) (21,34,35); herbal complementary therapy (chamomile, black cohosh, chasteberry, lavender, passionflower, and saffron) (38) as well as complementary and alternative therapies, such as integrating complementary medicine into the care of childhood cancer survivors with the collaboration of a multidisciplinary team (37, 55); a psycho-oncology approach (education and training program with a management of psychological symptoms module and medical communications module) that supports depressed cancer patients (39); counseling (41); psychosocial interventions as individual and group psychotherapies and relaxation techniques (20,43); WERPs that are effective in reducing depression among NSCLC patients (40); psychology education, problem-solving techniques, and couples therapy (45); balneotherapy (56); and health resort therapy interventions (57). ...
Background: Depression enhances the disease burden in patients with cancer. Psychological interventions and the rehabilitation of depression are required as a part of palliative care for cancer patients to improve their quality of life and mental health.
The aim of the study was to review the literature about depression rehabilitation interventions among patients with cancer in Palestine.
Method: The electronic databases used: PubMed, Science Direct, Research Gate, and Google Scholar to search for systematic review articles for the review study.
Results: A total of 23 articles were reviewed, including five from Palestine and five from Arab and Islamic nations. Pharmacological and non-pharmacological interventions used to decrease symptoms of depression and enhance mental health among cancer patients represent the majority of interventions for depression rehabilitation in cancer patients. Interventions for depression rehabilitation among cancer patients in Palestine are only available from the perspective of palliative care, which also involves family education, managing the symptoms of cancer patients, and providing psychological support.
Conclusion: In Palestine, non-pharmacological interventions, such as psychological interventions, are the primary options for treating and recovering from symptoms of depression. The management of symptoms in cancer patients also has a favorable impact on mental health and recovery from depression. In Palestine, there is a need for improvement in palliative care, particularly interventions for depressive symptoms. The main reason Palestinian patients with cancer have such limited treatment and recovery options are because of Israeli occupation.
... Dans le sous-groupe de patients décédés (n = 6 727), l'incidence cumulée de SPH était de 16,4% à 2 ans (IC95% [15,[5][6][7][8][9][10][11][12][13][14][15][16][17]3]) et 27,6% à 8 ans (IC95% [26,5 -28,7]). Chez les patients décédés ayant eu recours aux SPH, le délai médian de décès après SPH était de 20 jours (n = 1 859, Q1-Q3 [9 -43]). ...
... A 4 ans (48 mois), l'incidence cumulée de SPH était de 16,7% (IC95% [15,[9][10][11][12][13][14][15][16][17]5] Enfin, le genre et la localisation tumorale étaient prédictifs de la précocité de recours aux SPH. ...
... Dans le sous-groupe de patients décédés (n = 6 727), la survie médiane était de 21,1 mois (IC95% [20, 3 -22,4]). L'incidence cumulée de SPH était de 16,4% à 2 ans (IC95% [15,[5][6][7][8][9][10][11][12][13][14][15][16][17]3]) et 27,6% à 8 ans (IC95% [26,5 -28,7]). Parmi ceux ayant eu recours aux SPH (n = 1 859), le délai médian de décès après SPH était de 20 jours (Q1-Q3 [9 -43] 3 Défavorisés Annexe 9 : Comparaison de la population ESME-CSM 2008-2016, de la population éligible et de la population d'analyse dans l'étude du recours aux soins palliatifs hospitaliers des patients avec cancer du sein métastatique Annexe 11 : Facteurs associés à l'incidence cumulée de soins palliatifs hospitaliers à 5 ans chez les patients avec cancer du sein métastatique de la cohorte ESME-CSM 2008-2016. ...
Le vieillissement de la population et le nombre croissant de cancer interrogent l’accès aux soins palliatifs. L’intégration de ces soins en cancérologie et la diversification des structures spécialisées (unité, équipe mobile, lits identifiés, hôpital de jour) modifient les modalités de recours aux soins palliatifs hospitaliers (SPH). L’objectif de ce travail est d’étudier les facteurs prédictifs sociodémographiques, socioéconomiques, tumoraux et liés aux soins de la probabilité et de la précocité du recours aux SPH chez les patients avec cancer. Une revue systématique de la littérature a identifié les facteurs d’accès aux soins palliatifs dans le monde. L’incidence cumulée à 2 ans et en fin de suivi (probabilité) et le temps moyen de suivi après SPH (précocité) ont ensuite été étudiés dans deux analyses : l’une à partir de patients des registres des cancers de Gironde (n = 8 424, période 2014), l’autre à partir des patients avec cancer du sein métastatique (CSM) de la cohorte nationale ESME-CSM (n = 12 375, période 2008-2016). Selon l’analyse, les facteurs explicatifs étaient l’âge, le genre, le niveau socioéconomique, le lieu de résidence, la localisation ou sous-type tumoral, les caractéristiques des métastases et le type de centre. Plusieurs méthodes ont tenu compte du risque compétitif de décès (estimateur d’Aalen-Johansen, modèle multi-état, pseudo-valeurs). Dans les deux populations, les SPH étaient majoritairement initiés en phase terminale. Dans l’échantillon issu des registres (75+ ans : 2695, 32% ; Hommes : 4317, 51,3% ; Sein : 1247, 14,8%), les facteurs de l’incidence cumulée à 2 et 4 ans différaient selon le pronostic tumoral. En cas de pronostic défavorable, les patients ruraux, avec hémopathie maligne ou âgés traités hors des centres universitaires recevaient moins de SPH. En cas de pronostic favorable, les patients âgés, favorisés, avec cancer du poumon ou traités dans les centres universitaires recevaient plus de SPH. Les femmes et les patients avec tumeurs du système nerveux central de haut grade avaient un recours plus précoce. Dans l’échantillon des patients ESME-CSM (75+ ans : 2380, 19,2% ; CSM triple négatif : 1545, 12,6%), les facteurs de l’incidence cumulée dépendaient du temps de suivi. A 2 ans, les SPH concernaient surtout les plus jeunes avec CSM triple négatif, les plus âgés avec un autre sous-type, les patients en rechute ou avec plusieurs sites métastatiques. A 8 ans, ils étaient moins fréquents hors des centres à forte activité, en particulier pour les plus âgés. Le recours aux SPH était aussi moins précoce dans ces centres. En sus des disparités classiques d’accès aux soins, nous avons mis en évidence que le rôle des facteurs sociodémographiques dans le recours aux SPH dépendait du pronostic du cancer. Celui de l’âge dépendait en plus des caractéristiques du centre de prise en charge. Des études analytiques sur les mécanismes impliqués seraient utiles.
... Many issues, such as different types of pain, for example, neuropathic pain and breakthrough pain; subjective pain intensity; the history of addiction; psychological distress; and cognitive impairment have been found to be associated with complexities in pain management (Dalal et al 2012). Yennurajalingam et al (2011) report that up to 80% of cancer sufferers experience pain that impacts their health-related quality of life (HQoL). Further, Fallon et al (2018), identified that the prevalence of pain is estimated to be more than 70% in patients with advanced cancer. ...
... A multi-disciplinary team approach is a critical element of SPC (Yennurajalingam et al 2011). ...
... Although nine of the ten included studies measured the impact of outpatient SPC on pain, only one study measured this as its primary outcome (Yennurajalingam et al 2011). Nine studies measured symptom control, either by measuring control of common palliative care symptoms individually, or measuring mean symptom control or both. ...
Purpose
The aim of this systematic review was to determine the impact of specialist palliative care consultations in outpatient settings on pain control in adults suffering from cancer.
Methods
Systematic Review. Databases CINAHL, Medline, PsychInfo, and Embase were searched in February 2021. Relevant studies were also hand-searched and grey literature was searched in February 2021. The PICO mnemonic (Population, Intervention, Comparison, and Outcome) was used to form the review question. Of 1053 potential studies identified, 10 met the inclusion criteria. Quality appraisal of included studies was conducted using the evidence-based librarian (EBL) critical appraisal checklist.
Results
Outcome data from 56% (n=5/9) studies indicated a non-statistically significant reduction in pain. Narrative analysis of the remaining studies indicated a statistically significant reduction in pain in 50% (n=2/4) of the studies, one study showed mixed results, and one study found no statistically significant improvement in pain control. In relation to secondary outcomes, results from 33% (3/9) of studies indicated statistically significant improvement in symptom control. Data from 22% (n=2/9) of studies indicated no statistically significant improvement in symptoms measured. Narrative analysis of the remaining four studies indicated generally mixed results. EBL scores of included studies ranged between 50% - 95.23%.
Conclusion
Outpatient SPC consultations may have a positive impact on the control of pain and other distressing symptoms for cancer patients, however, results show mixed effects. Given that it is unclear what it is about outpatient SPC that impacts positively or otherwise on pain and symptom control.
... 10,11 A efetividade pode ser verificada pela evidência na melhoria da qualidade de vida, 7,11-14 pelo aumento do tempo de sobrevivência, pela diminuição da prevalência de depressão, por mais esperança, por uma melhor identificação, avaliação e controlo de sintomas, por uma melhor qualidade de sono, pela diminuição do sofrimento, pela satisfação com os cuidados por parte do doente e cuidador, pela possibilidade de morrer no local da sua preferência, pelo planeamento avançado dos cuidados, por uma menor admissão hospitalar em unidades de cuidados e no serviço de urgência, pela diminuição da agressividade dos cuidados no final da vida e pela redução dos custos em saúde. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Para se poder usufruir da efetividade da intervenção precoce pelos cuidados paliativos, é necessário que sejam identificados e referenciados os doentes com necessidades paliativas o mais precocemente possível. No entanto, existem diversas barreiras a essa identificação, nomeadamente a ausência de critérios perfeitamente claros 23,24 e a dificuldade de identificar o momento de referenciação. ...
... Analisando com base na tipologia de doença e em relação aos quais se obteve resposta a esta questão, ressalta que dos doentes oncológicos estavam referenciados 15,1% (IC95%: 8,3-22,0; n = 18), 4,6% (IC95%: 5,0-9,9; n = 23) dos não oncológicos e nenhum dos mistos (IC95%: 0,0-52,2). Estas dife- Quanto aos motivos para a não referenciação, apresentando apenas os cinco mais indicados como primeira escolha, e por ordem decrescente de fre-quência e tempo estimado de vida, temos, dos doentes com seis meses a um ano de tempo estimado de vida, ainda estar a fazer tratamento ativo (n = 66; 44,3%; IC95%: 36,0-52,6), ainda se poder fazer alguma coisa do ponto de vista curativo (n = 17; 11,4%; IC95%: 6,0- 16,9), ainda não estar a morrer (n = 15; 10,1%; IC95%: 4,[9][10][11][12][13][14][15]2), o doente estar controlado a nível sintomático (n = 8; 5,4%; IC95%: 1,4-9,3) e ainda se estar a aguardar novo ciclo de químio ou radioterapia para se avaliarem os resultados (n = 3; 2,0%; IC95%: 0, [4][5]8). Dos com um a seis meses de vida estimada, ainda estar a fazer tratamento ativo (n = 120; 58,8%; IC95%: 51, 8), o doente estar controlado a nível sintomático (n = 23; 11,3%; IC95%: 6,[7][8][9][10][11][12][13][14][15]9), ainda se poder fazer alguma coisa do ponto de vista curativo (n = 16; 7,8%; IC95%: 3, [9][10][11]8), os cuidados paliativos não serem uma mais-valia para o Ainda está a fazer tratamento ativo Ainda se poder fazer alguma coisa do ponto de vista curativo Doente controlado a nível sintomático Ainda não está a morrer Os cuidados paliativos não seriam uma mais-valia para este doente Família com recursos para outras alternativas Não haver resposta na Rede em termos de recursos Já se prestaram cuidados paliativos no serviço Aguarda-se novo ciclo de químio/radioterapia para serem avaliados Aguarda-se segunda opinião clínica Não se conhecer o processo de referenciação doente (n = 11; 5,4%; IC95%: 2,0-8,7) e por a família ter recursos para outras alternativas (n = 7; 3,4%; IC95%: 0,7-6,2). ...
