Desire for hastened death, cancer pain and depression: report of a longitudinal observational study

Values important to terminally ill African American older adults in receiving hospice care

While racial disparity in the use of hospice care by older African Americans is widely acknowledged, little is known about the values that they consider as important in receiving health care services along with direct experiences with having these values respected by hospice care providers. Using individual, face-to-face interviews, data were collected directly from 28 African American hospice patients about their experiences in hospice care. Content analysis was used to identify and categorize themes from multiple readings of the qualitative data. Resulting themes included: dying at home, open communications, independent decision-making, autonomy in daily life, unwillingness to be a burden, and relationships. Through the initial assessment, value preferences can be explored and then shared with hospice team members to ensure that services are provided in such a way that their values and preferences are respected.

Pain characteristics and management of inpatients admitted to a comprehensive cancer centre: a cross-sectional study

AIMS

This prospective, cross-sectional study aimed to assess cancer pain and its management in an inpatient setting at a comprehensive cancer centre in Denmark.

METHODS

One hundred and eighty-eight inpatients with cancer were invited to participate (May/June 2011). Demographics, diagnoses, World Health Organization performance status, health-related quality of life, pain and data regarding analgesic treatment were registered.

RESULTS

One hundred and thirty-four (71.3%) patients agreed to participate in the study. Most frequent diagnoses were leukaemia (27.6%) and lung cancer (14.2%). A high prevalence of pain was observed, 65.7%. Thirty-two per cent reported moderate to severe pain when it was at its worst, 96% reported no or mild pain when it was at its least. Nearly 22% reported moderate to severe pain when the pain was categorised as average. Breakthrough pain episodes were reported by 30.5%. Adjuvant medication was sparsely used and not always correctly indicated. Out of 88 patients with pain, 62.5% were left untreated according to the Electronic Medication System. Higher health-related quality of life was associated with lower pain intensity. The use of opioids with or without adjuvants was associated with higher pain intensity and higher number of breakthrough pain episodes.

CONCLUSIONS

Approximately two thirds of inpatients reported pain and one third had breakthrough pain. A substantial number of patients with pain were left untreated. Opioid-treated patients reported highest pain intensity and number of breakthrough episodes; however, analgesic medication seemed to be underused. Measures to improve pain assessment and management are highly required.

Prevalence and factors associated with desire for death in patients with advanced disease: results from a Portuguese cross-sectional study

BACKGROUND

Desire for death (DFD) within the context of palliative care has become a prominent medical issue and remains the subject of much controversy.

METHODS

Cross-sectional study designed to assess the prevalence and associated demographic, physical, psychiatric, and psychosocial factors for DFD in patients with advanced disease.

RESULTS

Seventy-five terminally ill patients were included in the analyses in a 28-month period. The prevalence of DFD was 20% (95% CI [11.7-30.8]). No statistical differences were observed between patients with and without DFD with respect to sex, age, race, education, religion, type of family, medical diagnosis, and medication. There were associations between DFD and being married/cohabitating (OR = 4.0; 95% CI [1.21-13.29]) and being socially isolated (OR = 0.3; 95% CI [0.06-0.98]). Significant positive correlations were found between moderate to severe Edmonton Symptom Assessment Scale (ESAS) scores and DFD for tiredness (OR = 10.1; 95% CI [1.57 ± inf]) and drowsiness (OR = 6.0; 95% CI [1.77-20.37]). DFD was also correlated with depression (DSM-IV criteria: OR = 5.5; 95% CI [1.56-19.47]; Hospital and Anxiety Depression Scale (HADS) depression subscale ≥11: OR = 8.6; 95% CI [1.33 ± inf]). In exact multivariate regression analyses predicting DFD, three independent factors emerged: marital status (OR = 5.3; 95% CI [1.16-29.89]); HADS depression sub-scale score ≥11 (OR = 8.3; 95% CI [1.11 ± inf]); drowsiness (OR = 5.8; 95% CI [1.29-32.85]).

DISCUSSION

Prevalence of DFD was high in this sample of patients. Identifying factors associated with DFD could help provide medical and social interventions capable of diminishing suffering in terminal ill patients.

Suicidality and its associated factors in cancer patients: results of a multi-center study in Korea

OBJECTIVE

The current study examined the prevalence and associated factors of suicidality among Korean cancer patients. Moreover, the association of multiple psychological morbidities with suicidality was investigated among cancer patients.

METHODS

A cross-sectional, multi-center survey of 400 cancer patients was administered in five cancer-treatment hospitals throughout South Korea. Study variables were assessed using standardized measures including the Mini International Neuropsychiatric Interview suicidality module, the Hospital Anxiety and Depression Scale, and the Impact of Event Scale-Revised.

RESULTS

20.1% (80/399) of patients were positive cases of suicidality. Having no religion (p = .010), poor performance status (p = .000), and psychological comorbidity (p = .021) were significantly associated with the experience of suicidality in the multivariate analysis. Compared to "fully active" patients, patients who were capable of self-care but unable to perform any work activities had about a six times higher risk of suicidality (p = .000). Compared to patients with no psychological morbidity, the risk of suicidality was significantly higher among patients with comorbid anxiety and depression (p = .024), those experiencing comorbid depression and post-traumatic stress disorder (PTSD) (p = 0.051), and those experiencing comorbid anxiety, depression and PTSD (p = .001).

