Symptom prevalence in the last week of life

The epidemiology of pain during the last 2 years of life

BACKGROUND

The epidemiology of pain during the last years of life has not been well described.

OBJECTIVE

To describe the prevalence and correlates of pain during the last 2 years of life.

DESIGN

Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status.

SETTING

The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006).

PARTICIPANTS

Older adult decedents.

MEASUREMENTS

Clinically significant pain, as indicated by a report that the participant was "often troubled" by pain of at least moderate severity.

RESULTS

The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195).

LIMITATION

Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available.

CONCLUSION

Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life.

PRIMARY FUNDING SOURCE

National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.

Symptoms in the month before death for stage 5 chronic kidney disease patients managed without dialysis

CONTEXT

There is little evidence on the symptoms experienced by those with advanced (Stage 5) chronic kidney disease (CKD), managed without dialysis, as they approach death. As palliative care extends to noncancer illnesses, understanding symptom prevalence and severity close to death will clarify which symptom interventions are most needed and which elements of (largely cancer-driven) models of palliative care best translate into end-of-life care for this population.

OBJECTIVES

To determine symptom prevalence and severity in the last month of life for patients with Stage 5 CKD, managed without dialysis.

METHODS

Longitudinal symptom survey in three U.K. renal units, using the patient-completed Memorial Symptom Assessment Scale-Short Form (MSAS-SF). We calculated the prevalence of individual symptoms (with 95% confidence intervals [CI] to reflect sample size), plus MSAS-SF subscales, in the month before death. Comparison is made with previously published data on symptoms in the last month of life in advanced cancer, also measured using the MSAS-SF.

RESULTS

Seventy-four patients (mean age: 81 years; standard deviation [SD]: 6.8) were recruited (response rate: 73%); 49 (66%) died during follow-up (mean age: 81 years; SD: 5.7). "Month before death" symptom data were available for 43 (88%) of the 49 participants who died. Median time of data collection was 18 days from death (interquartile range: 12-26 days). More than half had lack of energy (86%; 95% CI: 73%-94%), itch (84%; 70%-93%), drowsiness (82%; 68%-91%), dyspnea (80%; 66%-90%), poor concentration (76%; 61%-87%), pain (73%; 59%-85%), poor appetite (71%; 57%-83%), swelling arms/legs (71%; 57%-83%), dry mouth (69%; 55%-82%), constipation (65%; 50%-78%), and nausea (59%; 44%-73%). Levels of distress correspond to prevalence, with the exception of dyspnea, which was disproportionately more distressing. The median number of symptoms reported was 16.6 (range: 6-27), rising to 20.4 (range: 7-34) if additional renal symptoms were included. On average, psychological distress was moderate (mean MSAS-PSYCH: 1.55) but with wide variation (SD: 0.50; range: 0.17-2.40), suggesting diverse levels of individual distress. The prevalence of both physical and psychological symptoms and the number reported were higher than those in advanced cancer patients in the month before death.

CONCLUSION

Stage 5 CKD patients have clinically important physical and psychological symptom burdens in the last month of life, similar or greater than those in advanced cancer patients. Symptoms must be addressed through routine symptom assessment, appropriate interventions, and with pertinent models of end-of-life care.

The efficacy of haloperidol in the management of nausea and vomiting in patients with cancer

CONTEXT

Haloperidol is used commonly for the control of nausea and vomiting (N/V) in palliative care patients, but there is very little evidence to support its use.

OBJECTIVES

To assess the efficacy of haloperidol as an antiemetic in patients with cancer and N/V not related to cancer treatment.

METHODS

Patients with an N/V score of at least 1 on a 4-point scale were prescribed either oral or subcutaneous haloperidol. N/V and toxicity were assessed daily for the duration of the study (maximum five days) by both the patient and an observer (health professional).

RESULTS

At Day 2, 33 of 42 (79%) treated patients were assessable for response. Eight (24%; 95% confidence interval [CI]: 10%-39%) patients had complete control of N/V and 12 (36%; 95% CI: 20%-53%) had partial control, giving an overall response rate of 61% (95% CI: 44%-77%). At Day 5, 23 patients were assessable for response. The overall response rate was 17 of 23 (74%; 95% CI: 56%-92%). If all patients are included in the response analysis, the overall response rates at Days 2 and 5 were 47% and 40%, respectively.

CONCLUSION

Haloperidol has some efficacy in the treatment of N/V in this patient group. The results from this uncontrolled study provide pilot data from which to plan future controlled trials of antiemetics in the palliative care population.

A computer-assisted model for predicting probability of dying within 7 days of hospice admission in patients with terminal cancer

OBJECTIVE

The aim of the present study is to compare the accuracy in using laboratory data or clinical factors, or both, in predicting probability of dying within 7 days of hospice admission in terminal cancer patients.

METHODS

We conducted a prospective cohort study of 727 patients with terminal cancer. Three models for predicting the probability of dying within 7 days of hospice admission were developed: (i) demographic data and laboratory data (Model 1); (ii) demographic data and clinical symptoms (Model 2); and (iii) combination of demographic data, laboratory data and clinical symptoms (Model 3). We compared the models by using the area under the receiver operator curve using stepwise multiple logistic regression.

RESULTS

We estimated the probability dying within 7 days of hospice admission using the logistic function, P = Exp(betax)/[1 + Exp(betax)]. The highest prediction accuracy was observed in Model 3 (82.3%), followed by Model 2 (77.8%) and Model 1 (75.5%). The log[probability of dying within 7 days/(1 - probability of dying within 7 days)] = -6.52 + 0.77 x (male = 1, female = 0) + 0.59 x (cancer, liver = 1, others = 0) + 0.82 x (ECOG score) + 0.59 x (jaundice, yes = 1, no = 0) + 0.54 x (Grade 3 edema = 1, others = 0) + 0.95 x (fever, yes = 1, no = 0) + 0.07 x (respiratory rate, as per minute) + 0.01 x (heart rate, as per minute) - 0.92 x (intervention tube = 1, no = 0) - 0.37 x (mean muscle power).