... Estas dife- Quanto aos motivos para a não referenciação, apresentando apenas os cinco mais indicados como primeira escolha, e por ordem decrescente de fre-quência e tempo estimado de vida, temos, dos doentes com seis meses a um ano de tempo estimado de vida, ainda estar a fazer tratamento ativo (n = 66; 44,3%; IC95%: 36,0-52,6), ainda se poder fazer alguma coisa do ponto de vista curativo (n = 17; 11,4%; IC95%: 6,0- 16,9), ainda não estar a morrer (n = 15; 10,1%; IC95%: 4,[9][10][11][12][13][14][15]2), o doente estar controlado a nível sintomático (n = 8; 5,4%; IC95%: 1,4-9,3) e ainda se estar a aguardar novo ciclo de químio ou radioterapia para se avaliarem os resultados (n = 3; 2,0%; IC95%: 0, [4][5]8). Dos com um a seis meses de vida estimada, ainda estar a fazer tratamento ativo (n = 120; 58,8%; IC95%: 51, 8), o doente estar controlado a nível sintomático (n = 23; 11,3%; IC95%: 6,[7][8][9][10][11][12][13][14][15]9), ainda se poder fazer alguma coisa do ponto de vista curativo (n = 16; 7,8%; IC95%: 3, [9][10][11]8), os cuidados paliativos não serem uma mais-valia para o Ainda está a fazer tratamento ativo Ainda se poder fazer alguma coisa do ponto de vista curativo Doente controlado a nível sintomático Ainda não está a morrer Os cuidados paliativos não seriam uma mais-valia para este doente Família com recursos para outras alternativas Não haver resposta na Rede em termos de recursos Já se prestaram cuidados paliativos no serviço Aguarda-se novo ciclo de químio/radioterapia para serem avaliados Aguarda-se segunda opinião clínica Não se conhecer o processo de referenciação doente (n = 11; 5,4%; IC95%: 2,0-8,7) e por a família ter recursos para outras alternativas (n = 7; 3,4%; IC95%: 0,7-6,2). Dos com 15 dias a um mês de vida, ainda estar a fazer tratamento ativo (n = 36; 45,6%; IC95%: 34,0-57,2), ainda se poder fazer alguma coisa do ponto de vista curativo (n = 10; 12,7%; IC95%: 4,7-20,6) e ainda não estar a morrer (n = 6; 7,6%; IC95%: 1,1-14,1). ...
Introdução: A identificação e referenciação precoce dos doentes com necessidades paliativas é fundamental para que em tempo útil possam usufruir da efetividade da intervenção precoce de cuidados paliativos. Referenciar para cuidados Paliativos é um importante, crescente e complexo desafio e processo para a prática dos profissionais de saúde, nomeadamente para os médicos. A falta de informação e formação podem impedir a proatividade no processo de referenciação precoce. Atualmente, existem já alguns instrumentos multidimensionais que ajudam a identificar a população com necessidades paliativas. A pergunta surpresa, validada para Portugal, “Ficaria surpreendido se este doente morresse durante o próximo ano?” é uma ferramenta importante, útil e fiável para esta identificação. Objetivo: determinar a prevalência de doentes adultos com necessidades paliativas internados em hospitais públicos. Como objetivos secundários, determinar o número de doentes referenciados para cuidados paliativos e identificar os motivos de não referenciação destes doentes. Materiais e Métodos: Estudo analítico, observacional e transversal, realizado no primeiro trimestre de 2015 em 11 hospitais do SNS. O instrumento de colheita de dados consistiu num questionário com caracterização demográfica e clinica, a pergunta surpresa relativa a 1 ano, 6 e 1 mês e, 15 dias, e 19 possíveis motivos para não referenciação dos doentes. Os dados recolhidos forma analisados com recurso à estatística descritiva e analítica, considerando-se significância estatística se p
... Não se observaram outras diferenças. comum em pesquisas com doentes em cuidados paliativos (18)(19)(20)(21)(22), devido ao rápido declínio clínico que interfere no vigor do paciente. Mas, mesmo assim, o número final de doentes foi grande (n = 158) e suficiente para a comparação dos desfechos entre os grupos. ...
... Há estudos que avaliaram a evolução dos sintomas de pacientes em cuidados paliativos atendidos por equipe especializada e relataram melhora. No entanto, nesses estudos, o intervalo entre as avaliações foi longo (5 a 100 dias) (17) , o local utilizado era o ambulatório (17)(18) , não havia grupo-controle (17)(18)(19) , não havia critério de melhora clinicamente relevante e eram retrospectivos (18) . Essas características fragilizam o rigor das pesquisas e a força dos resultados. ...
... Há estudos que avaliaram a evolução dos sintomas de pacientes em cuidados paliativos atendidos por equipe especializada e relataram melhora. No entanto, nesses estudos, o intervalo entre as avaliações foi longo (5 a 100 dias) (17) , o local utilizado era o ambulatório (17)(18) , não havia grupo-controle (17)(18)(19) , não havia critério de melhora clinicamente relevante e eram retrospectivos (18) . Essas características fragilizam o rigor das pesquisas e a força dos resultados. ...
Objective:
To compare the relief of symptoms provided by palliative care consultation team (PCCT) compared to the traditional care team (TC), in patients with advanced cancer in the first 48 hours of hospitalization.
Method:
Allocated to PCCT Group and TC Group, this study assessed 290 patients according to the Edmonton Symptom Assessment System (ESAS) within the first 48 hours of hospitalization. The main outcome was a minimum 2-point reduction in symptom intensity.
Results:
At 48 hours, the PCCT Group had a 2-point reduction in the mean differences (p <0.001) in pain, nausea, dyspnea, and depression; and TC Group, on nausea and sleep impairment (p <0.001). Multiple Logistic Regression found for the PCCT Group a greater chance of pain relief (OR 2.34; CI 1.01-5.43; p = 0.049).
Conclusion:
There was superiority of the PCCT Group for pain relief, dyspnea and depression. There is a need for more studies that broaden the understanding of team modalities.
... Some studies investigated the use of corticosteroids in cancer patients. Thus, Nauck et al. (Yennurajalingam et al., 2011) conducted a large multicenter study in palliative care units. They found that corticosteroids were administered in 33% of patients, and also they found that younger patients were treated more often with corticosteroids (Nauck et al., 2004). ...
... In another study, it was reported that corticosteroids were administered in about 25% of patients in an outpatient clinic Yennurajalingam et al. (2011) and Gannon and McNamara (2002), found in their retrospective study that corticosteroids were prescribed in 51% of patients at the end of life, and it was continued until death in 53% of patients. ...
Despite significant advances in lung cancer treatment, patients with this disease still present with multiple symptoms that are very hard to control. Corticosteroids are widely used in patients with lung cancer, but without clear evidence for their efficacy. Thus, corticosteroids have been used for the treatment of conditions arising due to the tumor itself, adverse effects of the applied specific therapy and symptom palliation. In this review we are going to summarize clinical indications for corticosteroid use in patients with lung cancer: malignant airway obstruction, superior vena cava syndrome, brain metastases, treatment-related adverse events, anorexia and cachexia, fatigue, dyspnea, nausea and vomiting, spinal cord compression, and pain.
... diseases; however, now it is used widely from the initiation of the disease (Bakitas et al., 2009). Several studies have proven that PC could improve physical and psychosocial quality of life (QoL), quality of end-of-life care, treatment cost, and even life expectancy (Bakitas et al., 2009;Hui et al., 2014;Temel et al., 2010;Yennurajalingam, 2011). Palliative care could be given either in hospitals, communities, or in long-term care facilities such as home, homestay, and clinic (Kelley and Morrison, 2011). ...
... Health providers, together with patients and their families could decide about the goal of care (curative or palliative). Palliative intervention could improve patients' outcome, including, but not limited to, physical, psychosocial, patients' satisfaction, and even the quality of life (Hui et al., 2014;Temel et al., 2010;Yennurajalingam et al., 2011;Zimmermann et al., 2014). ...
Objective:
Over the past few years, an integrated approach of palliative care (PC) to chronic and/or life-threatening conditions care has been widely used. Home-based PC (HBPC) service is developed to meet the needs of patients at home; however, it has not been used widely. This study is aimed at determining the benefits of integrated HBPC for the quality of life (QoL) and symptoms intensity in Indonesian children with malignancies.
Method:
A randomized controlled trial was carried out to compare the quality of life between patients who were given PC (a three-month home visit) and those who did not receive PC (control group). Each group was constituted of thirty children with cancer and aged 2-18 years old and were consulted by a palliative team. The participants were randomly allocated to two groups. In the first and twelfth weeks of the intervention, all patients were assessed using the Pediatric Quality of Life Inventory (PedsQLTM) questionnaire cancer module 3.0 (report by proxy or self-report). Symptoms intensity (pain, anorexia, sleep disturbance) were scored by using Edmonton Symptoms Assessment Scale (ESAS). The mean score and each dimension score of both groups were compared and analyzed using bivariate analysis.
Results:
In total, fifty participants were included in the study. A significant difference was found between the two groups in terms of the mean total score in control group 62.39 and intervention group 81.63 (p<0.001). The QoL was improved in the intervention group, while it was declined in the control group as the disease progressed. The main improvements were in the pain and nausea aspects (p<0.001), followed by procedural anxiety (p=0.002), treatment anxiety (p=0.002), and worry (p=0.014). Palliative intervention significantly reduced sleep disturbances (p=0.003) and anorexia (p<0.001).
Conclusion:
Home-based PC improved several aspects of QoL and caused better symptom management in children with malignancies. An early intervention concurrent with the underlying treatment can improve QoL in these children.
... It aims to improve the quality of life of patients, their families and their caregivers". Several studies have shown positive clinical results in patients involved in PC programs: an improvement in the quality of life and mood [6,7], symptom control [8] and the reduction of emergency department visits and hospitalisations [9]. 2 of 11 Besides the clinical implications, the economic impact of PC programs has also been studied. In 2010, Simoens et al. [10] reviewed different studies trying to compare the cost of PC against standard care; the authors found that PC was consistently cheaper. ...
... Resource allocation to PC programs is a very relevant challenge because these programs present a list of clinical benefits to the patients but are often under-resourced [6][7][8][9]. If available, PC is usually provided to patients with a high symptom burden or in the terminal phase of illness. ...
Palliative care is an alternative to standard care for gravely ill patients that has demonstrated many clinical benefits in cost-effective interventions. It is expected to grow in demand soon, so it is necessary to detect those patients who may benefit from these programs using a personalised objective criterion at the correct time. Our goal was to develop a responsive and minimalist web application embedding a 1-year mortality explainable predictive model to assess palliative care at bedside consultation. A 1-year mortality predictive model has been trained. We ranked the input variables and evaluated models with an increasing number of variables. We selected the model with the seven most relevant variables. Finally, we created a responsive, minimalist and explainable app to support bedside decision making for older palliative care. The selected variables are age, medication, Charlson, Barthel, urea, RDW-SD and metastatic tumour. The predictive model achieved an AUC ROC of 0.83 [CI: 0.82, 0.84]. A Shapley value graph was used for explainability. The app allows identifying patients in need of palliative care using the bad prognosis criterion, which can be a useful, easy and quick tool to support healthcare professionals in obtaining a fast recommendation in order to allocate health resources efficiently.
... This study adds to the burgeoning literature describing the impact of programs that integrate oncologic and palliative care [4,5,15,[35][36][37][38][39]. In this study, it proved feasible to offer palliative care routinely to patients with metastatic colorectal cancer within 90 days of diagnosis or establishing care, with bolstered collaboration between oncology and palliative care teams. ...
... Given that symptom burden among our patients was modest, it is not surprising that a difference in the trend in symptoms over time could not be demonstrated. This is in contrast to other studies, including those from our clinical service, that have shown significant improvements in symptoms over time in more symptomatic patient populations [37]. In developing embedded palliative care programs when specialty palliative care is a limited resource, focusing on highly symptomatic or distressed patients or those with poor prognostic signs may maximize the impact of the program. ...
PurposePalliative care is recommended for patients with metastatic cancer, but there has been limited research about embedded palliative care for specific patient populations. We describe the impact of a pilot program that provided routine, early, integrated palliative care to patients with metastatic colorectal cancer.Methods
Mixed methods pre-post intervention cohort study at an academic cancer center. Thirty control then 30 intervention patients with metastatic colorectal cancer were surveyed at baseline and 1, 3, 6, 9, and 12 months thereafter about symptoms, quality-of-life, and likelihood of cure. We compared survey responses, trends over time, rates of advance care planning, and healthcare utilization between groups. Patients, family caregivers, and clinicians were interviewed.ResultsPatients in the intervention group were followed for an average of 6.5 months and had an average of 3.5 palliative care visits. At baseline, symptoms were mild (average 1.85/10) and 78.2% of patients reported good/excellent quality-of-life. Half (50.9%) believed they were likely to be cured of cancer. Over time, symptoms and quality-of-life metrics remained similar between groups, however intervention patients were more realistic about their likelihood of cure (p = 0.008). Intervention patients were more likely to have a surrogate documented (83.3% vs. 26.7%, p < 0.0001), an advance directive completed (63.3% vs. 13.3%, p < 0.0001), and non-full code status (43.3% vs. 16.7%, p < 0.03). All patients and family caregivers would recommend the program to others with cancer.Conclusions
We describe the impact of an embedded palliative care program for patients with metastatic colorectal cancer, which improved prognostic awareness and rates of advance care planning.
... 15 The negative effects of bed rest are well known which possibly induce a vicious cycle between inactivity and intensified fatigue. 16,17 Thus, recent research suggested a balance between activity and rest that could reduce fatigue particularly in the late stage of cancer. 18 Thus, nurses must be well trained and tailored to addressing populations' exercise tolerance and potential effects on fatigue management. ...