CONCLUSIONS

This study found that having no religion, impaired levels of overall functioning, and "multiple psychological morbidities" were associated with suicidality in Korean cancer patients. These findings suggest a need for careful monitoring of these factors and enhanced comprehensive care addressing both the physical and psychosocial functioning of patients with cancer in suicide prevention efforts.

Assessing cancer pain

Regular assessment for the presence of pain and response to pain management strategies should be high priority in cancer patients. Pain is a multidimensional experience in cancer patients. Pain management will be most effective when treatments are individualized after exploring the various physical and non-physical components of pain, and the patient and family are educated and involved in decision making. This article discusses the various issues that are pertinent to the assessment of pain in cancer patients.

The role of psychiatrists and mental disorder in assisted dying practices around the world: a review of the legislation and official reports

OBJECTIVE

To establish the role of psychiatrists and mental disorder in assisted dying practices in countries and states where such practices are legal.

METHODS

The authors reviewed the Assisted Dying Acts and official statistical reports from Belgium, The Netherlands, Luxembourg, and the states of Washington and Oregon in the U.S.A. The data extracted related to the role of psychiatrists in assisted dying practices, and the relevance of capacity, 'suffering', and mental disorder.

RESULTS

A psychiatry referral is recommended or required by all countries and states in certain circumstances. These circumstances include mental disorder 'impairing judgement' in Oregon and Washington, and cases of exclusive mental disorder in European countries. 'Exclusive mental disorder' refers to those with a mental disorder (e.g., major depression) who apply for assisted dying in the absence of any terminal physical illness. Capacity/competence and necessary suffering must be present. On average, 5.4% (range 4.2%-6.7%) of applicants see a psychiatrist. Patients with exclusive mental disorder can apply for assisted dying in European countries but not in Oregon and Washington; actual figures are low.

CONCLUSIONS

No country has a blanket policy of mandatory psychiatric review but the specialty contributes in circumstances of exclusive mental disorder or when there is doubt regarding capacity and sound judgement. The absence of a mandatory role for psychiatrists means that reversible psychopathology may be missed. As a result, the patient's decision to end his/her life may be more informed by treatable mental disorder than by his/her lifelong preferences.

Achievement of personalized pain goal in cancer patients referred to a supportive care clinic at a comprehensive cancer center

BACKGROUND

Cancer pain initiatives recommend using the personalized pain goal to tailor pain management. This study was conducted to examine the feasibility and stability of personalized pain goal, and how it compares to the clinical pain response criteria.

METHODS

Records of 465 consecutive cancer patients seen in consultation at the Supportive Care Clinic were reviewed. Pain relief was assessed as clinical response (≥30% or ≥2 point pain reduction) and personalized pain goal response (pain ≤ personalized pain goal).

RESULTS

One hundred fifty-two (34%), 95 (21%), and 163 (37%) patients presented with mild (1-4), moderate (5-6), and severe (7-10) pain, respectively. Median age (59 years), males (52%), and advanced cancer status (84%) did not differ by pain category. Median personalized pain goal at initial clinic consult was 3 (interquartile range, 2-3), was similar across pain groups, and remained unchanged (P = .57) at follow-up (median, 14 days). Clinical response was higher among patients with severe pain (60%) as compared with moderate (40%) and mild pain (33%, P < .001). Personalized pain goal response was higher among patients with mild pain (63%) as compared with moderate (44%) and severe pain (27%, P < .001). By using personalized pain goal response as the gold standard for pain relief, the sensitivity of clinical response was highest (98%) among patients with severe pain, but it had low specificity (54%). In patients with mild pain, clinical response was most specific for pain relief (98%), but had low sensitivity (52%).

CONCLUSIONS

Personalized pain goal is a simple patient-reported outcome for pain goals. The majority of patients were capable of stating their desired level for pain relief. The median personalized pain goal was 3, and it was highly stable at follow-up assessment.

Depression in palliative care settings: the need for training for nurses and other health professionals to improve patients' pathways to care

Depression is highly prevalent in patients receiving palliative care; however, detection rates are low, with many patients who suffer with depression continuing to go undetected and untreated. A number of factors unique to this setting, as well as issues relating to staff knowledge and self-efficacy working with depression, may impede the detection of patients who are depressed by professional health care staff. Although programmes aimed to train nurses and other allied health staff in depression may be an effective way to improve detection rates, there have been few studies investigating the efficacy of these interventions. This article draws upon recent literature to provide a narrative review of barriers to detection and factors relating to professional palliative care staffs' ability to provide pathways to care for patients who suffer with depression in this setting. Previously evaluated training programmes are reviewed and the argument is made that further development and empirical evaluation of depression training interventions for staff in this setting will provide services with evidence-based methods of training nurses and other professional care staff and improve the pathways to care for patients who suffer with depression.

Influence of patient coaching on analgesic treatment adjustment: secondary analysis of a randomized controlled trial

CONTEXT

For patients with cancer-related pain and their physicians, routine oncology visits are an opportunity to adjust the analgesic regimen and secure better pain control. However, treatment intensification occurs haphazardly in practice.

OBJECTIVES

To estimate the effect of patient-centered tailored education and coaching (TEC) on the likelihood of analgesic treatment adjustment during oncology visits, and in turn, the influence of treatment adjustment on subsequent cancer pain control, we studied patients enrolled in a randomized trial of TEC.