CONCLUSIONS

We proposed a computer-assisted estimated probability formula for predicting dying within 7 days of hospice admission in terminal cancer patients.

A proposed prognostic 7-day survival formula for patients with terminal cancer

BACKGROUND

The ability to identify patients for hospice care results in better end-of-life care. To develop a validated prognostic scale for 7-day survival prediction, a prospective observational cohort study was made of patients with terminal cancer.

METHODS

Patient data gathered within 24 hours of hospital admission included demographics, clinical signs and symptoms and their severity, laboratory test results, and subsequent survival data. Of 727 patients enrolled, data from 374 (training group) was used to develop a prognostic tool, with the other 353 serving as the validation group.

RESULTS

Five predictors identified by multivariate logistic regression analysis included patient's cognitive status, edema, ECOG performance status, BUN and respiratory rate. A formula of the predictor model based on those five predictors was constructed. When probability was >0.2, death within 7 days was predicted in the training group and validation group, with sensitivity of 80.9% and 71.0%, specificity of 65.9% and 57.7%, positive predictive value of 42.6% and 26.8%, and negative predictive value (NPV) of 91.7% and 90.1%, respectively.

CONCLUSION

This predictor model showed a relatively high sensitivity and NPV for predicting 7-day survival among terminal cancer patients, and could increase patient satisfaction by improving end-of-life care.

The impact of palliative care consultation on symptom assessment, communication needs, and palliative interventions in pediatric patients with cancer

BACKGROUND

There are few data describing symptom prevalence in children with cancer. The available literature suggests that similar to adults, symptom prevalence and distress are high and that communication regarding end-of-life care needs is limited.

OBJECTIVES

We evaluated symptom prevalence, treatment recommendations, and communication about end-of-life care issues for children seen in pediatric palliative care consultation (PCC) at one National Cancer Institute-designated comprehensive cancer center. The goal of our study was to obtain baseline data to target areas in need of intervention.

METHODS

A retrospective chart review was conducted of consecutive patients referred to a newly initiated PCC service. Analysis was descriptive.

RESULTS

Over the 9-month study period, 15 children were referred. Median age was 13 years (2-24), with 10 males. Eleven children were receiving chemotherapy and/or radiation. Median number of documented symptoms at PCC was 5 per child (2-10). PCC universally resulted in the detection of symptoms not identified by the primary team, for a median of 3 new symptoms per patient (0-9). Documented communication about most end-of-life care issues with parents was uncommon, and rarely involved children. Initial PPCC resulted in recommendations for medication changes in 14 of 15 children, allied health consultation in 8, counseling in 11, patient care conference in 3, and family conference in 6. For the 12 patients who died, median time from PPCC to death was 8 days (1-96).

CONCLUSIONS

PCC, although late in the course, resulted in the detection of multiple symptom control and communication needs, and corresponding treatment recommendations.

Symptom Variability During Repeated Measurement Among Hospice Patients With Advanced Cancer

Aim: In this prospective study, we explored symptom variability in patients with cancer during repeated measurements. Methods: Patients with cancer admitted to an inpatient hospice completed a daily questionnaire throughout their admission. The questionnaire consisted of 5 visual analogue scales (VAS) for anxiety, depression, nausea, pain, and sedation and 3 verbal rating scales (VRS) for depression, pain, and vomiting. Data from those who completed 5 consecutive days were used for the primary analysis. We used all available data points to compare VAS and VRS. An index was developed to assess for daily symptom variability. Results/Discussion: A total of 125 hospice inpatients were enrolled; 46 (38%) completed 3 consecutive daily questionnaires and 30 (24%), 5 days. We found (1) a statistically significant decrease in severity of symptoms present on admission, (2) new symptoms developed, (3) consequently overall symptom prevalence on days 1 and 5 appeared unchanged, (4) high daily symptom variability as demonstrated by the variability index and also changing daily symptom interrelationships, (5) demographic characteristics influenced symptom patterns on admission and subsequently, (6) severe pain predicted more frequent and severe symptom burden only on admission, (7) severe depression predicted more frequent and severe symptom burden on admission and thereafter, (8) VAS scores for depression and pain did not correspond with discrete VRS categories (mild, moderate, severe). Conclusions: (1) Symptom studies in advanced disease while difficult to conduct yield valuable information, (2) symptom relationships changed daily; strict timing of data collection is crucial for data analysis, (3) symptom monitoring following admission is an overlooked measure of risk assessment, (4) symptom prevalence studies alone for treatment follow-up may be misleading, (5) depression is an important predictor of symptoms and need to be more aggressively assessed and treated, (6) demographic characteristics may help identify symptom patterns and better direct treatment, (7) VRS rather than VAS was more reliable for assessing symptoms in hospice cancer patients.

Symptom prevalence and longitudinal follow-up in cancer outpatients receiving chemotherapy

Palliative care for cancer patients receiving chemotherapy in the outpatient setting is important. The aims of this study were 1) to identify symptom prevalence and intensity in cancer patients receiving chemotherapy and 2) to describe longitudinal follow-up data obtained from repeated assessment using the distress thermometer (DT). Questionnaires were distributed to consecutive cancer outpatients newly starting chemotherapy at the first appointment and at every hospital visit. The questionnaire included the severity of 11 symptoms (M. D. Anderson Symptom Inventory [MDASI], Japanese version), the DT, and the need for help in four psychosocial areas (decision-making, economic problems, nutrition, and daily activities). In total, 4000 questionnaires were returned by 462 patients. The frequently identified problems were oral problems (21%), insomnia (19%), psychological distress (defined as a DT score of 6 or more; 15%), help with information and decision-making (14%), severe fatigue (8.2%), and severe appetite loss (6.3%). Cluster analysis identified four symptom clusters: 1) fatigue and somnolence; 2) pain, dyspnea, and numbness; 3) nausea, appetite loss, and constipation; and 4) psychological distress. Of 165 patients with a DT of score 6 or more, 115 patients (70%) demonstrated a DT score below 6 at a median of 17 days follow-up. In the remaining 50 patients who had a DT score of 6 or more at follow-up, 34 patients (68%) had one or more physical symptoms rated at 7 or more on an 11-point numeric rating scale. Compared with patients with a DT score below 6 at follow-up, patients with a DT score of 6 or more at follow-up had higher levels of all physical symptoms. Frequent symptoms experienced by cancer outpatients receiving chemotherapy may be categorized as: 1) psychosocial issues (insomnia, psychological distress, decision-making support); 2) nutrition-gastrointestinal issues (oral problems, appetite loss, nausea); 3) fatigue; and 4) pain, dyspnea, and numbness. Developing a systematic intervention program targeting these four areas is urgently required. The DT score may be highly influenced by coexisting physical symptoms, and future studies to develop an appropriate system to identify patients with psychiatric comorbidity are necessary.