... [20][21][22] We recommend that effective and feasible interventions to improve fatigue in patients with late-stage cancer should be practiced in addition to five criteria: (1) practicing tailored to the patient. Nurses should build individualized programs according to the patient (such as current level of energy, tolerance, psychological functions, preferences, expectations, and motivation) and the advanced cancer (treatments and remaining lifetime); 5,9,17 (2) long-term intervention. The effects of fatigue alleviation would be transient unless the intervention is continued, especially cognitive behavior. ...
Objective
To evaluate the effectiveness of integrated nursing interventions for fatigue in patients with advanced cancer.
Methods
Medline, Pubmed, Embase, CINAHL, Web of Science, and the Cochrane Library were searched systematically till June 2017. A systematic review was conducted to collect randomized controlled trials (RCTs) reporting on the effect of nurse-driven interventions to improve fatigue in patients with advanced cancer. Quality assessment was conducted using the Cochrane Collaboration’s risk of bias tool.
Results
Six RCTs involving 736 adult participants were included. The fatigue intensity was improved significantly by nursing interventions. The analyzed results revealed significant improvements in the intervention group: less than 3 months (standard mean difference [SMD] = −0.33, 95% confidence interval [CI] [−0.48, −0.19], P < 0.01) and more than or equal to 3 months (SMD = −0.40, 95% CI [−0.57, −0.24], P < 0.01). Four studies with a moderate risk of bias were judged, and the remaining studies were at high risk of bias.
Conclusions
The results indicate that integrated nursing interventions may relieve fatigue in patients with advanced cancer. However, due to the high risk of bias in most of the included studies and the diversity of interventions, the results and implementation process should be carefully monitored.
... Palliative care consultation has been shown to decrease symptom intensity, especially in those with advanced cancer [15]. Earlier palliative care consultation has been shown to achieve superior pain control in multiple studies [16,17]. A meta-analysis of seven studies found significantly improved quality of life and decreased symptom intensity in patients with advanced cancer who received earlier palliative care consultations [14]. ...
Purpose
Unplanned readmissions have profound medical and financial implications for patients and hospitals. Cancer patients are particularly susceptible to readmission and often face complex care needs. This quality improvement project aimed to identify factors associated with avoidable hospitalizations among oncology patients.
Methods
Hospital discharges of adult cancer patients at Stony Brook University Hospital (June 2021–July 2022) were reviewed to identify unplanned 30-day readmissions. Readmissions were categorized as avoidable or unavoidable. Factors analyzed included patient demographics, cancer characteristics, social factors, outpatient follow-up, and palliative care involvement.
Results
Of the 468 hospitalized cancer patients, 96 (21%) were readmitted within 30 days of discharge. Most readmitted patients had stage IV disease (51%). Fifty-seven percent of patients were symptomatic on index admission compared to 100% on readmission. Pain was the most frequently reported symptom, increasing from 36 patients (38%) on index admission to 54 (56%) on readmission (p < 0.001). Notably, 16 patients (17%) were discharged on comfort-focused care and 11 (12%) died inpatient on readmission. Palliative care was consulted 2.3 times more frequently during readmission compared to index admission. Readmissions were determined to be avoidable for 27 patients (28%). A complaint of failure to thrive on readmission (p < 0.04), no identifiable post-discharge caretaker (p < 0.009), being symptomatic at index admission (p < 0.04), and not attending an outpatient visit prior to readmission (p < 0.05) were associated with avoidable readmissions.
Conclusion
Timely outpatient support and early palliative care involvement to manage symptoms and optimize care transitions are readily addressable measures that may reduce avoidable readmissions among advanced-stage cancer patients.
... 25 Other interventions that have been shown to improve multiple symptoms in the palliative care setting include music therapy, art therapy, exercise interventions and palliative care consultations. [35][36][37][38] Apart from these interventions, the practice of MBST by physicians during patient interactions has demonstrated a significant reduction in anxiety and depression levels, as well as a notable enhancement in overall quality of life in one randomised controlled study. 26 The study has several limitations. ...
Objectives
While single-session mindful breathing shows symptom reduction in palliative care, data on multi-session efficacy is lacking. This study aimed to determine the effectiveness of multi-session mindful breathing in reducing symptoms among patients with advanced cancer.
Methods
Adult patients with advanced cancer who scored ≥4 in at least two or more symptoms based on the Edmonton Symptom Assessment Scale (ESAS) were recruited from January to March 2020 at the University of Malaya Medical Centre, Malaysia. Participants were randomly assigned to receive either four daily sessions of 30 min mindful breathing and standard care (intervention) or standard care alone (control). The outcome measured was the change in the ESAS score after each session.
Results
80 patients were recruited and randomised equally into the intervention and control groups. The demographic and clinical characteristics between the two groups were not statistically different. For the intervention group, there were statistically significant reductions in the total ESAS scores following all four sessions of 30 min mindful breathing (n 1 =40: z 1 =−5.09, p<0.001; z 2 =−3.77, p<0.001; z 3 =−4.38, p<0.001; z 4 =−3.27, p<0.05). For the control group, statistically significant reductions in the total ESAS scores were seen only after sessions 1 and 3 (n 2 =40: z 1 =−4.04, p<0.001; z 3 =−4.53, p<0.001).
Conclusions
Our result provides evidence that four daily sessions of 30 min mindful breathing may be effective in reducing multiple symptoms rapidly in patients with advanced cancer.
Trial registration number
NCT05910541 .
... Total pain is the term associated with this condition, which is adequately taken into account in palliative care [10]. According to reports, up to 80% of cancer patients experience distress that lowers their quality of life (QoL) in terms of overall well-being [11]. Moreover, Fallon et al. noted that, among cancer patients with an advanced disease, pain was found to affect more than 70% of patients [9]. ...
Pain continues to be a significant problem for cancer patients, and the impact of a population-based strategy on their experiences is not completely understood. Our study aimed to determine the impact of palliative care on mitigating pain and its associated effects in determining the quality of life (QoL) among colon cancer outpatients. Six collection databases were used to perform a structured systematic review of the available literature, considering all papers published between the year 2000 and February 2023. PRISMA guidelines were adopted in our study, and a total of 9792 papers were evaluated. However, only 126 articles met the inclusion criteria. A precise diagnosis of disruptive colorectal cancer (CRC) pain disorders among patients under palliative care is necessary to mitigate it and its associated effects, enhance health, promote life expectancy, increase therapeutic responsiveness, and decrease comorbidity complications. Physical activities, the use of validated pain assessment tools, remote outpatient education and monitoring, chemotherapeutic pain reduction strategies, music and massage therapies, and bridging social isolation gaps are essential in enhancing QoL. We recommend and place a strong emphasis on the adoption of online training/or coaching programs and the integration of formal and informal palliative care systems for maximum QoL benefits among CRC outpatients.
... Pain relief was more prevalent in drowsy patients. Old age was associated with better health after 1-4 weeks of palliative care 27 . ...
Palliative care is critical to redundancy in cancer patients seeking to improve their quality of life. Evaluation should be incorporated into clinical practice routines at all stages of cancer. The Edmonton Symptom Assessment System (ESAS) was used to rate the intensity of ten symptom evaluations designed and validated for cancer patients in various languages and cultures. Therefore, the study aims to assess the symptoms reported using ESAS scores to identify patients who would benefit from palliative care that can improve the integration of palliative care into standard cancer care at An-Najah National University Hospital (NNUH). A cross-sectional study was selected for 271 cancer patients using a convenience sampling method at NNUH. Demographic, clinical, and lifestyle characteristics are described. Furthermore, patients' moderate to severe symptoms (score > 4) were obtained using ESAS-R. The survey consisted of 271 patients, with a response rate of 95%. The average age of the patients was 47 ± 17.7 years, ranging from 18 to 84 years. The male-to-female ratio was approximately 1:1, 59.4% of the patients were outpatients, and 153 (56.5%) had hematologic malignancies. Fatigue (62.7%) and drowsiness (61.6%) were the most common moderate to severe symptoms in ESAS. Furthermore, pain (54.6%), nausea (40.2%), lack of appetite (55.0%), shortness of breath (28.5%), depression (40.6%), anxiety (47.2%) and poor well-being (56.5%) were reported. In conclusion, fatigue and drowsiness were the most reported symptoms according to the ESAS scale among cancer patients, while moderate to severe symptoms were reported in cancer patients using the ESAS. The ESAS is a functional tool for assessing cancer patients' symptoms and establishing palliative care services.
... Nurses perform palliative care assessments, and physicians or advanced practice providers (APPs) then conduct a comprehensive visit to address all the domains of palliative care [27]. The Interdisciplinary Team (IDT) members are included as needed after the physician visit, followed by the conclusion and scheduling of a follow-up ap-pointment [28]. A similar workflow must be followed for telemedicine visits to ensure patients receive the same care level. ...
Simple Summary
Telemedicine has become a permanent platform for delivering palliative care. Our review highlights the best practices that palliative care teams can incorporate to provide high-quality, interdisciplinary virtual care to cancer patients.
Abstract
Cancer patients receiving palliative care may face significant challenges in attending outpatient appointments. Patients on controlled substances such as opioids require frequent visits and often rely on assistive devices and/or a caregiver to accompany them to these visits. In addition, pain, fatigue, and shortness of breath may magnify the challenges associated with in-person visits. The rapid adoption of telemedicine in response to the COVID-19 pandemic has proven to be highly beneficial for advanced cancer patients and caregivers. The hurried COVID-19-related implementation of telemedicine is now evolving into a permanent platform for providing palliative care. This review will focus on the best practices and recommendations to deliver high-quality, interdisciplinary tele-palliative care.
... There is a broad consensus that palliative care should be integrated in the treatment of patients with advanced tumours. [1][2][3][4] The background to these recommendations are studies showing positive effects of early integration of palliative care on patients quality of life and symptoms, [5][6][7][8] their treatment (less aggressive and costly oncological therapies at the end of life 9 ) and cost reductions. 10 11 However, recent reviews on the effects of integrating specialist palliative care (SPC) show positive but relatively small effects on quality of life 12 13 and symptoms. ...
Introduction
A range of referral criteria and scores have been developed in recent years to help with screening for the need of specialist palliative care (SPC) in advanced, incurable cancer patients. However, referral criteria have not yet been widely implemented in oncology, as they usually need to be revised by physicians or nurses with limited time resources. To develop an easily applicable screening for the need for SPC in incurable cancer inpatients, we aim to (a) test inter-rater reliability of multiprofessional expert opinion as reference standard for SPC need (phase I) and (b) explore the diagnostic validity of selected patient-reported outcome measures (PROMs) and routine data for the need of SPC (phase II).
Methods and analysis
Inclusion criteria for patients are metastatic or locally advanced, incurable cancer, ≥18 years of age and informed consent by patient or proxy. (Exclusion criteria: malignant haematological disease as main diagnosis). In phase I, three palliative care consultation teams (PCTs) of three German university hospitals assess the SPC need of 20 patient cases. Fleiss’ Kappa will be calculated for inter-rater reliability. In phase II, 208 patients are consecutively recruited in four inpatient oncology wards of Freiburg University Hospital. The PCT will provide assessment of SPC need. As potential referral criteria, patients complete PROMs and a selection of routine data on person, disease and treatment is documented. Logistic regression models and ROC analyses are employed to test their utility in screening for SPC need.
Ethics and dissemination
Our findings will be published in peer-reviewed journals and presented at national and international scientific meetings and congresses. Ethical approval was granted by the Ethics Committee of Albert-Ludwigs—University Freiburg, Germany (approval no. 20-1103).
Trial registration number
German Clinical Trials Register, DRKS00021686, registered on 17 December 2020.
... At least one quarter of patients reported relevant symptoms, either depression or anxiety. Besides, a lower proportion of patients complained of nausea and fatigue, while the prevalence from other published data is reported in up to 90% (Yennurajalingam et al., 2011). This difference may be explained by the focus on physical symptom control performed by the hospital staff during hospitalization, with clinical assessments from the medical team being performed at least twice daily, in addition to nurse evaluations every 6 h. ...
Objectives
The characterization of clinical–emotional aspects of advanced cancer patients is essential for palliative care. To date, there is scarce information regarding the socio-demographic and clinical profiles, as well as the quality of care given to hospitalized patients under this condition, particularly in South American countries. The objectives of this study were to analyze the socio-demographic profile, symptoms (including psychological well-being), and the quality of life of advanced cancer patients admitted to the oncology ward of the General Hospital of the University of Campinas, Brazil.
Methods
In this cross-sectional study, patients were invited to fill the selected questionnaires such as Edmonton Symptom Assessment Scale (ESAS) and Palliative Care Outcome Scale (POS). Descriptive analyses were performed, regarding socio-demographic profile, symptoms, level of information over treatment aims, and quality-of-life scores.
Results
Fifty-nine patients were included, of whom 29 were male and 30 female, with a mean age of 58 years. Overall, 31.9% presented pain at the time of the interview, 52.5% depression, and 76.3% anxiety. The median individual scores for ESAS and POS (and interquartile range) were, respectively, 27 (17–41) and 14 (9–19). Patients with previous knowledge of treatment objectives reported worse depression scores in the ESAS (median 2 vs. 0, p 0.02), even when correcting for possible confounders.