METHODS

Just before a scheduled oncology visit, 258 patients with at least moderate baseline pain received TEC or control; just after the same visit, they reported on whether the physician recommended a new pain medicine or a change in dose of an existing medicine. Pain severity and pain-related impairment were measured two, six, and 12 weeks later.

RESULTS

Patients assigned to TEC were more likely than controls to report a change in the analgesic treatment regimen (60% vs. 36%, P<0.01); significant effects persisted after adjustment for baseline pain, study site, and physician (adjusted odds ratio 2.61, 95% confidence interval 1.55, 4.40, P<0.01). In a mixed-effects repeated measures regression, analgesic change (but not TEC itself) was associated with a sustained decrease in pain severity (P<0.05).

CONCLUSION

TEC increases the likelihood of self-reported, physician-directed adjustments in analgesic prescribing, and treatment intensification is associated with better cancer pain outcomes.

Depression and anxiety in palliative care inpatients compared with those receiving palliative care at home

OBJECTIVE

This study compared the prevalence of anxiety and depression as measured on the Hospital Anxiety and Depression Scale (HADS) in palliative care patients being treated at home with those being treated as inpatients.

METHOD

The participants were palliative care patients being treated at home (n = 46) and palliative care inpatients (n = 46). Subjects were assessed for functionality on the Karnofsky Performance Status Scale (KPS) and anxiety and depression were measured on the HADS.

RESULTS

The results showed that ~20% of all patients were depressed and anxious as measured on the HADS, regardless of the cutoff criteria. There was no significant difference in depression and anxiety between the two groups when socioeconomic status and functionality were controlled for. Functionality, as measured on the KPS, was uniquely a predictor of depression, and younger patients were shown to have greater anxiety.

SIGNIFICANCE OF RESULTS

The results suggest that home-based palliative care patients and palliative care inpatients should receive equal psychological support, and that clinicians need to be aware of the psychological vulnerability of younger and less-functional patients. The prevalence of depression and anxiety indicates that all palliative care patients should be screened for psychological distress, to identify those who need further assessment and treatment.

Associations between depression, pain behaviors, and partner responses to pain in metastatic breast cancer

Women with metastatic breast cancer (MBC) rely on their partners for emotional and practical support. They also experience significant pain and depression, which can trigger maladaptive pain behaviors (eg, distorted ambulation). The biopsychosocial model of pain posits that partner solicitous responses can reinforce pain behaviors, whereas punishing or distracting responses can minimize their occurrence. This study explored how psychosocial variables (ie, depression and partner responses) influence patient pain behaviors and partner responses in 191 couples coping with MBC. Because few studies have examined the biopsychosocial model in cancer, it also examined associations between partner responses and patient pain behaviors. Multilevel models showed that depression partially mediated: (1) associations between patients' and partners' reports of patient pain (MPI) and their ratings of patient pain behaviors (PBCL), accounting for 41% to 71% of the variance; and (2) associations between both partners' reports of patient pain and the partner's distracting and punishing responses (MPI), accounting for 66% to 75% of the variance. Partner punishing responses moderated associations between patient pain severity and pain behaviors. Specifically, punishing responses were associated with more pain behaviors for patients with low levels of pain and fewer pain behaviors for patients with higher levels of pain (effect size r=.18). These findings provide partial support for the biopsychosocial model of pain but also clarify and extend it in the cancer context. Future pain management programs in MBC may benefit from addressing both partners' depression levels and teaching partners to engage in fewer punishing responses when the patient is experiencing low levels of pain.

Anxiety in terminally ill cancer patients

CONTEXT

Anxiety in terminal cancer is linked to diminished quality of life, yet overall it is poorly understood with regard to prevalence and relationship to other aspects of psychological distress.

OBJECTIVES

This study examines anxiety in terminally ill cancer patients, including the prevalence of anxiety symptoms, the relationship between anxiety and depression, differences in anxiety between participants receiving inpatient palliative care and those receiving outpatient care, and characteristics that distinguish highly anxious from less anxious patients.

METHODS

Participants were 194 patients with terminal cancer. Approximately half (n=103) were receiving inpatient care in a palliative care facility and half (n=91) were receiving outpatient care in a tertiary care cancer center. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression, and was administered along with measures of hopelessness, desire for hastened death, and social support.

RESULTS

Moderately elevated anxiety symptoms were found in 18.6% of participants (n=36) and 12.4% (n=24) had clinically significant anxiety symptoms. Level of anxiety did not differ between the two treatment settings. However, participants receiving palliative care reported significantly higher levels of depression and desire for hastened death. A multivariate prediction model indicated that belief in an afterlife, social support, and anxiolytic and antidepressant use were unique, significant predictors of anxiety.

CONCLUSION

Severity of anxiety symptoms did not differ between the study sites, suggesting that anxiety may differ from depression and desire for hastened death in the course that it takes over the duration of terminal cancer.

Depression and reasons for living among AIDS patients: protecting quality of life when the end is in sight

BACKGROUND

Patients with AIDS are at risk for becoming depressed, pessimistic, and may begin to desire to die. The desire to live may remain strong in AIDS patients through the maintenance of physical health and a lack of pain. However, improvement in physical health is not always followed by resurgence in the will to live. Psychological variables may be important for protecting reasons for living in AIDS patients.