Research participation by older adults at end of life: barriers and solutions

The purpose of this article is to elaborate on barriers to research participation by older adults at end of life. We focus on the hospice setting and classify barriers to research participation into six domains: societal attitudes toward death, research procedures, health care organizations, agency staff, patients' families and caregivers, and patient characteristics. We characterize particular participation issues, uncertainties in participation for individuals with advanced illness, and infringements on patient self-determination, as well as potential solutions to these research challenges. Our observation of the complex palliative context includes the realization that a singular change will not have large enough impact on participation. We conclude that, along with the responsibility to expand the research base addressing the needs of dying individuals, there is also a need to understand the challenges of implementing research projects with older adults at end of life.

Fatigue in cancer: a review of literature

Fatigue is a common symptom of advanced cancer limiting one's activity and affecting the quality of life. It is a multidimensional symptom complex with subjective and objective components. Hence, its definition and assessment seems arbitrary, incomplete, and elusive. Components of fatigue often merge with other 'disease states' as anemia, depression and so on, compounding difficulty to assess it separately. Fatigue has a high prevalence rate, and lasts longer in chronic diseases like cancer. Its association with treatment modalities like chemotherapy, radiotherapy alongside the primary disease process makes it seemingly ubiquitous in many cases. Systemic manifestation of cancer causes excess demand on body resources on cell repair, uncontrolled growth with metabolite accumulation causing fatigue. Co-morbid conditions of organic and psychological nature causes fatigue. There are many assessment tools for fatigue with different uses and objectives, simple and reproducible tools like Brief Fatigue Inventory, Edmonton Symptom assessment scale seem feasible in everyday practice. Management of fatigue is not straightforward and rewarding. Although treatment of cause appears to be an attractive option, it is not possible in all cases. Therapeutic agents targeting cytokine load is in early stages of study and available results are not favorable. Specific measures aimed at pain relief, prevention/treatment of sepsis, management of depression, avoidance of drugs causing fatigue, restoring the metabolic profile are important. Methyl phenidate, megestrol, and modafinil are some drugs with promising effect to treat fatigue, though confirmatory studies are yet to be established. Non-pharmacological methods are also helpful. Forewarning patients on upcoming fatigue, active regular exercise, and stress management are some of them. Fatigue being a multidimensional entity, single mode of therapy is insufficient. Combined modality tailored to individual patient need and understanding may be the right way to battle this ill-understood symptom. This review article examines the etiopathogenesis and management strategies of fatigue in cancer.

Dyspnea--a bad prognosis symptom at the end of life

PURPOSES

Dyspnea as refractory symptom leading to sedation at the end of life and the place of death. Survival study in population with dyspnea.

METHODS

Longitudinal study of terminally ill patients in a year (n = 195). We divided populations as (a) population with dyspnea: prevalent and incident dyspnea and (b) population without dyspnea. We used the statistical program Stata9 (Kaplan-Meier and Cox logistic regression models).

RESULTS

The probability of being sedated was 5 times higher in population with dyspnea. Dying in hospital odds ratio was 2.13 in patients with dyspnea. The average survival time was 52 days in patients with dyspnea and 69 in non-dyspnea patients. The average survival was similar between both groups. Patients with incident dyspnea showed a higher average survival than those with prevalent dyspnea.

CONCLUSIONS

The connection between dyspnea and sedation was clearly shown. There were significant differences between prevalent dyspnea and incident dyspnea groups.

Are one or two simple questions sufficient to detect depression in cancer and palliative care? A Bayesian meta-analysis

The purpose of this study is to examine the value of one or two simple verbal questions in the detection of depression in cancer settings. This study is a systematic literature search of abstract and full text databases to January 2008. Key authors were contacted for unpublished studies. Seventeen analyses were found. Of these, 13 were conducted in late stage palliative settings. (1) Single depression question: across nine studies, the prevalence of depression was 16%. A single ‘depression’ question enabled the detection of depression in 160 out of 223 true cases, a sensitivity of 72%, and correctly reassured 964 out of 1166 non-depressed cancer sufferers, a specificity of 83%. The positive predictive value (PPV) was 44% and the negative predictive value (NPV) 94%. (2) Single interest question: there were only three studies examining the ‘loss-of-interest’ question, with a combined prevalence of 14%. This question allowed the detection of 60 out of 72 cases (sensitivity 83%) and excluded 394 from 459 non-depressed cases (specificity of 86%). The PPV was 48% and the NPV 97%. (3) Two questions (low mood and low interest): five studies examined two questions with a combined prevalence of 17%. The two-question combination facilitated a diagnosis of depression in 138 of 151 true cases (sensitivity 91%) and gave correct reassurance to 645 of 749 non-cases (specificity 86%). The PPV was 57% and the NPV 98%. Simple verbal methods perform well at excluding depression in the non-depressed but perform poorly at confirming depression. The ‘two question’ method is significantly more accurate than either single question but clinicians should not rely on these simple questions alone and should be prepared to assess the patient more thoroughly.