Significance of results
In contrast to current literature, in which pain is a prevalent report, depression and anxiety were more evident in this specific population of hospitalized patients. This framework reflects the need for valuing not only physical but also emotional symptoms to achieve the integrality of care.
... Corticosteroids are commonly prescribed in the setting of palliative care, with an estimated prevalence of around one-third to one-half of all patients in palliative care units [1][2][3][4]. Patients receiving corticosteroids in the palliative care setting, especially those with metastatic cancer, can have specific indications such as brain metastases, bone metastases, or spinal cord compression as well as non-specific indications such as fatigue, anorexia, or nausea [5][6][7][8][9][10]. The strength of evidence for each indication varies, but the specific cancer-related indications are better supported than the non-specific indications [11][12][13][14][15][16][17][18]. ...
Purpose
Dexamethasone is a commonly prescribed corticosteroid by both palliative care physicians and radiation oncologists for the treatment of metastatic cancer pain. However, clinical evidence for dexamethasone dose and efficacy is lacking, and prescribing between these different specialties may be influenced by other factors. This study investigates the dexamethasone prescriptions of palliative care physicians and radiation oncologists for cancer pain and their prescription rationales.
Methods
Palliative care physicians and radiation oncologists in British Columbia, Canada, were surveyed on their preferred dexamethasone prescription in response to 4 case vignettes of patients with metastatic cancer and asked to choose a rationale from a list of options which were then categorized as “habit-based,” “results-based,” or “evidence-based.” Response frequencies between the specialties were compared with odds ratios.
Results
The total daily dose and duration of dexamethasone prescriptions were similar between the specialties. Palliative care physicians were significantly more likely than radiation oncologists to prescribe a single daily dose of dexamethasone rather than a divided dose (OR 3.3 [95% CI 2.0–5.5]). This significant difference persisted when separately analyzing results at different total daily doses. Both specialties were more likely to select habit-based rationales rather than evidence-based rationales, with no significant difference between specialties.
Conclusion
These findings show that dexamethasone prescriptions are habit-based and that prescribing habits are different between palliative care physicians and radiation oncologists. Interventions based on these findings could potentially prevent unequal patient care. Further qualitative investigations of physician perceptions are indicated to better understand habit-based corticosteroid prescribing patterns.
... Denton et al. found that that 65% (n=1174) of the patients receiving palliative care in New Zealand receive at least one course of corticosteroid treatment [10]. In a study of 403 patients receiving ambulatory palliative care, our team found changes in corticosteroid prescription occurred in more than 23% of the patients [11]. ...
Opinion statement
Patients with advanced cancer in the last 6 months of their lives have a higher frequency of distressing and debilitating physical and psychosocial symptoms such as cancer pain, cancer-related fatigue (CRF), anorexia, shortness of breath, poor sleep, anxiety, and depression. Often these symptoms significantly impact the patients’ quality of life, and therefore require prompt assessment and effective treatment. There are specific treatments for certain distressing cancer-related symptoms (e.g., opioids for pain), but for the other symptoms such as CRF, anorexia-cachexia, and shortness of breath, there are limited or no evidence-based treatments. Also, in the management of cancer pain in this population, many patients are refractory to opioids. Hence, corticosteroids are one of the most common adjuvant medications prescribed for the management of this distressing symptom. However, there is limited evidence in regard to the effectiveness of corticosteroids in the improvement of the symptoms, side-effect profile, most optimal duration of use, dose, type of steroid, and most recently, the use with immunotherapy in advanced cancer patients at the end of life. These factors significantly limit the use of this important medication in terminally ill cancer patients. Further research is therefore critical to provide the optimal prescription of corticosteroids in this highly distressed population.
... Pretreatment of the cancer patient with antidepressants reduces depression symptoms induced by Interferon Alfa. And other nonpharmacological psychosocial interventions can be applied to reduce depressive symptoms in cancer patients as relaxation techniques, individual and group psychotherapies (Bottino, Fráguas, & Gattaz, 2009), additionally palliative care counseling (Yennurajalingam et al., 2011). ...
Background
Depression enhances disease burden in cancer patients, psychological interventions and rehabilitation of depression are required as a part of palliative care for cancer patients to improve the quality of life and mental health
The aim of the study to review the literature about depression treatments and rehabilitation interventions among cancer patients in Palestine
Method: Review articles used electronic databases PubMed, Science Direct, Research Gate and Google Scholar to search for materials for the literature review study.
Results: twenty three articles reviewed five of them from Arab and Islamic countries, and five articles from Palestine. Overall depression rehabilitation interventions for cancer patients are defined on two themes includes pharmacological interventions, and non-pharmacological interventions used that reduce depression symptoms and improve mental health among cancer patients. Depression rehabilitation interventions among cancer patients in Palestine are limited to palliative care perspective includes psychosocial support, cancer patient symptoms management, and family education.
Conclusion: Depression symptoms treatments and rehabilitation interventions in Palestine are limited to non-pharmacological interventions from the perspective of palliative care for cancer patients including psychosocial interventions, besides cancer patient’s symptoms management affects mental health positively and depression recovery. Palliative care including depression symptoms rehabilitations in Palestine needs improvement. Israeli occupation is the main cause of limited rehabilitation and treatment interventions for Palestinian cancer patients.
... Given that tobacco, alcohol and obesity contribute to the incidence of SPM, drinking and smoking cessation, and keeping fit could prevent the incidence to some extent 18 . Moreover, some of the oldest old have contraindications to aggressive curative therapy, so palliative care should be considered in such patients 22,23 . This study had some limitations. ...
The cancer burden in the oldest old has increased rapidly. This study aimed to investigate the epidemiology of second primary malignancy (SPM) in malignant solid tumor survivors aged 85 years and older utilizing the Surveillance, Epidemiology, and End Results (SEER) database. A total of 128,466 malignant solid tumor patients had been identified between 2000 and 2011, including 6774 patients who developed a SPM. The overall crude incidence of developing a SPM was 5.3%. Considering death as a competing event, the 3, 5, and 10-year cumulative incidence was 1.9%, 3.2%, and 5.4%, respectively. Relative younger age, male gender, surgery history, local stage and first primary malignancy (FPM) site located in the urinary system were related to higher cumulative incidence. A median time interval of 24.0 months was found between diagnosis of FPM and SPM. The most common SPM site was digestive system, whereas the least common was oral cavity and pharynx. The median overall survival (OS) was 49.0 months, and the median survival after SPM was 13.0 months. Relative older age, male gender and black race were associated with worse OS and survival after SPM, as well as higher hazard ratios of death. In conclusions, this study performed a comprehensive analysis of SPM among malignant solid tumor survivors aged 85 years and older. Additional studies are needed to characterize the specific cancer type of interest.
... Accordingly, management of these symptoms and psychological distress is considered a core feature of nursing practice in oncology. Despite the fact that patient satisfaction is generally high in outpatient cancer [5][6][7][8], onethird of patients report that healthcare professionals are not doing everything in their power to optimize symptoms management and emotional support during chemotherapy [9]. On the other hand, attending to the individual patients needs can be a challenge in time-constrained oncology units [10,11]. ...
Purpose
This pilot-controlled trial aimed to examine the feasibility and acceptability of hypnosis-derived communication (HC) administered by trained nurses during outpatient chemotherapy to optimize symptom management and emotional support — two important aspects of patient well-being in oncology.
Methods
The trial was conducted in two outpatient oncology units: (1) intervention site (usual care with HC), and (2) control site (usual care). Nurses at the intervention site were invited to take part in an 8-h training in HC. Participants’ self-ratings of symptoms and emotional support were gathered at predetermined time points during three consecutive outpatient visits using the Edmonton Symptom Assessment Scale and the Emotional Support Scale.
Results
Forty-nine patients (24 in the intervention group, 25 in the control group) with different cancer types/stages were recruited over a period of 3 weeks and completed the study. All nurses ( N = 10) at the intervention site volunteered to complete the training and were able to include HC into their chemotherapy protocols (about ± 5 min/intervention). Compared to usual care, patients exposed to HC showed a significant reduction in physical symptoms during chemotherapy. In contrast, perception of emotional support did not show any significant effect of the intervention. Participants exposed to HC report that the intervention helped them relax and connect on a more personal level with the nurse during chemotherapy infusion.
Conclusions
Our results suggest that HC is feasible, acceptable, and beneficial for symptom management during outpatient chemotherapy. While future studies are needed, hypnosis techniques could facilitate meaningful contacts between cancer patients and clinicians in oncology.
Trial registration
Clinical Trial Identifier: NCT04173195, first posted on November 19, 2019
... Cancer-related fatigue (CRF) is a frequent and serious consequence of cancer and cancer-related treatment [1,2]. The frequency of CRF varies from 60 to 90% [3,4]. ...
Purpose
Cancer-related fatigue (CRF) is the most frequent and debilitating symptom in patients with advanced cancer. There are limited effective treatments for CRF. The objective of this prospective longitudinal study was to evaluate the change in CRF at Day 43 after treatment with combination therapy of oral Anamorelin 100 mg daily with physical activity and nutrition counseling.
Methods
In this study, patients with CRF [≤ 34 Functional Assessment of Chronic Illness Therapy-Fatigue subscales(FACIT-F)] received Anamorelin 100 mg orally daily with standardized physical activity and nutrition counseling for 43 days. Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Anorexia Cachexia(FAACT-ACS), Multidimensional Fatigue Symptom Inventory-Short Form(MFSI-SF), Patient-Reported Outcomes Measurement Information System(PROMIS-Fatigue), body composition, and physical performance tests were assessed at baseline, Day 15, 29, and 43. Frequency and type of side effects were determined by NCI CTAE 4.0.(NCT03035409).
Results
28/45 (62%) of patients dosed were evaluable at Day 43. The mean, SD for FACIT-F subscale improvement from baseline was 4.89 (± 13.07), P = .058, MFSI-SF (G) − 3.46 (± 6.86), P = 0.013, PROMIS-fatigue − 4.14 (± 7.88), P = 0.010, FAACT ACS 3.48 (± 8.13), P = 0.035. Godin Liesure-Time physical activity questionnaire 7.41 (± 16.50), P = 0.038. Weight (kg) 1.81 (± 2.63), P = 0.005, and Lean Body Mass 1.54 (± 1.85), P = 0.001, IGF-1 36.50 (± 48.76), P = 0.015. There was no significant improvement in physical performance outcomes. No adverse events > grade 3 related to the study drug were reported.
Conclusion
The use of the combination therapy was associated with improvement of CRF (FACIT-F fatigue, PROMIS-fatigue, MFSI-SF-general), activity (Godin-leisure time), anorexia (FAACT), body composition, and IGF-1 levels. Further studies using combination therapy for CRF are justified.
... [2][3][4][5][6] In addition, we only identified few studies assessing the association between changes in symptomatology and patient characteristics. [7][8][9] Chile has a population of 17.5 million inhabitants and has 52 hospital-based palliative care services/units in tertiary hospitals of the public healthcare system. 10 Palliative care in the tertiary sector is provided by physicians (oncologists, internists or surgeons) and non-physicians such as nurses, paramedics and psychologists. ...
Objectives
This study aimed to examine the symptomatology of patients with advanced cancer at admittance to palliative care services and to investigate how the symptomatology changed during the first month, and whether these changes were associated with various patient characteristics.
Methods
In a longitudinal study in Chile, outpatients with advanced cancer completed the questionnaires European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care and the Hospital Anxiety and Depression Scale. Prevalence and severity of symptoms and problems (S/Ps) at baseline were calculated. Differences in S/P scores from baseline to follow-up were calculated overall and according to patient characteristics. Multiple linear regression was used to study the associations between patient characteristics and changes in S/P scores.
Results
At baseline, 201 patients answered the questionnaires and 177 completed the follow-up. Fatigue, pain and sleeping difficulties were the most prevalent S/Ps reported, and also had the highest mean scores at baseline. S/P scores at baseline varied significantly according to sex, age, civil status, residence, children, prior and current antineoplastic treatment. Emotional functioning, pain, sleeping difficulties, constipation and anxiety improved significantly during the first month of palliative care. Residence, cohabitation status, diagnosis and current antineoplastic treatment were associated with changes in S/P scores.
Conclusions
Patients reported moderate-to-severe levels of S/Ps at admittance to palliative care. Several S/Ps improved the first month. Certain patient characteristics were associated with changes in S/P scores. This information may guide clinicians to more effective interventions that can improve the quality of life of patients receiving palliative care.
... Weitere Studien und Reviews bestätigten den Wert der frühen palliativmedizinischen Mitbetreuung (Higginson & Evans, 2010;T. J. Smith et al., 2012;Yennurajalingam et al., 2011;Zimmermann, Riechelmann, Krzyzanowska, Rodin & Tannock, 2008 (Chochinov, Tataryn, Wilson, Ennis & Lander, 2000;Mack et al., 2012). ...