AIMS

The current study was designed to examine protective factors associated with the will to live among AIDS patients, including physical functioning, depression, and quality of life.

METHOD

Sixty-eight AIDS patients participated in the current study during their outpatient visits to an infectious disease unit. Self-report questionnaires were administered to assess depression, quality of life, a variety of physical health variables, and reasons for living.

RESULTS

Analyses revealed that reasons for living reported by AIDS patients were best understood by overall quality of life. Depression was associated with pessimistic beliefs about the medical illness. Depression was not significantly related to physical functioning or role limitations.

CONCLUSIONS

AIDS patients with poor physical functioning may maintain important reasons for living if a high sense of quality of life is achieved. The assessment and treatment of quality of life in AIDS patients should include strategies that foster a sense of achievement, strengthen interpersonal relationships, and increase positive self-expression.

Intervention for depression among palliative care patients and their families: A study protocol for evaluation of a training program for professional care staff

Background

Clinical depression is highly prevalent yet under-detected and under-treated in palliative care settings and is associated with a number of adverse medical and psychological outcomes for patients and their family members. This article presents a study protocol to evaluate a training intervention for non-physician palliative care staff to improve the recognition of depression and provide support for depressed patients and their family members. Details of the hypotheses and expected outcomes, study design, training program development and evaluation measures are described.

Methods and Design

A randomised controlled trial will be implemented across two palliative care services to evaluate the "Training program for professional carers to recognise and manage depression in palliative care settings". Pre-, post- and three-month follow-up data will be collected to assess: the impact of the training on the knowledge, attitudes, self-efficacy and perceived barriers of palliative care staff when working with depression; referral rates for depression; and changes to staff practices. Quantitative and qualitative methods, in the form of self-report questionnaires and interviews with staff and family members, will be used to evaluate the effectiveness of the intervention.

Discussion

This study will determine the effectiveness of an intervention that aims to respond to the urgent need for innovative programs to target depression in the palliative care setting. The expected outcome of this study is the validation of an evidence-based training program to improve staff recognition and appropriate referrals for depression, as well as improve psychosocial support for depressed patients and their family members.

Trial Registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000183088

Anxiety, helplessness/hopelessness and 'desire for hastened death' in Korean cancer patients

Despite a relatively high rate of suicide associated with cancer, this issue has not been explored in Korean patients. This study investigates the prevalence and factors related to 'the desire for hastened death' (DHD) in Korean cancer patients. A cross-sectional survey using standardised measures, including the Schedule of Attitudes toward Hastened Death and the Hospital Anxiety and Depression Scale, was performed with 131 patients with different types of cancer. 13.7% of the participants experienced moderate DHD (Schedule of Attitudes toward Hastened Death scores 5-9) and 1.7% experienced high DHD (≥10). Socio-demographic and disease-associated factors of the DHD included age, overall health and shortness of breath. The majority of psychosocial variables such as sadness, distress, 'helplessness/hopelessness' and 'anxious preoccupation' had a moderate association with DHD. Patients with a clinically significant level of anxiety or depression reported higher levels of DHD. Other significant correlates included 'meaning/peace', a sense of burdening family, dignity impairment and suicidal thoughts after diagnosis. Helplessness/hopelessness and anxiety were the strongest predictors of DHD in multivariate analysis. In view of significant role of helplessness/hopelessness and anxiety in the DHD of cancer patients, careful monitoring and management of these factors should be an integral part of cancer care to reduce the occurrence of DHD.

Cancer pain: an age-based analysis

OBJECTIVE

Although cancer pain (consistent and breakthrough pain [BTP; pain flares interrupting well-controlled baseline pain]) is common among cancer patients, its characteristics, etiology, and impact on health-related quality of life (HRQOL) across the lifespan are poorly understood.

DESIGN

This longitudinal study examines age-based differences and pain-related interference in young and old patients with cancer-related pain over 6 months. Patients in the community with stage III or IV breast, prostate, colorectal, or lung cancer, or stage II-IV multiple myeloma with BTP completed surveys (upon initial assessment, 3 and 6 months) assessing consistent pain, BTP, depressed affect, active coping ability, and HRQOL using previously validated measures.

RESULTS

Respondents (N= 96) were 70% white and 66% female, with a mean age of 57±10 years. There were no significant differences in pain severity based upon age. However, the younger group experienced more pain flares with greater frequency (P=0.05). The oldest group had better emotional functioning at baseline but worse physical functioning at 6 months. Younger groups also had worse cognitive functioning at 6 months (P=0.03). Pain interference was independent of age.

CONCLUSIONS

These data provide evidence for the significant toll of cancer pain on overall health and well-being of young and old adults alike but demonstrate an increased toll for younger adults (especially financially). Beyond race and gender disparities, further health care disparities in the cancer and cancer pain were identified by age, illustrating the need for additional research across the lifespan in diverse cancer survivors.