Clinical experience of the use of a pharmacological treatment algorithm for major depressive disorder in patients with advanced cancer

The objective of this study was to describe the applicability and the dropout of the pharmacological treatment algorithm for major depressive disorder in patients with advanced cancer. Psychiatrists treated major depressive disorder in advanced cancer patients on the basis of the algorithm. For discussing the problems related to the algorithm, we reviewed the reasons for the non-application of the algorithm and the reasons for dropout of patients within a week of initiation of treatment. The algorithm was applied in 54 of 59 cases (applicability rate, 92%). The reasons for the non-application of the algorithm were as follows: the need to add a benzodiazepine to an antidepressant in 4 cases and the need to choose alprazolam despite the depression being moderate in severity, in order to obtain a rapid onset action and reduce anxiety in a patient with short prognosis. Nineteen of the 55 patients dropped out within a week of initiation of treatment based on the algorithm. Delirium was the most frequent reason for dropout. The applicability rate was high, but several problems were identified, including those related to the combination of antidepressants and benzodiazepines, pharmacological treatment of depression in patients with short prognosis, and delirium due to antidepressants.

Changes in symptoms and pain intensity of cancer patients after enrollment in palliative care at home

This study describes the activities and interventions carried out by an at-home palliative care team treating cancer patients who died within two years of being enrolled in a palliative care program. It analyzes which changes in symptoms and pain occurred and which sociodemographic and medical characteristics were related to these changes. The analysis is based on 102 cancer patients. Data were collected through systematic registration during the palliative care process. At enrollment, patients were interviewed by the coordinating general practitioner concerning their sociodemographic background, medical history, psychological status, and symptoms. During the palliative care process, symptoms and functioning of the patients were recorded by the physician and nurses. The results show that cancer patients enrolled in palliative care at home have many symptoms, often associated with metastatic disease and comorbidities. The palliative care teams delivered frequent and various interventions. The number of symptoms decreased considerably, as did pain intensity and the intensity of other symptoms. Patients living in urban areas and with low income particularly benefited from a reduction in the number of symptoms they displayed. Cancer patients who needed palliative care benefited significantly from this at-home palliative care service.

High prevalence of pain in patients with cancer in a large population-based study in The Netherlands

At present, no definite conclusions can be drawn about the real extent of the pain suffered by cancer patients. A population-based study was conducted to obtain reliable information about the prevalence and severity of pain in cancer patients (all phases) and about predictors of pain. A representative sample of cancer patients was recruited in the area from a cancer registry. Pain was assessed by the Brief Pain Inventory (BPI). Adequacy of pain treatment was assessed with the Pain Management Index (PMI). We found that 55% of the 1429 respondents had experienced pain past week; in 44% (n=351), the pain was moderate to severe (BPI score>or= 4). Total prevalence of pain/moderate to severe pain was present in 49%/41% in patients with curative treatment >or=6 months ago, 57%/43% in patients with current curative treatment or treatment <6 months ago, 56%/43% in patients with current palliative anti-cancer treatment and in 75%/70% in patients for whom treatment was no longer feasible. Positive predictors of the prevalence of pain were lower education level, more advanced disease and haematological (excluding (non)-Hodgkin lymphoma), gastro-intestinal, lung, or breast malignancies. According to the PMI, analgesic treatment was inadequate in 42% of the patients. Negative predictors of adequate treatment were current curative anti-cancer treatment and low education level.

CONCLUSION

A substantial proportion of cancer patients does suffer from moderate to severe pain and does not receive adequate pain treatment.

Oropharyngeal dysphagia: the experience of patients with non-head and neck cancers receiving specialist palliative care

BACKGROUND

Difficulty swallowing is a well-documented symptom in head and neck cancer and oesophageal malignancy. The frequency of oropharyngeal swallowing difficulties in the palliative phase of other malignancies is less reported.

AIM

1) To describe the patient experience of swallowing and associated difficulties while receiving specialist palliative care for malignancies other than those affecting the head and neck and 2) to identify the quality of life issues for the participants with dysphagia and compare with normative and dysphagic data provided by SWAL-QOL.

DESIGN

Four month prospective pilot study - questionnaire design.

SETTING

Acute teaching hospital.

PARTICIPANTS

Eleven patients receiving specialist palliative care.

METHODS

Participants were interviewed using a modified version of the SWAL-QOL, a validated quality of life assessment tool for use specifically with people with oropharyngeal dysphagia. Eight quality of life domains were explored as well as fourteen dysphagic symptoms.

RESULTS

Seven of the 11 participants had dysphagic symptoms detailed in the SWAL-QOL and a further two patients reported transient dysphagic symptoms since diagnosis of their disease. Nine participants reported an impact on their quality of life and three reported a considerable impact in four or more domains. Eight of the 11 participants had self-selected softer textured foods. A notable group were three patients with lung cancer and one with lung metastases with a history of vocal fold motion impairment, all of who had experienced dysphagic symptoms since diagnosis.

CONCLUSIONS

Patients with cancers not affecting the head and neck are at risk of developing symptoms of oropharyngeal dysphagia and subsequently, compromized nutrition, hydration and quality of life. Areas for further research are suggested.

Symptoms in patients receiving palliative care: a study on patient-physician encounters in general practice

Most people with an incurable disease prefer to stay and die at home, cared for by their general practitioner (GP). This paper aims at describing the prevalence of symptoms in patients receiving palliative care at home. Within the framework of a nation wide survey of general practice in the Netherlands, GPs received a questionnaire for all patients who died within the 1-year survey period to determine whether patients received palliative care (n = 2,194). The response rate was 73% (n = 1,608), and 38% of these patients received palliative care until death. Information regarding encounters during the last 3 months of life was derived from the records kept by the GPs. Digestive symptoms (59%) and pain (56%) were the most prevalent. The total number of symptoms per patient was higher in cancer patients (11.99) than in non-cancer patients (7.62). Not reported in previous studies were musculoskeletal symptoms (20%) and chronic ulcer (18%). Concluding, this showed that Dutch GPs encounter a diversity and wide range of symptoms in palliative care. To face these complex challenges in patients receiving palliative care at home, GPs have to be trained as well as supported by specialized palliative care consultants.