Uns interessierten die Symptome und Belastungen der radioonkologischen Patienten bei Erstvorstellung in der Strahlenklinik sowie die Übereinstimmung des Therapieziels des Patienten mit dem ärztlich dokumentierten Therapieziel. Insbesondere die Unterschiede zwischen palliativen und kurativen Patienten sollten eruiert werden. Auch ein möglicher Zusammenhang zwischen dem Bestrahlungsverlauf und der Symptomintensität der Patienten wurde thematisiert. Des Weiteren sollte untersucht werden, welche Faktoren mit Symptomen und Belastungen assoziiert sind. Dazu wurde in der Klinik und Poliklinik der Strahlentherapie ein routinemäßig verteilter Selbsteinschätzungsbogen retrospektiv ausgewertet. Dieser enthielt neben einer an die Bedürfnisse der Strahlenmedizin adaptierten Version der Integrated Palliative care Outcome Scale (aIPOS) und dem Distress-Thermometer (DT) auch die Frage nach dem Therapieziel aus Patientensicht.
... It is recommended that it be incorporated early in the disease trajectory, even in conjunction with potentially curative treatments [1]. PC can improve quality of life [2], mood [3], symptom control [4], reduce emergency department visits and hospitalisation [5], and even increase the one-year survival [6] PC services have traditionally been mainly accessed by cancer patients but there is growing consensus about the importance of promoting access for patients with non-malignant disease at earlier stages [7,8,9]. In the same line, Raudonis et al. [10] suggest in their study that frail older adults could benefit from involvement in PC programs. ...
Introduction
Palliative care (PC) has demonstrated benefits for life-limiting illnesses. Nowadays, there is a growing consensus about giving access these care services to non-cancer older patients. Bad survival prognosis and patients’ decline are working criterions to guide PC decision making.
Objective
The main aim of this work is to propose complementary models based on machine learning approaches to predict frailty and mortality in older patients in the context of supporting PC decision making.
Methods
The dataset used in this study is composed by 39,310 hospital admissions for 19,753 older patients (age >= 65) from January 1st, 2011 to December 30th, 2018. Predictive models based on Gradient Boosting Machines and Deep Neural Networks were implemented for binary one-year mortality classification, survival estimation and binary one-year frailty classification. Besides, we tested the similarity between mortality and frailty distributions.
Results
The one-year mortality classifier achieved an AUC ROC of 0.87 [0.86, 0.87]; whereas the mortality regression model achieved an MAE of 333.13 [323.10, 342.49] days. Moreover, the one-year frailty classifier obtained an AUC ROC of 0.89 [0.88, 0.90].
Conclusions
The performance of our one-year mortality model is competitive with the current state-of-the-art. Besides, to our knowledge, this is the first study predicting one-year frailty status based on a frailty index. We found mortality and frailty criteria are weakly correlated and have different distributions; therefore, we interpreted them as complementary assessment measurements for palliative care decision making. Predictive models are accessible as an online tool at http://demoiapc.upv.es . The models presented here may be part of decision support systems for care services in non-cancer older patients after their external validation.
... [28] Yennurajalingam et al also have reported that the palliative consultation could achieve significant symptom improvement in advanced cancer patients. [29] Furthermore, the clinical pharmacist-led guidance teams have been established in China, showing efficiency and efficacy for cancer pain management. [30] However, a randomized controlled trial failed to demonstrate the beneficial effect of hospital-based palliative care on the improvement of physical symptoms and QOL in cancer patients, when compared with limited telephone advice. ...
To investigate the effect of multidisciplinary interventions on pain management in cancer inpatients.
Four hundred thirty eight patients with cancer pain, who performed the multidisciplinary intervention were recruited. Before and after intervention, the Brief Pain Inventory (BPI) and the MD Anderson Symptom Inventory (MDASI) score as the primary endpoints and QOL scores as the secondary endpoint were all evaluated. To investigate the factors that led to different responses to multidisciplinary interventions, patients were classified as non-responders or responders.
Finally, 92 patients (63 male and 29 female) scheduled for cancer pain management by inter-professional team were studied. After individualized multidisciplinary therapy, both pain and symptom severity was improved, as demonstrated by lowered BPI worst and average pain scores, as well as symptom severity score measured by MDASI (P = .017, P = .003, and P = .011, respectively). The proportion of patients with mild pain increased regarding the BPI worst and average pain at baseline and after treatment (P < .05). The QOL analyses showed multidisciplinary interventions could significantly improve the function and symptom scores (P < .001). More patients in responder group received chemotherapy (58, 70.7%, P = .003), while fewer received mini-invasive therapy (6, 7.32%, P = .011).
Multidisciplinary interventions had certain beneficial effect on cancer pain management, especially in patients with moderate or severe pain.
... The aim of palliative care (PC) is to improve the quality of life of patients and their families faced with advanced-stage life-threatening diseases [1]. Such interventions have proven effective in this regard [2,3] and, moreover, reduce the symptom burden [2,4]. PC is associated with improved care planning [2], greater patient and caregiver satisfaction with the care provided and lower levels of healthcare uptake [2,5,6]. ...
The current treatment approach for patients in palliative care (PC) requires a health model based on shared and individualised care, according to the degree of complexity encountered. The aims of this study were to describe the levels of complexity that may be present, to determine their most prevalent elements and to identify factors that may be related to palliative complexity in advanced-stage cancer patients. An observational retrospective study was performed of patients attended to at the Cudeca Hospice. Socio-demographic and clinical data were compiled, together with information on the patients’ functional and performance status (according to the Palliative Performance Scale (PPS)). The level of complexity was determined by the Diagnostic Instrument of Complexity in Palliative Care (IDC-Pal©) and classified as highly complex, complex or non-complex. The impact of the independent variables on PC complexity was assessed by multinomial logistic regression analysis. Of the 501 patients studied, 44.8% presented a situation classed as highly complex and another 44% were considered complex. The highly complex items most frequently observed were the absence or insufficiency of family support and/or caregivers (24.3%) and the presence of difficult-to-control symptoms (17.3%). The complex item most frequently observed was an abrupt change in the level of functional autonomy (47.6%). The main factor related to the presence of high vs. non-complexity was that of performance status (odds ratio (OR) = 10.68, 95% confidence interval (CI) = 2.81–40.52, for PPS values < 40%). However, age was inversely related to high complexity. This study confirms the high level of complexity present in patients referred to a PC centre. Determining the factors related to this complexity could help physicians identify situations calling for timely referral for specialised PC, such as a low PPS score.
Background
Ambulatory palliative care clinics are associated with improved outcomes in cancer patients, including short-term quality of life. However, their impact on individual patient-reported symptoms is not well understood.
Aim
We evaluated the impact of ambulatory palliative care on individual symptoms in adult cancer patients.
Design
Following a standard protocol (PROSPERO: CRD42022321909), investigators independently identified randomised and non-randomised intervention studies that assessed patient-reported symptom scores using validated symptom assessment scales longitudinally. Data were synthesised using random-effects meta-analyses.
Data sources
Database of PubMed, CINAHL, EMBASE, PsycINFO and Cochrane Central was searched from inception to September 2023 for eligible studies.
Results
20 studies encompassing 4 prospective cohort studies, 1 randomised control trial and 15 retrospective studies were included. Most studies focused on cohorts with advanced cancers of mixed primary tumour type, were colocated within or linked to a tertiary cancer centre and assessed symptoms using the Edmonton Symptom Assessment Scale (ESAS). The meta-analyses confirmed evidence for improvement in pain (standardised mean difference (SMD) 0.31, 95% CI 0.18 to 0.44), anxiety (SMD 0.31, 95% CI 0.12 to 0.49), fatigue (SMD 0.31, 95% CI 0.10 to 0.51), insomnia (SMD 0.29, 95% CI 0.15 to 0.42), depression (SMD 0.25, 95% CI 0.09 to 0.40), drowsiness (SMD 0.23, 95% CI 0.11 to 0.34), well-being (SMD 0.28, 95% CI 0.12 to 0.45) and overall symptom burden (SMD 0.29, 95% CI 0.22 to 0.36). There was no evidence for improvement in nausea (SMD 0.19, 95% CI −0.02 to 0.40), dyspnoea (SMD 0.16, 95% CI 0.02 to 0.29) and appetite scores (SMD 0.14, 95% CI −0.00 to 0.29).
Conclusions
Ambulatory palliative care had positive effects on multiple common symptoms. The strength of this evidence however is low, largely due to the considerable heterogeneity among included studies. Further research could determine thresholds on symptom assessment scales to guide urgency of referral, timing of follow-up and optimal multidisciplinary staff involvement.
Background: Patients with advanced cancer frequently have a wide range of mental and physical symptoms, making it difficult for them to communicate and make informed decisions. Necessitating the incorporation of palliative care in this population to meet their supportive care requirements. Objective: To investigate the effects of integrating Palliative care in advanced cancer patients. Methods: PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases were comprehensively and systematically searched for Randomized clinical trials (RCTs) published up to February 2024. According to the PICOS criteria, trials enrolling adult patients with advanced cancer subjected to PC were included. Moreover, a risk of bias assessment was performed using the Cochrane Risk of Bias tool, and statistical analyses were performed using the Review Manager software. Results: Only 13 RCTs with 3,294 advanced cancer patients were included in the final analysis. A pooled analysis of data from these trials revealed that patients subjected to PC had improved quality of life (QoL) scores than those receiving standard care (SMD: 0.18; 95% CI: 0.07 – 0.30; p = 0.002). However, no significant difference was observed in depression (SMD: -0.03; 95% CI: -0.16 – 0.10; p = 0.63), anxiety (SMD: - 0.04; 95% CI: -0.23 – 0.15; p = 0.69), and survival (OR: 0.81; 95% CI: 0.56 – 1.16; p = 0.25). Conclusion: Integrating PC in patients with advanced cancer results in improved QoL with limited effect on psychological distress symptoms.
Objectives
Identifying stable co-occurring symptoms in breast cancer (BC) patients during chemotherapy can improve symptom management and the treatment process. This study examines symptom cluster stability in Iranian BC patients receiving chemotherapy and evaluates stability across three-time points within each cluster.
Methods
This study collected data from three-time points: initial chemotherapy commencement, 2½ months postdiagnosis, and 5 months postdiagnosis. The research used exploratory factor analysis (EFA) in combination with hierarchical cluster analysis (HCA) and K means clustering to address research questions.
Results
In the initial clustering step, EFA identified five clusters with high consistency across three-time points. The first cluster showed depression, anxiety and irritability, while the second cluster was characterised by sexual interest and pain. The third cluster was associated with diarrhoea and vomiting. In the second step, we obtained the HCA item output and two clusters of K means clustering that recorded depression and anxiety symptoms over time. Vomiting, dry mouth, sexual interest, worrying and numbness were observed during the first and second points, but the frequency has decreased since then.
Conclusions
Cancer’s psychological and physiological symptoms, including depression, anxiety, digestive and hormonal issues, remain stable throughout the disease. Palliative care centres can improve patients’ quality of life and treatment process by addressing persistent symptoms.
Palliative care (PC) has demonstrated benefits for life-limiting illnesses. Bad survival prognosis and patients' decline are working criteria to guide PC decision-making for older patients. Still, there is not a clear consensus on when to initiate early PC. This work aims to propose machine learning approaches to predict frailty and mortality in older patients in supporting PC decision-making. Predictive models based on Gradient Boosting Machines (GBM) and Deep Neural Networks (DNN) were implemented for binary 1-year mortality classification, survival estimation and 1-year frailty classification. Besides, we tested the similarity between mortality and frailty distributions. The 1-year mortality classifier achieved an Area Under the Curve Receiver Operating Characteristic (AUC ROC) of 0.87 [0.86, 0.87], whereas the mortality regression model achieved an mean absolute error (MAE) of 333.13 [323.10, 342.49] days. Moreover, the 1-year frailty classifier obtained an AUC ROC of 0.89 [0.88, 0.90]. Mortality and frailty criteria were weakly correlated and had different distributions, which can be interpreted as these assessment measurements are complementary for PC decision-making. This study provides new models that can be part of decision-making systems for PC services in older patients after their external validation.
This review aimed to critically evaluate the impact of pharmacist involvement in managing pain in cancer patients. Databases (including MEDLINE, Embase and CENTRAL) were searched with a broad search strategy for studies involving pharmacists and cancer pain management until February 10, 2021. The quality of studies and evidence were assessed using standardized tools and GRADE, respectively. A random-effects model was used for meta-analysis. Sixty-four studies were included. Common interventions delivered by the pharmacists were medication review, patient education, adverse drug reactions (ADRs) detection and management, pharmacological recommendations (in dosing and pharmacotherapy choice), and pain assessment. A pooled analysis of 3 randomized control trials showed a significant reduction in pain intensity with a standardized mean difference (SMD) of 0.35 [95% confidence intervals (CI): -0.55, -0.16]. Pooled analyses from nonrandomized studies of interventions also showed significant results in reduction of ADRs with an odds ratio of 0.69 (95% CI: 0.61, 0.79) and improvement in quality of life with SMD of 0.80 (95% CI: 0.29, 1.32). Thus, pharmacists significantly improve the clinical outcomes of cancer patients related to pain. This indicates the involvement of pharmacists directly or in collaboration with healthcare professionals in the oncology team is highly beneficial for the patients.