Cancer Health Empowerment for Living without Pain (Ca-HELP): effects of a tailored education and coaching intervention on pain and impairment

We aimed to determine the effectiveness of a lay-administered tailored education and coaching (TEC) intervention (aimed at reducing pain misconceptions and enhancing self-efficacy for communicating with physicians) on cancer pain severity, pain-related impairment, and quality of life. Cancer patients with baseline "worst pain" of ≥4 on a 0-10 scale or at least moderate functional impairment due to pain were randomly assigned to TEC or enhanced usual care (EUC) during a telephone interview conducted in advance of a planned oncology office visit (265 patients randomized to TEC or EUC; 258 completed at least one follow-up). Patients completed questionnaires before and after the visit and were interviewed by telephone at 2, 6, and 12 weeks. Mixed effects regressions were used to evaluate the intervention adjusting for patient, practice, and site characteristics. Compared to EUC, TEC was associated with increased pain communication self-efficacy after the intervention (P<.001); both groups showed significant (P<.0001), similar, reductions in pain misconceptions. At 2 weeks, assignment to TEC was associated with improvement in pain-related impairment (-0.25 points on a 5-point scale, 95% confidence interval -0.43 to -0.06, P=.01) but not in pain severity (-0.21 points on an 11-point scale, -0.60 to 0.17, P=.27). The improvement in pain-related impairment was not sustained at 6 and 12 weeks. There were no significant intervention by subgroup interactions (P>.10). We conclude that TEC, compared with EUC, resulted in improved pain communication self-efficacy and temporary improvement in pain-related impairment, but no improvement in pain severity.

Change in cancer pain management in Korea between 2001 and 2006: results of two nationwide surveys

CONTEXT

In Korea, many health care professionals have shown increased concern about the management of cancer pain. Five years after a pain management guideline was distributed to Korean physicians, the Korean Society of Hospice and Palliative Care evaluated the change in cancer pain management. The period evaluated was between 2001 and 2006.

METHODS

We did a prospective, cross-sectional cancer pain survey on the change of the pain prevalence and pain intensity, its impact on daily activities and the adequacy of pain management between 2001 and 2006.

RESULTS

Overall, 7565 patients were enrolled from 72 cancer hospitals in the 2001 cancer pain survey and 7245 patients were enrolled from 63 cancer hospitals in the 2006 cancer pain survey. The overall prevalence of cancer pain and the percentage of patients reporting a negative pain management index were significantly decreased in the 2006 cancer pain survey compared with the 2001 cancer pain survey (44.9% vs. 52.1%, P<0.0001 and 41.6% vs. 45.0%, respectively, P=0.0005). However, in 2006, physicians did not prescribe analgesics to 25.8% of the patients with severe pain and they did not adjust the prescribed analgesics properly in 47.4% of the patients with severe pain.

CONCLUSION

Some improvement in cancer pain management was noted during the five years between 2001 and 2006. However, all of the physicians who care for cancer patients should pay more attention to cancer pain management, and an educational program for cancer pain management should be distributed to all of the physicians who care for cancer patients.

Assessment of depression and anxiety in adult cancer outpatients: a cross-sectional study

Background

The prevalence of anxiety and depressive disorders in cancer patients and its associated factors in Pakistan is not known. There is a need to develop an evidence base to help introduce interventions as untreated depression and anxiety can lead to significant morbidity. We assessed the prevalence of depression and anxiety among adult outpatients with and without cancer as well as the effect of various demographic, clinical and behavioral factors on levels of depression and anxiety in cancer patients.

Methods

This cross-sectional study was carried out in outpatient departments of Multan Institute of Nuclear Medicine and Radiotherapy and Nishtar Medical College Hospital, Multan. Aga Khan University Anxiety and Depression Scale (AKUADS) was used to define the presence of depression and anxiety in study participants. The sample consisted of 150 diagnosed cancer patients and 268 participants without cancer (control group).

Results

The mean age of cancer patients was 40.85 years (SD = 16.46) and median illness duration was 5.5 months, while the mean age of the control group was 39.58 years (SD = 11.74). Overall, 66.0% of the cancer patients were found to have depression and anxiety using a cutoff score of 20 on AKUADS. Among the control group, 109 subjects (40.7%) had depression and anxiety. Cancer patients were significantly more likely to suffer from distress compared to the control group (OR = 2.83, 95% CI = 1.89-4.25, P = 0.0001). Performing logistic regression analysis showed that age up to 40 years significantly influenced the prevalence of depression and anxiety in cancer patients. There was no statistically significant difference between gender, marital status, locality, education, income, occupation, physical activity, smoking, cancer site, illness duration and mode of treatment, surgery related to cancer and presence of depression and anxiety. Cancers highly associated with depression and anxiety were gastrointestinal malignancies, chest tumors and breast cancer.

Conclusions

This study highlights high prevalence rates of depression and anxiety in cancer patients. Younger age was associated with a higher likelihood of meeting criteria for psychological morbidity. The findings support screening patients for symptoms of depression and anxiety as part of standard cancer care and referring those at a higher risk of developing psychological morbidity for appropriate care.

Meaning in life in palliative care patients

CONTEXT

The construct "meaning in life" (MiL) has recently raised the interest of clinicians working in psycho-oncology and end-of-life care and has become a topic of scientific investigation.

OBJECTIVES

The aim of this study was to compare MiL in palliative care (PC) patients with a representative sample of the German population.