Symptom prevalence in patients with incurable cancer: a systematic review

The suffering of patients with incurable cancer is determined to a large degree by the presence and intensity of the symptoms of their disease. Knowledge of symptom prevalence is important for clinical practice. The main aim of this study was to obtain a reliable estimation of symptom prevalence in patients with incurable cancer by performing a systematic review of studies assessing this topic. We included 44 studies (including 25,074 patients) on overall symptom prevalence (Group 1) and six studies (including 2,219 patients) on symptom prevalence during the last one to two weeks of life (Group 2). In these studies, symptom prevalence was assessed by a questionnaire, a standardized interview, or the medical record. We identified 37 symptoms assessed in at least five studies. Almost all symptoms occurred in more than 10% of the patients. Five symptoms (fatigue, pain, lack of energy, weakness, and appetite loss) occurred in more than 50% of the patients of Group 1. Weight loss occurred significantly more often in Group 2 compared to Group 1, and pain, nausea, and urinary symptoms occurred significantly less often. Generally, symptom prevalence was highest if assessed by a questionnaire. The results of this study should be used to guide doctors and nurses in symptom management. Proper attention to symptom burden and suffering should be the basis for individually tailored treatment aimed at improving or maintaining quality of life of patients in their last period of life.

Are anxiety and depressed mood related to physical symptom burden? A study in hospitalized advanced cancer patients

BACKGROUND

Anxiety and depressed mood are common symptoms in hospitalized advanced cancer patients. It is often presumed that anxiety and depression affect the occurrence and experience of physical symptoms.

PURPOSE

To analyse the relation between anxiety, depressed mood and the presence and intensity of physical symptoms.

PATIENTS AND METHODS

Anxiety and depressed mood were assessed in a hospitalized advanced cancer population (n = 79) primarily by the Hospital Anxiety and Depression Scale (HADS), and also by a single-item question ;Are you anxious and/or depressed?' and by the Edmonton Symptom Assessment System (ESAS). Physical symptoms were assessed by a semi-structured interview and by the ESAS.

RESULTS

Thirty-four percent of the patients reported anxiety, 56% depressed mood and 29% both, as assessed by the HADS. The correlations between HADS, the single-item question and the ESAS were low. No association was found between anxiety or depressed mood and the presence of physical symptoms. Patients who were anxious or depressed had higher ESAS scores for insomnia and drowsiness; scores for pain, anorexia, asthenia, nausea and dyspnea were independent of anxiety and/or depressed mood.

CONCLUSION

The relationship between anxiety, depressed mood and the presence and intensity of physical symptoms in hospitalized advanced cancer patients is very limited.

Prevalence of pain in patients with cancer: a systematic review of the past 40 years

BACKGROUND

Despite the abundant literature on this topic, accurate prevalence estimates of pain in cancer patients are not available. We investigated the prevalence of pain in cancer patients according to the different disease stages and types of cancer.

PATIENTS AND METHODS

A systematic review of the literature was conducted. An instrument especially designed for judging prevalence studies on their methodological quality was used. Methodologically acceptable articles were used in the meta-analyses.

RESULTS

Fifty-two studies were used in the meta-analysis. Pooled prevalence rates of pain were calculated for four subgroups: (i) studies including patients after curative treatment, 33% [95% confidence interval (CI) 21% to 46%]; (ii) studies including patients under anticancer treatment: 59% (CI 44% to 73%); (iii) studies including patients characterised as advanced/metastatic/terminal disease, 64% (CI 58% to 69%) and (iii) studies including patients at all disease stages, 53% (CI 43% to 63%). Of the patients with pain more than one-third graded their pain as moderate or severe. Pooled prevalence of pain was >50% in all cancer types with the highest prevalence in head/neck cancer patients (70%; 95% CI 51% to 88%).

CONCLUSION

Despite the clear World Health Organisation recommendations, cancer pain still is a major problem.

Fatigue and Its Associated Factors in Hospice Cancer Patients in Taiwan

Fatigue is one of the most distressful problems faced by terminally ill cancer patients, but few studies have explored fatigue experiences in this population. The purpose of this descriptive correlational study was to examine fatigue status and its related factors in terminally ill cancer patients in an institutionalized hospice in Northern Taiwan. Data were collected using the Fatigue subscale of the Profile of Mood States, modified Symptom Distress Scale, Hospital Anxiety and Depression Scale, Karnofsky's Performance Status Index and a background information form. We found that patients generally had moderate to severe levels of fatigue. Fatigue was associated with the overall symptom distress, depression, anxiety, and performance status. Furthermore, fatigue was significantly correlated with 8 individual distressful symptoms: nausea, vomiting, lack of appetite, sleep disturbance, dyspnea, dry mouth, restlessness, and problems of concentration. These results suggest that fatigue is still a problem faced by terminally ill cancer patients. To provide better care to this population, the above-mentioned fatigue-related factors should be simultaneously assessed and cared for. The authors recommend examining the causal relationship between these factors and fatigue, using symptom cluster concepts and skills to examine the possible shared mechanisms among fatigue and related symptoms and developing interventions to decrease fatigue in terminally ill cancer patients.

Symptom experience in the last year of life among individuals with cancer

Individuals with cancer often experience many symptoms that impair their quality of life at the end of life. This study examines symptom experience at end of life among individuals with cancer, and determines if symptom experience changes with proximity to death, or differs by depressive symptomatology, sex, site of cancer, or age. A secondary analysis of data from three prospective, descriptive, longitudinal studies (n=174) was performed, using a three-level hierarchical linear model. Fatigue, weakness, pain, shortness of breath, and cough were the five most prevalent symptoms in the last year of life. The symptom experience in the last year of life was significantly associated with site of cancer, depressive symptomatology, dependencies in activities of daily living, and independent activities of daily living at the start of the study. These findings shed light on the symptom experience in the last year of life for individuals with cancer. With greater understanding of the symptom experience, intervention strategies can be targeted to achieve the desired outcome of increased quality of life at the end of life.