Perspectives
This systematic review presents a comprehensive evaluation of pharmacist involvement in cancer pain management. This shows the importance of direct involvement of the pharmacist or as an important member of the multidisciplinary oncology team.
Background
Patients with metastatic hepatocellular carcinoma (HCC) suffer symptoms of both end-stage liver disease and cancer. Palliative care (PC) enhances the quality of life via symptom control and even improves survival for some cancers. Our study characterized rates of PC utilization among metastatic HCC patients and determined factors associated with PC receipt.
Methods
We conducted a retrospective review of adult National Cancer Database patients diagnosed with metastatic HCC between 2004 and 2016. Chi-square tests were used to analyze two cohorts: those who received PC and those who did not. Logistic regression was performed to assess the impact of clinicodemographic factors on the likelihood of receiving PC.
Results
PC utilization was low at just 17%. Later year of diagnosis, insured status, and higher education level were associated with an increased likelihood of receiving PC. Treatment at academic centers or integrated network cancer programs increased the likelihood of receiving PC compared to treatment at a community center (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.03–1.33 and OR = 1.25, 95% CI = 1.07–1.45; respectively). Hispanics were significantly less likely to received PC than non-Hispanic Whites (OR = 0.73, 95% CI = 0.64–0.82).
Conclusions
PC utilization among patients with metastatic HCC remains low. Targeted efforts should be enacted to increase the delivery of PC in this group.
Fatigue is the most commonly reported symptom in survivors of hematopoietic stem cell transplantation (HSCT), and even in very long‐term survivors, fatigue levels remain elevated compared with the general population. Fatigue may be accompanied by a variety of features including generalized weakness, diminished mental concentration, insomnia or hypersomnia, and emotional reactivity. This chapter summarizes evidence for the effectiveness of pharmacologic interventions in improving fatigue outcomes in non‐HSCT populations. There is an expanding body of evidence supporting the efficacy of complementary and integrative therapies in the management of fatigue in cancer survivors, and evidence is emerging that these strategies may be effective in managing fatigue survivors of HSCT. A wide range of pharmacologic and nonpharmacologic interventions have been studied, though a majority have only been tested in uncontrolled or pilot studies with small samples, and few have been studied exclusively in HSCT survivor populations.
Background:
COVID-19 pandemic necessitated rapid adoption of telemedicine at our supportive care center (SCC) to ensure continuity of care while maintaining social distancing.
Objective:
To document the process of transition from in-person to virtual care.
Design:
The charts of 1744 consecutive patients in our SCC located in the United States were retrospectively reviewed during the four weeks before transition (February 14-March 12), four weeks after transition (March 20-April 16), and transition week (March 13-March 19). Patient demographics, vital aspects of a supportive care visit such as assessments (Edmonton Symptom Assessment Scale-Financial and Spiritual [ESAS-FS], Cut-down, Annoyed, Guilty, Eye-opener Screen-Adapted to Include Drugs [CAGE-AID], and Memorial Delirium Assessment Scale [MDAS]), interdisciplinary team involvement, and visit type were recorded.
Results:
In total 763 patients were seen before transition, 168 during the transition week, and 813 after transitioning to virtual care. Patient characteristics, ESAS-FS, CAGE-AID, and nurse assessment did not significantly differ among the three groups. The after-transition group had a small reduction in counseling intervention compared with before (20.2% vs. 26.2%; p = 0.0068). MDAS completion was higher after transition (99.6% vs. 98%; p = 0.007). In-person visits decreased from 100% before to 12.7% after transition (p < 0.0001) and virtual visits increased to 49.3% (video) and 38% (telephone). In-person visits decreased to 49% in the week one, 3% in week two, and <2% in week four after transition (p < 0.0001).
Conclusions:
Our supportive care team transitioned from in-person care to virtual visits within weeks while maintaining a high patient volume, continuity of care, and adherence to social distancing. Our transition can serve as a model for other centers.
Background
Metastatic foregut cancers (MFC) are associated with debilitating symptoms that negatively impact patients’ quality of life. Palliative care (PC) is effective in mitigating disease-, psychosocial-, and treatment-related effects and may improve survival in select cases. Our study characterizes PC utilization rates in MFC and identifies factors associated with PC receipt.Methods
We conducted a retrospective review of 228,027 National Cancer Database patients diagnosed with MFC between 2004 and 2016. Chi-squared tests were used to analyze differences between groups receiving and not receiving PC. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC.ResultsOverall PC utilization was low (17.8%). A greater proportion of patients not receiving PC were in the lowest median income quartile of < $38,000/year versus those receiving PC (18.1% vs 17.8%, p < 0.0001). Higher education was associated with increased likelihood of receiving PC (OR 1.23 for communities with < 6.3% no high school degree vs ≥ 17.6%, p < 0.0001). Hispanics were significantly less likely to receive PC compared to Whites (OR 0.72, 95% CI 0.68–0.76). Patients treated at academic centers were also more likely to receive PC compared to those treated in the community (OR 1.10, 95% CI 1.05–1.14).ConclusionsPC is a key component in improving quality of life among MFC patients. Despite slight increases in PC rates over time, PC remains drastically underutilized. Significant racial and socioeconomic disparities in patterns of PC delivery exist. Further studies are needed to understand these disparities in order to identify key targets for interventions aimed at improving equity.
People with severe psychiatric illnesses and an additional oncological illness represent great challenges to therapists in the palliative setting. Behavior patterns often appear incomprehensible or disconcerting. Depressive withdrawal or delusion in the context of a chronic psychosis can be frightening. This article outlines the epidemiological data as well as the particularities in the experience of this group of people. Following selected case studies from a psychological perspective, thoughts on the tasks of the psychiatrist in the palliative setting are presented.
Background: In these last few years, an integrated approach between palliative care (PC) and chronic and/or life-threatening conditions care have been widely used. Home-based PC service is developed to meet the needs of the patients at home, but hasn’t been applied widely. This study is aimed to determine the benefit of integrated home-based PC in the quality of life (QOL) and symtomps intensity of Indonesian children with malignancies.
Method: A randomized controlled trial to compare the quality of life between patients who were given PC (a 3-month home visit) and those who were not (intervention vs control group) was conducted, each group containing 30 children with cancer aged 2-18 years old who were consulted to palliative team. Participants were randomly assigned into each group. In the first and twelfth week of the intervention, all patients were assessed with the Pediatric Quality of Life Inventory (PedsQLTM) questionnaire cancer module 3.0 (report by proxy or self-report). Symptoms intensity (pain, anorexia, sleep disturbance) were scored by using Edmonton Symptoms Assessment Scale (ESAS). Mean score and each dimension score of both group were compared and analyzed using bivariate analysis.
Results: A total 50 participants were included in analysis. Significant difference was found between two groups with average total score in control group 62.39 and intervention group 81.63 (p<0.001). In the intervention group QoL tends to improve, whereas in the control group, those did not get palliative intervention, quality of life tends to decrease as the disease progress. The most improved aspect in QoL is pain and nausea (p<0.001), followed by procedural anxiety (p=0.002), treatment anxiety (p=0.002), and worry (p=0.014). Palliative intervention was found to be able to reduce sleep disturbances (p=0.003) and anorexia (p<0.001) significantly.
Conclusion: Home-based PC improved several aspects of the QOL and provide better symptoms management of children with malignancies. An early intervention concurrent with the underlying treatment is believed to be able to improve their quality of life.
Trial Registration: This study has been retrospectively registered in ClinicalTrials.gov ID: NCT04067687 (August, 22nd 2019).
In addressing end-of-life care in veterinary medicine, the role of the veterinary technician can have a profound impact on quality of life during the final days in a pet's life. The role of the veterinary technician in end-of-life care is multifaceted, as duties range from nursing care to social and emotional support for pet caregivers. Human hospice care is helpful as a a model to better understand the importance of palliative care in animals. The skills of the veterinary technician are well suited for caring for hospice and palliative care patients. This article demonstrates and reviews how a technician's expertise is used in end-of-life care including assistance in the euthanasia process.
Introduction
The primary function of palliative care is to improve quality of life. The recognition and treatment of symptoms causing suffering is central to the achievement of this goal. Insomnia reduces quality of life of patients under palliative care. Knowledge about prevalence, associated factors, and treatment of insomnia in palliative care is scarce.
Methodology
Literature review about the prevalence, predictors, and treatment options of insomnia in palliative care patients. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in identified articles and selected reviews. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.
Results
A total of 65 studies were included in the review. Most studies had acceptable /good quality. The prevalence of insomnia in the included studies ranged from 2.1% to 100%, with a median overall prevalence of 49.5%. Sociodemographic factors such as age; clinical characteristics such as functional status, disease stage, pain, and use of specific drugs, including opioids; psychological factors such as anxiety/depression; and spiritual factors such as feelings of well-being were identified as predictors. The treatment options identified were biological (pharmacological and nonpharmacological), psychological (visualization, relaxation), and spiritual (prayer).
Conclusions
The systematic review showed that the prevalence of insomnia is high, with at least one in 3 patients affected in most studies. Insomnia’s risk factors and treatment in palliative care are both associated to physical, psychological, social, and spiritual factors, reflecting its true holistic nature.
Patients in medical settings with more adverse childhood experiences (ACEs), such as sexual abuse, demonstrate reduced treatment adherence and greater relational difficulties with providers, potentially contributing to negative health outcomes. Integrated care addresses holistic patient healthcare needs within an interdisciplinary treatment team. Trauma-informed care serves as a potential approach to address patient and provider difficulty, yet practical guidance as to how to implement this approach within integrated care settings is lacking. This article makes the case for trauma-informed integrated care and provides a case example in an oncology setting to illustrate the utility of trauma-informed integrated care with the use of an embedded mental health counselor. Resulting training and practice recommendations include (a) universal screening for ACE in medical settings, (b) enhanced interprofessional education, and (c) provision of embedded counseling and supervision services within integrated care settings. Future research directions are explored.
Background
Our aim was to determine feasibility and effect sizes of bright light therapy (BLT), melatonin (MLT), methylphenidate (MP) and eight combinations (BLT+MLT+MP, BLT+MLT, BLT+MP, BLT alone, MLT+MP, MLT alone, MP alone, placebo for BLT, MLT and MP) defined as multimodal therapy (MMT), to improve sleep quality (SQ) (Pittsburgh Sleep Quality Index (PSQI)) from baseline to day 15. We also examined the effects of MMT on insomnia, fatigue, depression, quality of life and actigraphy.
Methods
Patients with advanced cancer with poor SQ (PSQI ≥5) were eligible. Using a double-blind randomised factorial study design, patients were randomised into 1 of the 8 arms for 2 weeks. Feasibility and effect sizes were assessed.
Results
81% (54/67) of randomised patients completed the study. There were no differences in the demographics and SQ between groups. The adherence rates for BLT, MLT and MP were 93%, 100% and 100%, respectively. BLT+MLT+placebo of MP; BLT+placebo of MLT+placebo of MP; BLT+MLT+MP showed an effect size (Cohen’s d) for change in PSQI scores of 0.64, 0.57 and 0.63, respectively. PSQI change using linear regression showed BLT (n=29) has effect size of 0.46, p=0.017; MLT (n=26), 0.24, p=0.20; MP (n=26), 0.06, p=0.46. No significant differences were observed in scores for insomnia, fatigue, depression, quality of life and actigraphy. There were no differences in adverse events by groups(p=0.80).
Conclusions
The use of MMT to treat SQ disturbance was feasible. BLT+MLT showed the most promising effect size in improvement in SQ, and additional larger studies are needed.
Trial registration number
NCT01628029 .
Background
To the best of our knowledge, the change in opioid prescription patterns upon referral to a palliative care team (PCT) was not previously investigated in the Middle East.
Objective
This study aimed to explore the change in the pattern of opioid prescription and the pain scores before and after referring inpatients to a PCT.
Methods
We conducted a retrospective review of patients’ records including all inpatients ≥15 years newly referred to the PCT over a period of 21 months at King Faisal Specialist Hospital and Research Center, Riyadh.
Results
Of 631 patients, 52.3% were females, the median age was 54 years, and 96.7% had cancer. The proportion of patients on opioids before referral (83.4%) increased to 93.3% in the postreferral period, P < .0001. Patients receiving opioids on a regular basis increased from 31.9% before referral to 49.9% after referral to the PCT, P < .0001. Morphine was the most commonly prescribed opioid on a regular basis pre- and postreferral. Upon referral, the administration of opioids through the subcutaneous route increased from 3.7% to 10.9%, P < .0001. On average, pain scores were reduced by 1 point on a 0 to 10 numeric scale within 48 hours of seeing a patient by the PCT, P < .0001.
Conclusion
Patients referred to a PCT are likely to get their opioid prescription optimized and pain scores improved shortly after the PCT involvement. Patients with cancer-related pain requiring opioids should be referred to a PCT as early as possible.