METHODS

In this cross-sectional study, all PC patients treated in the PC inpatient unit and through the PC consult service at Ludwig-Maximilians-University Hospital, Munich, from May 2005 to July 2007 were eligible to participate. Patients were interviewed by a doctoral student, psychologist, or physician, all previously trained to administer the Schedule for Meaning in Life Evaluation (SMiLE) in a standardized way. In the SMiLE, respondents first list individual areas that provide meaning to their life before rating their current level of importance and satisfaction with each area. Overall indices of weighting (IoW, range 20-100), satisfaction (IoS, range 0-100), and weighted satisfaction (IoWS, range 0-100) are calculated.

RESULTS

One hundred PC patients completed the SMiLE: the IoS was 70.2 ± 19.7, the IoW was 84.7 ± 11.5, and the IoWS was 72.0 ± 19.4. The representative sample (n=977) scored significantly higher in the IoS (82.8 ± 14.7) and IoWS (83.3 ± 14.8) but not in the IoW (85.6 ± 12.3). Compared with healthy individuals, PC patients are more likely to list partner, friends, leisure, spirituality, well-being, nature/animals, and pleasure as meaningful areas. Examining the satisfaction ratings, it is noteworthy that PC patients' satisfaction scores are fairly high (and not lower than their healthy counterparts') in a number of domains: family, partner, home/garden, spirituality, and finances. On the other hand, they score significantly lower in nature/animals, leisure, friends, well-being, altruism, work, pleasure, and health.

CONCLUSION

These findings underscore the potential of the SMiLE for identifying areas that are particularly important to individuals, and that can be targeted by the PC team to improve overall life satisfaction at the end of life.

[A wish to hasten death : what is behind it]

"There's nothing more to do, so let's come to an end, Doc!" A request for euthanasia or physician-assisted suicide is a dramatic expression of patients' suffering and causes difficulties for staff members to react to these questions. Great efforts have been made in the last two centuries to gain a deeper understanding of the wish for hastened death of terminally ill patients and to develop conclusions for the management of these situations. This article presents differences in international legislation on euthanasia and summarises the ethical background. The current results from the literature according to motivations for the wish for hastened death, communicative functions of the request, attitudes and practices of physicians and their willingness to accompany the patient in euthanasia as well as practical implications for clinical practice are discussed.

The association of depression and pain with health-related quality of life, disability, and health care use in cancer patients

CONTEXT

Pain and depression are two of the most prevalent and treatable cancer-related symptoms, each present in at least 20%-30% of oncology patients.

OBJECTIVE

To determine the associations of pain and depression with health-related quality of life (HRQL), disability, and health care use in cancer patients.

METHODS

The Indiana Cancer Pain and Depression study is a randomized clinical trial comparing telecare management vs. usual care for patients with cancer-related pain and/or clinically significant depression. In this article, baseline data on patients enrolled from 16 urban or rural community-based oncology practices are analyzed to test the associations of pain and depression with HRQL, disability, and health care use.

RESULTS

Of the 405 participants, 32% had depression only, 24% pain only, and 44% both depression and pain. The average Hopkins Symptom Checklist 20-item depression score in the 309 depressed participants was 1.64 (on 0-4 scale), and the average Brief Pain Inventory (BPI) severity score in the 274 participants with pain was 5.2 (on 0-10 scale), representing at least moderate levels of symptom severity. Symptom-specific disability was high, with participants reporting an average of 16.8 of the past 28 days (i.e., 60% of their days in the past four weeks) in which they were either confined to bed (5.6 days) or had to reduce their usual activities by 50% (11.2 days) because of pain or depression. Moreover, 176 (43%) participants reported being unable to work because of health-related reasons. Depression and pain had both individual and additive adverse associations with quality of life. Most patients were currently not receiving care from a mental health or pain specialist.

CONCLUSION

Depression and pain are prevalent and disabling across a wide range of types and phases of cancer, commonly co-occur, and have additive adverse effects. Enhanced detection and management of this disabling symptom dyad is warranted.

The interpersonal theory of suicide

Suicidal behavior is a major problem worldwide and, at the same time, has received relatively little empirical attention. This relative lack of empirical attention may be due in part to a relative absence of theory development regarding suicidal behavior. The current article presents the interpersonal theory of suicidal behavior. We propose that the most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs-thwarted belongingness and perceived burdensomeness (and hopelessness about these states)-and further that the capability to engage in suicidal behavior is separate from the desire to engage in suicidal behavior. According to the theory, the capability for suicidal behavior emerges, via habituation and opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences. In the current article, the theory's hypotheses are more precisely delineated than in previous presentations (Joiner, 2005), with the aim of inviting scientific inquiry and potential falsification of the theory's hypotheses.

The effect of chronic mild stress on tumor-bearing rats' behavior and its mechanism

OBJECT

Much evidence has demonstrated that stress and tumor interact, but the mechanisms are poorly understood. The purpose of this study is to discuss the effect of unpredictable chronic mild stress (CMS) upon the behavior of Walker 256 tumor-bearing rats and its mechanism.

METHODS

Observe the effects of CMS on the sucrose consumption, activities, body weight and levels of serums TNF-alpha and IL-6 of both tumor-bearing rats and non-tumor-bearing rats, and on the levels of Bcl-2 and the phosphor-ERK1/2 in their hippocampus.