Symptom control in palliative care--Part I: oncology as a paradigmatic example

Achieving the best quality of life for patients and their families when a disease becomes progressive and no longer remains responsive to curative therapy is the primary goal of palliative care. A comprehensive care plan focusing on control of physical symptoms as well as psychological, social, and spiritual issues then becomes paramount in that context. Symptom assessment and treatment are a principle part of palliative care. This paper is the first of three in a series addressing non-pain symptoms, which are frequently encountered in the palliative care populations. The most frequent non-pain symptoms are constipation, chronic nausea and vomiting, anorexia, dyspnea, fatigue, and delirium. As symptoms are subjective, their expression varies from patient to patient, depending on the individual patient's perception and on other factors such as psychosocial issues. While symptoms are addressed individually, patients frequently have multiple coexisting symptoms. Generally told, once the intensity of a symptom has been assessed, it is necessary to assess the symptom in the context of other symptoms such as pain, appetite, fatigue, depression, and anxiety. Given that fact, adopting a multidimensional assessment allows for formulation of a more effective therapeutic strategy. More pertinently, this paper highlights the management of non-pain symptoms as an integral part of patient care and reviews the pathophysiologies, causes, assessment, and management of constipation, chronic nausea, and vomiting, each of which is common among the palliative care population.

Prognostic significance of symptoms of hospitalised advanced cancer patients

PURPOSE

To assess the prognostic value of symptoms in hospitalised advanced cancer patients.

PATIENTS AND METHODS

A prospective analysis was performed of 181 hospitalised patients referred to a Palliative Care Team. Comprehensive symptom questionnaire, functional status, estimated life expectancy and survival were assessed. Using a Cox regression model, a predictive survival model was built.

RESULTS

Median survival: 53 d. Median number of symptoms: 4; 20 symptoms occurred in 10%. Multivariate analysis showed nausea, dysphagia, dyspnoea, confusion and absence of depressed mood as independent prognostic factors for survival (p<0.05) with relative risks of dying of 1.96, 1.81, 1.79, 2.35 and 1.79, respectively. Patients with 2, 3 or 4 of these factors at the same time had a relative risk of dying of 2.7, 2.1 and 9.0, respectively.

CONCLUSION

A cluster of factors comprising nausea, dysphagia, dyspnoea, confusion and absence of depressed mood may be used to accurately predict survival in hospitalised advanced cancer patients.

Two methods for predicting limited life expectancy in nursing homes

PURPOSE

To compare two methods of identifying nursing home residents with a life expectancy of 6 months or less.

DESIGN

Secondary analysis of Minimum Data Set (MDS) assessment data from 111 U.S. nursing homes was used in two approaches to compare the prognostic value of each approach. MDS assessment data were collected during 2003 and 2004, and secondary analyses were completed during 2004 and 2005.

METHODS

A bivariate analysis was used to identify variables associated with death within 6 months and a summative index was produced. Second, logistic regression was performed to develop a formula for calculating a Probability of Death score.

FINDINGS

Both methods were reasonably sensitive in identifying dying residents. In the total sample of 21,852 residents, 17.5% died within 6 months. When the bivariate analysis and summative index were used, 51.1% of residents who had a score of 4 or higher died within 6 months, and residents who scored 10 or higher had an 80% mortality rate. With use of the logistic regression and Probability of Death scores, 52% of residents who had scores of 0.4 or higher died within 6 months, and residents who scored 0.9 or higher had an 80% mortality rate.

CONCLUSIONS

MDS assessment data, collected in all U.S. nursing homes, can be useful to increase the specificity of identifying terminal residents. These statistical methods have high and similar prognostic values, but the summative index is easier to understand. It also is more user-friendly and could be incorporated into the nursing home assessment process with minimal additional training, and with no additional hardware or changes in software programming.

Cancer symptom assessment instruments: a systematic review

PURPOSE

A variety of assessment instruments have been created to identify cancer symptoms. We reviewed systematically cancer symptom assessment instruments published in English.

METHODS

A systematic search of the MEDLINE database, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and EMBASE was performed. Non-peer-reviewed articles were identified through BIOSIS. Articles were accessed through the related article links in PubMed and references were searched by hand. Studies were included if the instrument had symptom assessment as the primary outcome. Quality-of-life instruments were excluded.

RESULTS

We identified 21 instruments; some had undergone modification or validation. An additional 28 studies examined symptom prevalence and interrelations; many involved symptom checklists. Studies varied in design, patient characteristics, symptoms, and outcome. Meta-analysis was not possible due to heterogeneity in design, study outcomes, and validation. Seventy-six articles and two conference abstracts (derived from MEDLINE, Cochrane, CINAHL, EMBASE, BIOSIS, related articles link in PubMed, and search by hand) met inclusion/exclusion criteria. The electronic search (without related links) yielded only 26% of those articles and conference abstracts that met inclusion criteria. Searches by hand of related articles identified 59% of studies.

CONCLUSION

Twenty-one instruments were identified as appropriate for clinical use. The instruments vary in symptom content and extent of psychometric validation. Both comprehensive and shorter instruments have been developed, and some instruments are intended for specific symptom assessment or symptoms related to treatment. There is no ideal instrument, and the wide variety of instruments reflects the different settings for symptom assessment. Additional research is necessary.

Self-Report Instruments for Fatigue Assessment: A Systematic Review

This systematic review analyzed 18 self-reported fatigue instruments for adults. Five databases were searched combining fatigue with instrument, questionnaire, inventory, scale, or assessment. Eighteen fatigue instruments and six definitions of fatigue were found. Six instruments apply to physical or psychiatric disease; five are cancer-specific. Nine were unidimensional; others included intensity (n= 10), mental (n= 7), and physical (n= 7) dimensions. Eleven instruments had 15 or fewer items; the longest had 40 items. Four instruments were discriminative; 14 were evaluative. Fifteen assessed reliability using Cronbach’s alpha, which was greater than or equal to .90 seven times. Validity tests were convergent or divergent (n= 11), discriminant (n= 10), and factor analysis (n= 9). Because fatigue is a highly prevalent limiting symptom, this review is important for improving fatigue assessment.

Symptom priority and course of symptomatology in specialized palliative care

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.