The term hospice was coined in medieval times to denote rest homes for pilgrims, travelers and foreigners who needed shelter for temporary rest. Hospices then reappeared in the history of mankind in mid-nineteenth century as places where severely ill persons received end of life care. Usually managed by religious orders, they also sheltered the indigents and patients with “incurable” diseases.
Although there is increasing advocacy for timely symptom control in patients with cancer, few studies have assessed outpatient palliative care clinics. This study assessed prospectively the efficacy of an Oncology Palliative Care Clinic (OPCC) in improving patient symptom distress and satisfaction.
Eligible patients were new referrals to an OPCC, had metastatic cancer, were at least 18 years old, and were well enough and able to speak and read English sufficiently to provide informed consent and complete questionnaires. Patients received a consultation by a palliative care team. The primary end points of symptom control and patient satisfaction were assessed using the Edmonton Symptom Assessment Scale (ESAS) and patient-adapted Family Satisfaction with Advanced Cancer Care (FAMCARE) scale at baseline, 1 week, and 1 month. Initial and follow-up scores were compared using paired t tests.
Of 150 patients enrolled, 123 completed 1-week assessments, and 88 completed 4-week assessments. At baseline, the mean ESAS Distress Score (EDS) was 39.5. The mean improvement in EDS was 8.8 points (P < .0001) at 1 week and 7.0 points (P < .0001) at 1 month. Statistically significant improvements were observed for pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, dyspnea, insomnia, and constipation at 1 week (all P < or = .005) and 1 month (all P < or = .05). The mean improvement in FAMCARE score was 6.1 points (P < .0001) at 1 week and 5.0 points (P < .0001) at 1 month.
This phase II study demonstrates efficacy of an OPCC for improvement of symptom control and patient satisfaction with care. Randomized controlled trials are indicated to further evaluate the effectiveness of specialized outpatient palliative care.
As part of a longitudinal prospective study we sought a self-completed instrument of symptom assessment suitable for a population of cancer patients who were receiving palliative therapy. The modified Edmonton Symptom Assessment System (ESAS) is such an instrument, but it required validation for this population. This study represents a validation of the modified ESAS with the Rotterdam Symptom Checklist and the Brief Pain Inventory--two instruments widely used in patients receiving palliative therapy for cancer. We conclude that the modified ESAS is a valid, self-administered instrument to assess symptoms for patients from differing palliative care settings.
The objective of the study was to determine whether teams providing specialist palliative care improve the health outcomes of patients with advanced cancer and their families or carers when compared to conventional services. The study involved a systematic literature review of published research.
The source of the data included studies identified from a systematic search of computerized databases (Medline, psychINFO, CINAHL and BIDS to the end of 1996), hand-searching specialist palliative care journals, and studying bibliographies and reference lists. The inclusion criteria for articles were that the study considered the use of specialist palliative care teams caring for patients with advanced cancer. Articles were assessed and data extracted and synthesized, with studies graded according to design.
A variety of outcomes were considered by the authors. These addressed aspects of symptom control, patient and family or carer satisfaction, health care utilization and cost, place of death, psychosocial indices and quality of life.
Overall, 18 relevant studies were identified, including five randomized controlled trials. Improved outcomes were seen in the amount of time spent at home by patients, satisfaction by both patients and their carers, symptom control, a reduction in the number of inpatient hospital days, a reduction in overall cost, and the patients' likelihood of dying where they wished to for those receiving specialist care from a multiprofessional palliative care team.
It was concluded that all evaluations were of services considered to be leading the field, or were pioneering training and treatments. However, when compared to conventional care, there is evidence that specialist teams in palliative care improve satisfaction and identify and deal with more patient and family needs. Moreover, multiprofessional approaches to palliative care reduce the overall cost of care by reducing the amount of time patients spend in acute hospital settings.
A multivariate analysis of the data was conducted to evaluate the effects of age, gender, and performance status on symptom profile. A comprehensive prospective analysis of symptoms was conducted in 1,000 patients on initial referral to the Palliative Medicine Program of the Cleveland Clinic. The median number of symptoms per patient was 11 (range 1-27). The ten most prevalent symptoms were pain, easy fatigue, weakness, anorexia, lack of energy, dry mouth, constipation, early satiety, dyspnea, and greater than 10% weight loss. The prevalence of these 10 symptoms ranged from 50% to 84%. Younger age was associated with 11 symptoms: blackout, vomiting, pain, nausea, headache, sedation, bloating, sleep problems, anxiety, depression, and constipation. Gender was associated with 8 symptoms. Males had more dysphagia, hoarseness, >10% weight loss and sleep problems; females, more early satiety, nausea, vomiting, and anxiety. Performance status was associated with 14 symptoms. Advanced cancer patients are polysymptomatic. Ten symptoms are highly prevalent. Symptom prevalence for 24 individual symptoms differs with age, or gender, or performance status.
Subjective symptom assessment should be a fundamental component of health-related quality of life (HRQL) assessment in end-stage renal disease (ESRD). Unfortunately, no symptom checklist has established reliability or validity in ESRD. We report the validation of a modified Edmonton Symptom Assessment System (ESAS) in 507 dialysis patients who concurrently completed the Kidney Dialysis Quality of Life-Short Form (KDQOL-SF) questionnaire. The ESAS demonstrated a mean of 7.5+/-2.5 symptoms. The symptoms reported as most severe were tiredness, well-being, appetite, and pain. The overall symptom distress score was strongly correlated with the KDQOL-SF subscales symptom/problem list (r=-0.69, P<0.01), effects of kidney disease (r=-0.52, P<0.01), and burden of kidney disease (r=-0.50, P<0.01), as well as lower RAND-12 physical health composite (PHC) (r=-0.54, P<0.01) and lower RAND-12 mental health composite (MHC) (r=-0.62, P<0.001). In the multivariate regression analysis, after controlling for potential confounding variables including comorbidity using the modified Charlson Comorbidity Index, the ESAS symptom distress score remained strongly associated with the MHC (slope=-0.82+/-0.07, P<0.01) and PHC (slope=-0.48+/-0.07, P<0.01). The ESAS symptom distress score accounted for 29% of the impairment in PHC and 39% of the impairment in MHC. The intraclass correlation coefficient for the total symptom distress score in a 1-week test-retest was 0.70, P<0.01. Symptom burden is high and adversely affects HRQL in dialysis patients. The modified ESAS is a reliable, valid, simple, and useful method for regular symptom assessment in this patient population.
Specialized palliative care teams are increasingly providing care for the terminally ill. However, the impact of such teams on quality of life, satisfaction with care, and economic cost has not been examined systematically using detailed criteria for study quality.
To systematically review the evidence for effectiveness of specialized palliative care.
We performed a keyword search of the following databases from their inception to January 2008: MEDLINE, Ovid Healthstar, CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials.
We included all randomized controlled trials in which specialized palliative care was the intervention and for which outcomes included quality of life, satisfaction with care, or economic cost.
Data on population, intervention, outcome, methods, and methodological quality were extracted by 2 investigators using standardized criteria.
Of 396 reports of randomized controlled trials, 22 met our inclusion criteria. There was most consistent evidence for effectiveness of specialized palliative care in improvement of family satisfaction with care (7 of 10 studies favored the intervention). Only 4 of 13 studies assessing quality of life and 1 of 14 assessing symptoms showed a significant benefit of the intervention; however, most studies lacked statistical power to report conclusive results, and quality-of-life measures were not specific for terminally ill patients. There was evidence of significant cost savings of specialized palliative care in only 1 of the 7 studies that assessed this outcome. Methodological limitations were identified in all trials, including contamination of the control group, failure to account for clustering in cluster randomization studies, and substantial problems with recruitment, attrition, and adherence.
The evidence for benefit from specialized palliative care is sparse and limited by methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population, are needed.
We describe a simple method for the assessment of symptoms twice a day in patients admitted to a palliative care unit. Eight visual analog scales (VAS) 0–100 mm are completed either by the patient alone, by the patient with nurse's assistance, or by the nurses or relatives at 10:00 and 18:00 hours, in order to indicate the levels of pain, activity, nausea, depression, anxiety, drowsiness, appetite, and sensation of well-being. The information is then transferred to a graph that contains the assessments of up to 21 days on each page. The sum of the scores for all symptoms is defined as the symptom distress score. The Edmonton Symptom Assessment System (ESAS) was carried out for 101 consecutive patients for the length of their admission to our unit. Of these, 84% were able to make their own assessment sometime during their admission. However, before death 83% of assessments were completed by a nurse or relative. Mean symptom distress score was 410±95 during day 1 of the admission, versus 362±83 during day 5 (p<0.01). Mean symptom distress scores throughout the hospitalization were 359±105, 374±93, 359±91 and 406±81 when the ESAS was completed by the patient alone, patient with nurse's assistance (p=N.S.), nurse alone (p=N.S.), or relative (p<0.01) respectively. We conclude that this is a simple and useful method for the regular assessment of symptom distress in the palliative care setting.
The aims of this study were (a) to estimate the prevalence of pain and eight other common symptoms in a large population of patients with advanced cancer from different palliative care centers, and (b) to assess the differences in prevalence of the symptoms by primary site. In 1990–1991, the prevalence of eight major symptoms and performance status were assessed prospectively among 1840 cancer patients in seven hospices in Europe, the United States, and Australia. The data were collected at each institution using structured data collection sheets from the World Health Organization's (WHO) Cancer and Palliative Care Unit. The prevalence of moderate to severe pain was 51%, ranging from 43% in stomach cancer to 80% in gynecological cancers. Nausea was most prevalent in gynecological (42%) and stomach (36%) cancers, and dyspnea (46%) in lung cancer. There were statistically significant differences in the prevalence of most symptoms depending on the primary site of cancer and the hospice. Population-based follow-up studies are needed to document the incidence and prevalence of symptoms throughout the course of the disease.
The aims of this study were (a) to estimate the prevalence of pain and eight other common symptoms in a large population of patients with advanced cancer from different palliative care centers, and (b) to assess the differences in prevalence of the symptoms by primary site. In 1990-1991, the prevalence of eight major symptoms and performance status were assessed prospectively among 1840 cancer patients in seven hospices in Europe, the United States, and Australia. The data were collected at each institution using structured data collection sheets from the World Health Organization's (WHO) Cancer and Palliative Care Unit. The prevalence of moderate to severe pain was 51%, ranging from 43% in stomach cancer to 80% in gynecological cancers. Nausea was most prevalent in gynecological (42%) and stomach (36%) cancers, and dyspnea (46%) in lung cancer. There were statistically significant differences in the prevalence of most symptoms depending on the primary site of cancer and the hospice. Population-based follow-up studies are needed to document the incidence and prevalence of symptoms throughout the course of the disease.
The Edmonton Symptom Assessment Scale (ESAS) is a nine-item patient-rated symptom visual analogue scale developed for use in assessing the symptoms of patients receiving palliative care. The purpose of this study was to validate the ESAS in a different population of patients.
In this prospective study, 240 patients with a diagnosis of cancer completed the ESAS, the Memorial Symptom Assessment Scale (MSAS), and the Functional Assessment Cancer Therapy (FACT) survey, and also had their Karnofsky performance status (KPS) assessed. An additional 42 patients participated in a test-retest study.
The ESAS "distress" score correlated most closely with physical symptom subscales in the FACT and the MSAS and with KPS. The ESAS individual item and summary scores showed good internal consistency and correlated appropriately with corresponding measures from the FACT and MSAS instruments. Individual items between the instruments correlated well. Pain ratings in the ESAS, MSAS, and FACT correlated best with the "worst-pain" item of the Brief Pain Inventory (BPI). Test-retest evaluation showed very good correlation at 2 days and a somewhat smaller but significant correlation at 1 week. A 30-mm visual analogue scale cutoff point did not uniformly distinguish severity of symptoms for different symptoms.
For this population, the ESAS was a valid instrument; test-retest validity was better at 2 days than at 1 week. The ESAS "distress" score tends to reflect physical well-being. The use of a 30-mm cutoff point on visual analogue scales to identify severe symptoms may not always apply to symptoms other than pain.