RESULTS

CMS can reduce the average sucrose consumption, behavioral scores, body weight gain, expression of Bcl-2 and p-ERK1/2 protein in hippocampus, and increase serums TNF-alpha and IL-6 of both tumor-bearing rats and non-tumor-bearing rats. The stressed tumor-bearing rats had less sucrose consumption, body weight gain and lower behavioral scores, but higher level of serum TNF-alpha than stressed non-tumor-bearing rats. A negative correlation was found between the levels of serum TNF-alpha and sucrose consumption, while a positive correlation between the expression of Bcl-2 protein in hippocampus proper and sucrose consumption.

CONCLUSION

CMS can reduce the protein levels of Bcl-2 and p-ERK1/2 in the rats' hippocampus, which contributes to the changes in the rats' behavior caused by CMS. Tumor-bearing rats are prone to behave depressively after the exposure to CMS. Our findings have suggested that the tumor, by increasing the inflammatory reaction, can be taken as a stressor, affecting the hippocampus and consequently causing depression by decreasing the expression of Bcl-2 and p-ERK1/2 in hippocampus.

Consistent and breakthrough pain in diverse advanced cancer patients: a longitudinal examination

Although cancer pain, both consistent and breakthrough pain ([BTP]; pain flares interrupting well-controlled baseline pain), is common among cancer patients, its prevalence, characteristics, etiology, and impact on health-related quality of life (HRQOL) are poorly understood. This longitudinal study examined the experience and treatment of cancer-related pain over six months, including an evaluation of ethnic differences. Patients with Stage III or IV breast, prostate, colorectal, or lung cancer, or Stage II-IV multiple myeloma with BTP completed surveys on initial assessment and at three and six months. Each survey assessed consistent pain, BTP, depressed affect, active coping ability, and HRQOL. Among the respondents (n=96), 70% were white, 66% were female, and had a mean age of 56+/-10 years. Nonwhites reported significantly greater severity for consistent pain at its worst (P = 0.009), least (P < or = 0.001), on average (P = 0.004), and upon initial assessment (P = 0.04), and greater severity for BTP at its worst (P = 0.03), least (P = 0.02), and at initial assessment (P = 0.008). Women also had higher levels of some BTP measures. Ethnic disparities persisted when data estimation techniques were used. Examined longitudinally, consistent pain on average and several BTP measures reduced over time, although not greatly, indicating the persistence of pain in the cancer experience. These data provide evidence for the significant toll of cancer pain, while demonstrating further health care disparities in the cancer pain experience.

Depression in women with metastatic breast cancer: a review of the literature

OBJECTIVE

The aim of this article is to review the available literature on depression in women with metastatic breast cancer in terms of prevalence, potential risk factors, and consequences, as well as pharmacological and psychological interventions.

METHOD

An extensive review of the literature was conducted.

RESULTS

The prevalence of depression appears to be especially elevated in patients with advanced cancer. Many demographic, medical, and psychosocial factors may increase the risk that women will develop depressive symptoms during the course of their illness. Despite the fact that depression appears to be associated with numerous negative consequences, this disorder remains underdiagnosed and undertreated. Both pharmacotherapy and psychotherapy have been found to treat effectively depressive symptoms in this population, but cognitive-behavioral therapy appears to be the most cost-effective approach.

SIGNIFICANCE OF RESULTS

Areas for future research are suggested.

Preliminary Report of a Pilot Tele-Health Palliative Care and Bioethics Program for Residents in Skilled Nursing Facilities

Currently about 25% of Americans die in nursing homes, many with poorly controlled pain and other symptoms, with minimal provisions for psychosocial support. New models are necessary to lessen structural and process barriers to give effective end-of-life care in nursing homes.

Objectives

1) To extend hospital-based Bioethics Consultation Services (BCS) and Palliative Care Services (PCS) at Montefiore Medical Center (MMC) in the Bronx to two local Skilled Nursing Facilities (SNFs), Morningside House Aging in America (MSH) using direct face-to-face consultations and Beth Abraham Health Systems (BAHS) via video consultations (VC); 2) Achieve improvements in quality of life and comfort for elderly residents and their families; 2a) Improve the level of practice and increase staff satisfaction with palliative care content-related knowledge and bioethical analysis.

Methods

We report preliminary findings of this two group quasi experimental project with results of pre- and post-tests rating content-related knowledge in aspects of end-of-life care for staff. Select pre-test and post-test questions were given to physicians and other staff, but were re-configured for, registered and licensed practice nurses, social workers, and certified nursing assistants from the End-of-Life Physician Education Resource Center (EPERC). Patient, family, and staff ratings of the quality of palliative care were measured with a Palliative Outcomes Scale (POS) one week prior to and post consultation.

Results

72 staff attended in-services; 53 completed pre-tests and 49 post-tests. Overall knowledge scores increased for 9 of the 16 items that were analyzed. There were improvements in knowledge scores in 12 of 16 items tested for staff content related knowledge which were statistically significant in regard to management of cancer pain from 63.8% to 81.5% (p = 0.03) and a trend to significance for assessment and management of delirium from 31.6% to 61.9% (p = 0.073). Seventy five POS surveys were completed from 13 video-conferenced Palliative Care consultations and 14 direct face-to-face consultations from March 2008 to January 2009. There were improvements in ratings for some aspects of quality of care on the POS. Patient and staff aggregate response scores for the POS were significantly improved between baseline and follow-up (Wilcoxon signed-rank test p = 0.0143 and p = 0.005) at the videoconsultation site and for family and staff at the face-to-face consultation site (Wilcoxon signed-rank test p = 0.0016 and p = 0.0012).