Cancer Anorexia-Cachexia Syndrome

The majority of patients with advanced cancer experience weight loss, reduced appetite, fatigue, and weakness. Chronic nausea and early satiety may also occur. This constellation of symptoms is known as the cancer anorexia-cachexia syndrome. Together with cancer pain, cancer anorexia-cachexia syndrome has been identified as 1 of the 2 most frequent and devastating problems affecting individuals with advanced malignancies. Research examining the issue of cancer anorexia-cachexia syndrome has been conducted; however, such work is largely biomedical in orientation. In contrast, the psychologic dimensions of the cancer anorexia-cachexia syndrome experience from the perspective of terminally ill patients and their family members is less well explored or described. The ability to provide psychosocial support to patients and families requires that caregivers appreciate the psychologic effect of cancer anorexia and cachexia on these individuals. This article examines that effect in light of existing knowledge and discusses the clinical implications arising from this work.

Analysis of symptom assessment and management content in nursing textbooks

This article reports on one goal of a project designed to improve end-of-life (EOL) care in nursing education. The goal was to improve the content regarding pain and EOL care included in major textbooks used in nursing education. A descriptive study design was selected using content analysis of 50 texts selected from a potential of over 700 texts. The 50 texts included 45,683 pages. The text review was conducted using an analysis framework encompassing 9 essential areas of EOL care. The study methods included content analysis as well as quantification of the content present in the texts. The 9 areas of the analysis framework were: palliative care defined; quality of life; pain; other symptom assessment/management; communication with dying patients and families; role/needs of family caregivers in EOL care; death; issues of policy, ethics, and law; and bereavement. This article reports on the findings of the analysis related to symptom assessment/management. Nursing texts have limited content on symptom assessment and management. Increased attention to this area, a critical role of nursing, is essential to improved care for patients at EOL.

Symptom distress as rated by advanced cancer patients, caregivers and physicians in the last week of life

OBJECTIVES

To study the symptom distress as rated by patients with advanced cancer during their last week of life, and to compare patients' ratings with those perceived by caregivers and physicians.

METHOD

This was a prospective study on all patients admitted to the Hospice Unit of the Caritas Medical Centre with an estimated life expectancy of two weeks or less from May 2002 to September 2002. A questionnaire with a list of 13 symptoms, including pain, dyspnoea, nausea, vomiting, dry mouth, cough, fatigue, cachexia, anorexia, constipation, diarrhoea, insomnia and haemoptysis, was administered to assess the distress. Distress was rated by a verbal rating scale consisting of five grades (grade 0 to grade 4). Patients, caregivers and physicians completed the questionnaire weekly until the patient died. Only the questionnaires completed in the last week of life were included for analysis.

RESULTS

Of 82 patients who were recruited in the study, 30 patients were able to complete the questionnaire within the last week of life. Their median age was 69 years and the gender ratio was 1:1. Lung cancer was the most common primary tumour. Fatigue, cachexia and anorexia caused distress of all grades in nearly all 30 patients and caused significant distress of grade 3 and above in two-thirds of patients. Neither the caregivers nor the physicians gave congruent distress scores for these three symptoms (kappa<0.4). Caregivers' ratings agreed well with those of patients for five symptoms (kappa>0.4, P<0.005), including dyspnoea, cough, dry mouth, constipation and insomnia. For physicians, good agreement was found for three symptoms only, including pain, dyspnoea and cough. Moreover, physicians tended to underrate the distress.

CONCLUSION

Fatigue, cachexia and anorexia were the three most distressful symptoms in the last week of life in this group of patients, but caregivers and physicians failed to rate them in agreement with patients.

Health Problems Encountered by Dying Patients Receiving Palliative Home Care Until Death

Many of the studies reviewing the needs of the dying patient have used specified time points rather than following the patients through the last span of their lifetime, until death. This prospective study, using clinical records and nursing anecdotes, examined the health problems encountered by dying patients receiving home care from referral to home care until death. Thirty-two subjects were recruited in the study. The clinical records were content-analyzed using the Omaha system, and the anecdotes of the nurses were used to illuminate the numerical findings. This study reveals that patients who were discharged home were living in good environmental and social conditions. The physical symptoms were generally well controlled, except for dyspnea. The psychological aspects caused the most concern to patients, families, and healthcare professionals. The severity of the psychological signs and symptoms was moderate at the time of the initial visits, but improved toward the final visits. Understanding the needs of palliative home care patients can facilitate the healthcare team to plan care to support "good dying" of these patients.

A prospective study of the pathophysiology and clinical characteristics of pain in a palliative medicine population

Comprehensive pain evaluation is requisite for optimal management. Few studies have evaluated pain syndromes and adequacy of associated analgesic regimens in one population. Available studies in cancer populations have focused on ambulatory patients or hospice-type inpatients. This study was designed to evaluate multiple characteristics of pain and adequacy of therapy in a broad spectrum of patients with advanced cancer presenting to a palliative medicine service. One hundred pain patients (95 with cancer) underwent a comprehensive pain evaluation consisting of history, physical examination, review of available diagnostics, and a pain assessment tool designed for routine clinical use. Seventy-one percent of 141 evaluable patients reported pain in the month before referral. In these 100 patients, 158 distinct sites of pain were reported, with 88 percent reporting a maximum of 2. Pain due to tumor was the most common cause (68 percent), and the most common pathophysiologic mechanism, somatic (52 percent). Pain was almost equally divided between continuous (48 percent) and intermittent (52 percent). Breakthrough pain occurred in 75 percent of continuous pains. Of these, 30 percent were exclusively incidental, 26percent nonincidental, and 16 percent due to end-of-dose failure. The remainder was of mixed etiology, but almost always with an incidental component. Of intermittent pain syndromes, 61 percent were incidental. On referral, analgesic dosing was inadequate and was compounded by use of regimens that typically did not meet peer-reviewed guidelines. Comprehensive studies rigorously evaluating characteristics of pain and response to treatment are a necessary first step toward more effective treatments for difficult pain syndromes.

COX-2 Selective NSAIDs and Advancing Legal Issues in Palliative Care

The role of the cycloxygenase-2 selective NSAIDs in palliative care has not been studied, per se, but the improved adverse gastrointestinal and platelet effect profiles of these newer agents over nonselective NSAIDs offers potential advantages in patients with advanced disease. These issues are discussed. The need for greater emphasis on scientific and evidence-based approaches to palliative care is great and generally recognized in the clinical and scientific communities. Recent legal opinions about aggressive care of patients approaching end of life has increased this need. The clinical and ethical implications of these decisions are discussed.