The purpose of this study was to determine the levels of change on standard pain scales that represent clinically important differences to patients. Data from analgesic studies are often difficult to interpret because the clinical importance of the results is not obvious. Differences between groups, as summarized by a change in mean values over time, can be difficult to apply to clinical care. Baseline scores vary widely and group mean differences could reflect large changes in a few patients, small changes in many patients, or any combination of these outcomes. Determination of the proportion of patients who have a clinically important improvement in their pain would provide a more interpretable result with direct clinical implications. However, determining a clinically important outcome requires information about the degree of change over time that is clinically important. Data from the titration phase of a multiple cross-over randomized clinical trial of oral transmucosal fentanyl citrate (OTFC) for the treatment of cancer-related breakthrough pain were re-analyzed to examine the differences in pain scores between treatment episodes that did and did not yield adequate pain relief. The scales evaluated were absolute pain intensity difference (PID, 0-10 scale), percentage pain intensity difference (PID%, 0-100% scale), pain relief (PR, 0 (none), 1 (slight), 2 (moderate), 3 (lots), 4 (complete)), sum of the pain intensity difference (SPID over 60 min), percentage of maximum total pain relief (% Max TOTPAR over 60 min), and global medication performance (0 (poor), 1 (fair), 2 (good), 3 (very good), 4 (excellent)). Adequate relief was defined by the patient's decision not to use another dose of opioid medication as a rescue, in addition to the study medication, to treat each painful episode. One hundred thirty OTFC naive patients contributed data on 1268 episodes of breakthrough pain. The scales that were converted to a percentage change yielded the best accuracy in predicting adequate relief, with balanced sensitivity and specificity. The best cut-off point for both the % Max TOTPAR and the PID% was 33%. The best cut-off points for the absolute scales were absolute pain intensity difference of 2, pain relief of 2 (moderate), and SPID of 2. The global medication performance of 2 (good) had excellent values as well. This study presents data-derived cut-off points for the changes in several pain scales, each reflecting the clinically important improvement for patients treating breakthrough cancer pain episodes with OTFC. Confirmation in other patient populations and different pain syndromes will be needed. The use of consistent clinically important cut-off points as the primary outcome in future pain therapy clinical trials will enhance their validity, comparability, and clinical applicability.
Our objective in this study was to review the characteristics, symptom intensity and satisfaction of patients referred to a half-day symptom control clinic (SCC) for advanced cancer patients. This was a retrospective study. The setting was a multidisciplinary symptom control clinic in a cancer centre. Those taking part were 166 consecutive advanced cancer patients referred to the half-day multidisciplinary SCC because of symptom distress. Patients referred to the clinic were assessed in a private room by a physician, a nurse, a pharmacist, a psychologist, and social, rehabilitation, nutrition, respiratory and pastoral care workers. Symptom distress (multiple visual analogue scales), cognition, and CAGE (alcoholism) were determined. Recommendations were given to the patient and sent to the oncologist, family physician and home care nurse. For 110 patients a second assessment was carried out 1 week later, and 64 patients underwent a telephone assessment 2 weeks after the second visit. Symptom intensity was determined during initial and follow-up visits, as well as during two follow-up telephone assessments. In addition, demographics and patient satisfaction with the SCC were determined. Overall symptom distress, depression, anxiety and sensation of wellbeing improved significantly from the first (n = 166) to the second clinic visit (n = 110). Further significant improvement was observed in overall symptom distress, pain, anxiety, sense of wellbeing and depression at the 2- (n = 64) and 4-week (n = 38) telephone follow-up assessments. Mean satisfaction with the SCC (0-10) was 7.7 +/- 2. Our findings suggest that the work of the SCC results in long-term effectiveness in symptom control and high levels of patient satisfaction. The SCC allows for better integration of care between a cancer center and community-based physicians and nurses. It also allows patients access to multiple disciplines that are not available outside tertiary centers.
Pain intensity is frequently measured on an 11-point pain intensity numerical rating scale (PI-NRS), where 0=no pain and 10=worst possible pain. However, it is difficult to interpret the clinical importance of changes from baseline on this scale (such as a 1- or 2-point change). To date, there are no data driven estimates for clinically important differences in pain intensity scales used for chronic pain studies. We have estimated a clinically important difference on this scale by relating it to global assessments of change in multiple studies of chronic pain. Data on 2724 subjects from 10 recently completed placebo-controlled clinical trials of pregabalin in diabetic neuropathy, postherpetic neuralgia, chronic low back pain, fibromyalgia, and osteoarthritis were used. The studies had similar designs and measurement instruments, including the PI-NRS, collected in a daily diary, and the standard seven-point patient global impression of change (PGIC), collected at the endpoint. The changes in the PI-NRS from baseline to the endpoint were compared to the PGIC for each subject. Categories of "much improved" and "very much improved" were used as determinants of a clinically important difference and the relationship to the PI-NRS was explored using graphs, box plots, and sensitivity/specificity analyses. A consistent relationship between the change in PI-NRS and the PGIC was demonstrated regardless of study, disease type, age, sex, study result, or treatment group. On average, a reduction of approximately two points or a reduction of approximately 30% in the PI-NRS represented a clinically important difference. The relationship between percent change and the PGIC was also consistent regardless of baseline pain, while higher baseline scores required larger raw changes to represent a clinically important difference. The application of these results to future studies may provide a standard definition of clinically important improvement in clinical trials of chronic pain therapies. Use of a standard outcome across chronic pain studies would greatly enhance the comparability, validity, and clinical applicability of these studies.
Research in palliative care is considered difficult due to the poor health of patients. However, patient-provided data are essential for a thorough description of patient symptomatology and for the evaluation of care.
The authors examined the feasibility of a questionnaire-based study using the European Organization for Research and Treatment of Cancer quality-of-life instrument EORTC QLQ-C30, the Edmonton Symptom Assessment System (ESAS), and the Hospital Anxiety and Depression Scale (HADS) in cancer patients who were receiving palliative care. This report describes the symptomatology of participating patients and examines differences in symptomatology between patients in three palliative care functions: inpatient, outpatient, and palliative home care.
Of 267 eligible patients who were referred to a department of palliative medicine, initial self-assessment questionnaires were obtained from 176 patients (65.9%). The 91 nonparticipants were older and had lower Karnofsky Performance status (KPS) values than the participants. Almost all participating patients suffered from impaired role function and physical function and had high levels of pain, fatigue, and other symptoms. According to the HADS, 47% of patients suffered from depression. Outpatients had better scores than inpatients and patients in palliative home care for physical function, role function, cognitive function, depression, and inactivity.
It is possible to carry out a questionnaire-based study of symptomatology in consecutive cancer patients in palliative care, achieving rather complete data from the participants. The symptomatology in these patients was very pronounced. The questionnaires were able to detect clinically important differences between places of service.
To evaluate the relationships between quality of life (QOL) and symptom distress, pain intensity, dyspnea intensity, and constipation intensity in people with advanced cancer who were newly admitted to hospice home care.
Descriptive and correlational.
A large hospice that provides primarily home care.
178 adult hospice homecare patients with cancer who were accrued to a clinical trial funded by the National Institutes of Health focusing on symptom management and QOL. Patients were excluded if they received a score lower than seven on the Short Portable Mental Status Questionnaire.
The patients were invited to participate in the clinical trial within 48 hours of admission to hospice home care. Among the questionnaires they completed were a QOL index and a distress scale. Scales measuring present intensity of pain, dyspnea, and constipation also were administered.
QOL, symptom distress, pain intensity, dyspnea intensity, and constipation intensity.
The most frequently reported symptoms among the sample were lack of energy, pain, dry mouth, and shortness of breath. Lack of energy caused the greatest distress, followed closely by dry mouth and pain. The results of the regression analysis indicated that total distress score, pain intensity, dyspnea intensity, and constipation intensity were related to QOL at the univariate level. When all predictors were considered simultaneously, only the total distress score remained a significant predictor of QOL (p< 0.001), accounting for about 35% of variance.
QOL was affected by symptom distress in people with advanced cancer near the end of life.
The symptoms most commonly reported and those that cause the greatest patient distress should be addressed first by hospice nurses. Continued effort is needed in the important area of symptom management.
Approximately 1 in 3 individuals in the developed world will be diagnosed
with cancer and half of those patients will die of progressive disease.1 More than 80% of patients with cancer develop pain
before death.2 Pain is consistently one of
the most feared consequences of cancer for both patients and families. Major
improvements in the management of cancer pain in recent years include better
assessment of pain, recognition and treatment of opioid-induced neurotoxicity,
and the emerging use of opioid rotation and of methadone.
Little is known about the use of palliative care for outpatients who continue to pursue treatment of their underlying disease or whether outpatient palliative medicine consultation teams improve clinical outcomes.
We conducted a year-long controlled trial involving 50 intervention patients and 40 control patients in a general medicine outpatient clinic. Primary care physicians referred patients with advanced congestive heart failure, chronic obstructive pulmonary disease, or cancer who had a prognosis ranging from 1 to 5 years. In the intervention group, the primary care physicians received multiple palliative care team consultations, and patients received advance care planning, psychosocial support, and family caregiver training. Clinical and health care utilization outcomes were assessed at 6 and 12 months.
Groups were similar at baseline. Similar numbers of patients died during the study year (P =.63). After the intervention, intervention group patients had less dyspnea (P =.01) and anxiety (P =.05) and improved sleep quality (P =.05) and spiritual well-being (P =.007), but no change in pain (P =.41), depression (P =.28), quality of life (P =.43), or satisfaction with care (P =.26). Few patients received recommended analgesic or antidepressant medications. Intervention patients had decreased primary care (P =.03) and urgent care visits (P =.04) without an increase in emergency department visits, specialty clinic visits, hospitalizations, or number of days in the hospital. There were no differences in charges (P =.80).
Consultation by a palliative medicine team led to improved patient outcomes in dyspnea, anxiety, and spiritual well-being, but failed to improve pain or depression. Palliative care for seriously ill outpatients can be effective, but barriers to implementation must be explored.
To characterize a new, one-stop multidisciplinary palliative care (MD) clinic which offers standardized multidisciplinary assessment, specific care recommendations, patient and family education, and on-site counseling, we retrospectively compared the assessments of 138 consecutive patients with advanced cancer referred to the MD clinic and 77 patients referred to a traditional pain and symptom management (PSM) clinic. The two groups were similar in tumor type, demographics, and symptom distress. The MD clinic team (physicians; nurses; pharmacists; physical, speech, and occupational therapists; social workers; chaplains; nutritionists; psychiatric nurse practitioner) delivered 1,066 non-physician recommendations (median 4 per patient, range 0-37). The PSM clinic team made no non-physician recommendations, but referred 14 patients to other medical specialists. In 80 (58%) MD-clinic patients with follow-up 9 days (median) after assessment, significant improvement was observed in pain, nausea, depression, anxiety, sleep, dyspnea, and well-being, but not in fatigue, anorexia, or drowsiness. In 83 patients interviewed after the MD clinic, satisfaction was rated as excellent (5 out of 5) in 86-97% of seven areas. Assessment at an MD clinic results in a high number of patient care recommendations, improved symptoms, and high levels of patient satisfaction.
The control, and ideally prevention, of symptoms such as pain, depression, and fatigue is dependent on a comprehensive clinical assessment. Furthermore, to advance the science of this field, symptom research requires the use of multidimensional instruments with proven validity and reliability in a cancer population across the lifespan. Studies demonstrate a significant correlation among pain, depression, fatigue, and other symptoms commonly seen throughout the course of cancer. Therefore, multidimensional scales incorporating the most common symptoms would ensure systematic assessment. Optimally, valid and reliable tools that measure symptom clusters would be feasible for use in both clinical and research settings. Currently available instruments that measure symptom clusters include the Edmonton Symptom Assessment Scale, the M.D. Anderson Symptom Inventory, the Memorial Symptom Assessment Scale, the Rotterdam Symptom Checklist, the Symptom Distress Scale, and others. Special populations include cancer patients with advanced disease, where symptom prevalence is expected to increase. Newer tools that attempt to address these populations are the Brief Hospice Inventory and the Hospice Quality of Life Index, appropriate for cancer patients with more advanced disease. Each of these tools has demonstrated utility in measuring symptom severity and quality of life. Few scales have been validated in the measurement of symptom clusters in children, in cognitively impaired adults, or in non-English speaking patients from various cultural backgrounds. The strengths and limitations presented in the clinical and research uses of each these instruments will be presented, as will be areas for future investigation.
The study aim was to explore which symptoms/problems cancer patients in palliative care consider most distressing, and to investigate how prioritization at first contact was associated with patient-assessed symptom intensity and change in intensity over time. Initially, 175 patients named and prioritized their five most distressing symptoms. Weekly, they completed the following self-assessment questionnaires: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30, Edmonton Symptom Assessment System, and the Hospital Anxiety and Depression Scale. Initial symptom intensity scores and weekly changes were calculated and compared with prioritization of the same symptom. Pain, fatigue, physical function, appetite, nausea/vomiting, dyspnea, and depression were the symptoms most often prioritized. Priority was associated with initial scoring of pain, appetite, nausea/vomiting, dyspnea, constipation, depression, and anxiety, but not with fatigue, physical function, role function, or inactivity. Priority was associated with change in symptom intensity for pain, reduced appetite, nausea/vomiting, and constipation. Symptom prioritization may be a useful guide to choice of treatment as well as to longitudinal symptom evaluation.
Fatigue is the most common chronic symptom associated with cancer and other chronic progressive diseases. The assessment and treatment of fatigue at or near the end of life can be complex. Some of the challenges include its subjective nature, with great variability in its source, how it is expressed, and how it is perceived, requiring treatment to be based on patient report of frequency and severity; its multidimensional character; and the limited understanding of its pathophysiology. Using the case of an 82-year-old retired nurse with fatigue that could be explained by a number of concurrent conditions, including anemia, weight loss, depression and isolation, dyspnea, deconditioning, and medications, the authors illustrate the clinical approach to assess and treat fatigue at the end of life.
Pain and symptom burden: lessons from patients with cancer
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