Conclusion

Preliminary evidence suggests that use of real time videoconferencing to connect hospital-based Bioethics and Palliative Care clinicians with patients, families, and staff in Skilled Nursing Facilities may enhance some aspects of end-of-life care for their residents, as well as content related knowledge in core aspects of end-of-life care for interdisciplinary groups of staff or caregivers.

Cancer, mental disorders, suicidal ideation and attempts in a large community sample

PURPOSE

To determine the association between cancer diagnosis, mental disorders and suicidal behavior among community dwelling adults.

METHODS

Data were drawn from the nationally representative Canadian Community Health Survey Cycle 1.2 (N=36 984, response rate 77%, age 15+). Respondents were grouped into three age groups (15-54, 55-74, and 75+ years), and multiple regression analyses were conducted to examine the relationship between cancer and mental disorders: unadjusted and adjusted for sociodemographics, social supports and other mental disorders.

RESULTS

Among respondents aged 15-54, cancer was associated with increased odds of major depression (odds ratio [OR]=3.18; 95% confidence interval [CI]: 1.69-5.96), panic attacks (OR=2.15; 95% CI: 1.22-3.77) and any mental disorder. Among respondents aged 55-75, cancer was associated with increased odds of agoraphobia (OR=5.94; 95% CI: 1.68-21.03) and decreased odds of social phobia (OR=0.22; 95% CI: 0.06-0.80). Cancer was not associated with any mental disorder in the 75+ age group. Results persisted after adjustments for the covariates. Suicidal ideation was associated with cancer in the 55-74 age group (OR=5.07; 95% CI: 1.25-20.47) in unadjusted models; however, this relationship became non-significant when adjusting for the other covariates.

CONCLUSION

Clinicians should consider screening for depression and panic disorder in young, community dwelling patients with cancer.

Assessment and management of psychiatric issues during cancer treatment

Since its beginnings in the mid-1970s, the field of psycho-oncology has developed rapidly. A substantial body of literature has evolved toward identifying key issues for psychiatric treatment and care management of cancer patients. The spectrum of cancer care encompasses patient experiences through initial diagnosis, active treatment, after-care and survivorship, as well as palliative care and end-of-life. This article highlights recognition and management of psychiatric syndromes in the context of cancer care.

"I know he controls cancer": the meanings of religion among Black Caribbean and White British patients with advanced cancer

There is evidence that religion and spirituality affect psychosocial adjustment to cancer. However, little is known about the perceptions and meanings of religion and spirituality among Black and minority ethnic groups living with cancer in the UK. We conducted semi-structured interviews with 26 Black Caribbean and 19 White British patients living in South London boroughs with advanced cancer to explore how religion and spirituality influenced their self-reported cancer experience. Twenty-five Black Caribbean patients and 13/19 White British patients volunteered views on the place of religion or God in their life. Spirituality was rarely mentioned. Christianity was the only religion referred to. Strength of religious belief appeared to be more pronounced among Black Caribbean patients. Three main themes emerged from patients' accounts: the ways in which patients believed religion and belief in God helped them comprehend cancer; how they felt their faith and the emotional and practical support provided by church communities assisted them to live with the physical and psychological effects of their illness and its progression; and Black Caribbean patients identified the ways in which the experience of cancer promoted religious identity. We identified that patients from both ethnic groups appeared to derive benefit from their religious faith and belief in God. However, the manner in which these were understood and expressed in relation to their cancer was culturally shaped. We recommend that when health and social care professionals perform an assessment interview with patients from different cultural backgrounds to their own, opportunities are made for them to express information about their illness that may include religious and spiritual beliefs since these may alter perceptions of their illness and symptoms and thereby influence treatment decisions.

Tetrodotoxin for moderate to severe cancer pain: a randomized, double blind, parallel design multicenter study

Cancer pain is a serious public health issue and more effective treatments are needed. This study evaluates the analgesic activity of tetrodotoxin, a highly selective sodium channel blocker. This randomized, placebo-controlled, parallel design study of subcutaneous tetrodotoxin, in patients with moderate or severe unrelieved cancer pain persisting despite best available treatment, involved 22 centers across Canada. The design called for tetrodotoxin administered subcutaneously over Days 1-4 with a period of observation to Day 15 or longer. All patients could enroll into an open-label extension efficacy and safety trial. The primary endpoint was the proportion of analgesic responders in each treatment arm. Eighty-two patients were randomized, and results on 77 were available for analysis. There was a nonstatistically significant trend toward more responders in the active treatment arm based on the primary endpoint (pain intensity difference). However, analysis of secondary endpoints, and an exploratory post hoc analysis, suggested there may be a robust analgesic effect if a composite endpoint is used, including either fall in pain level, or fall in opioid dose, plus improvement in quality of life. Most patients described transient perioral tingling or other mild sensory phenomena within about an hour of each treatment. Nausea and other toxicities were generally mild, but one patient experienced a serious, adverse event, truncal and gait ataxia. This trial suggests tetrodotoxin may potentially relieve moderate to severe, treatment-resistant cancer pain in a large proportion of patients, and often for prolonged periods following treatment, but further study is warranted using a composite primary endpoint.