The Validity and Clinical Utility of Symptom Monitoring in Advanced Lung Cancer: A Literature Review

Symptom monitoring and quality-of-life (QOL) evaluation in lung cancer patients might improve care. Brief, valid, and responsive tools are available to measure symptoms and their effect on QOL. Instruments available for use in lung cancer patients can be classified into 3 categories: generic, cancer-specific, and lung cancer symptom-specific. These instruments might assist clinicians in assessing and interpreting treatment outcomes from the patient perspective. They also can assist in treatment decision making, symptom palliation, and they might even be prognostic of survival. Over the past 20 years, these brief evaluations have been used in clinical trials to evaluate patient-reported outcomes. Now, with the advent of less toxic, targeted molecular therapies such as gefitinib (Iressa) in non-small-cell lung cancer, these instruments' value in showing symptomatic improvement from tumor control or regression might be further enhanced. To date, however, such assessments are not widely implemented in routine clinical practice. To better understand benefits of such assessments, we review existing evidence surrounding the instruments' use, evaluate their success, and highlight recent developments. We hope to encourage clinicians to incorporate these evaluations in clinical practice.

Care of the dying: is pain control compromised or enhanced by continuation of the fentanyl transdermal patch in the dying phase?

The introduction of fentanyl transdermal patches has led to concern and confusion regarding the management of pain control in the dying phase. Data were collected retrospectively from 94 dying patients. Two groups were identified-patients treated with fentanyl transdermal patch who remained on the patch in the dying phase and patients on oral morphine who converted to a 24-hour subcutaneous infusion of diamorphine via a syringe driver in the dying phase. Both the fentanyl group and the diamorphine group had good pain control in the last 48 hours of life. During the last 48 hours of life, the proportion of patients with controlled pain was statistically significant in favor of the fentanyl group in 2 of the 12 observations undertaken, in particular whether the fentanyl transdermal patch should be continued or discontinued. Patients in the fentanyl group received fewer "as required" opioid doses compared to patients in the diamorphine group, although the difference was statistically significant only for the last day of life. This study showed that pain control was not compromised in the dying phase with continued use of the fentanyl patch.

The measurement, causes and effective management of cancer-related fatigue

A review of research into cancer-related fatigue undertaken since 1995 is presented. The manner in which such fatigue varies with cancer diagnosis, stage of disease and anti-cancer treatment is discussed, and the causes of cancer-related fatigue are categorized according to whether they are cancer-specific, common to other chronic illnesses or common to the general population. Interventions to alleviate fatigue are discussed in terms of whether they are pharmacological or non-pharmacological in nature. It is concluded that cancer-related fatigue is a common problem with a major impact on quality of life. It shares a common aetiology with other forms of fatigue. Graded aerobic exercise has been shown in randomized controlled trials to be an effective intervention in specific patient groups. Less direct evidence supports the use of psychological interventions, but there is very little evidence to support the use of pharmacological treatment, with the possible exception of erythropoietin therapy for anaemic patients undergoing chemotherapy.

Self-assessment in cancer patients referred to palliative care: a study of feasibility and symptom epidemiology

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Xerostomia in patients with advanced cancer

The aim of the study was to investigate the features of xerostomia in patients with advanced cancer. The protocol involved completion of the Memorial Symptom Assessment Scale, and measurement of the unstimulated whole salivary flow rate (UWSFR) and the stimulated whole salivary flow rate (SWSFR). One hundred twenty patients participated in the study. Xerostomia was the fourth most common symptom (78% of patients). It was associated with a poor performance status (P = 0.01). The usual cause of xerostomia was drug treatment. There was an association with the total number of drugs prescribed (P = 0.009): the median number of xerostomic drugs prescribed was 4. Xerostomia was ranked the third most distressing symptom. Its severity was correlated with the severity of oral discomfort, dysgeusia, dysmasesia, dysphagia, dysphonia, and anorexia. The UWSFR was a relatively sensitive, but nonspecific, investigation. In contrast, the SWSFR was a relatively specific, but insensitive, investigation.

A preliminary study of the utility of the brief hospice inventory

The increasing number of palliative care patients necessitates a simple, reliable instrument to routinely measure outcomes among hospice patients. We tested the utility of the Brief Hospice Inventory (BHI) to assess outcomes of hospice patients and estimations of patients' outcomes by nurse caregivers. In a prospective study, 145 home-based hospice patients were enrolled in the study from VistaCare Hospice. During the first week of admission, patients and nurse caregivers completed the BHI, which assessed patients' symptoms, satisfaction with care, and quality of life. Factor analysis supported a two-factor structure for the BHI for patients and caregivers, including a symptom subscale and quality of life subscale. Patients with severe symptoms showed improvement on the symptom subscale, but not the quality of life subscale, during the first 2 weeks after admission. The BHI shows utility in measuring hospice patients' symptom severity and quality of life over time.

Family reports of dying patients' distress: the adaptation of a research tool to assess global symptom distress in the last week of life

Understanding dying patients' symptom distress is an important component of efforts to improve care at the end of life. It can, however, be problematic to conduct research with dying patients. Family members can serve as sources of information about decedents' last days of life. In order to assess family reports of decedents' global symptom distress in the last week of life, we adapted the Memorial Symptom Assessment Scale Global Distress Index (MSAS-GDI), a brief measure of patient global symptom distress, for use in a retrospective study of family reports about end-of-life care. It was administered to a sample of 103 family members to assess the psychometric properties of the instrument in bereaved family members. The Family MSAS-GDI consists of questions about 11 psychological and physical symptoms commonly experienced by dying patients. The majority of family members were able to respond to the scale items. The mean Family MSAS-GDI score was 1.14 (SD = 0.87) with a range of 0 to 3.73. The scale demonstrated good internal consistency (alpha = 0.82). The average item-total correlation was r = 0.49 and the average inter-item correlation was r= 0.30, suggesting items were moderately correlated with the overall total scale and with each other. The Family MSAS-GDI could prove to be a useful tool in assessing and tracking global symptom distress in dying patients.