Measuring Symptoms in Terminal Cancer: Are Pain and Dyspnoea Controlled?

The relationship between dyspnea and patient satisfaction with quality of life in advanced cancer

GOALS OF THE WORK

Dyspnea is a common symptom in patients with advanced cancer. The goal of this study was to investigate the relationship between dyspnea and patient satisfaction with quality of life (QoL) in advanced cancer.

MATERIALS AND METHODS

A case series of 954 cancer patients treated at the Cancer Treatment Centers of America was investigated. Dyspnea was measured using the EORTC dyspnea subscale. Patient satisfaction with QoL was measured using the Ferrans and Powers Quality of Life Index (QLI). The relationship between dyspnea and QLI was evaluated using multivariate analysis of variance and multiple regression analysis.

RESULTS

Of 954 patients, 579 were females and 375 males with the median age at presentation of 56 years (range: 20-90 years). Of these patients, 66% did not respond to prior treatment. Most common cancers were breast (26%), colorectal (19%) and lung (16%). After controlling for the effects of age and treatment history, every ten unit increase in dyspnea was statistically significantly associated with 0.81, 0.16, 0.47, and 0.47 unit decline in QLI health/physical, social/economic, psychological/spiritual and global function score, respectively.

CONCLUSIONS

We found that dyspnea is strongly correlated with patient satisfaction with QoL in advanced cancer. Future studies should evaluate the impact of integrative cancer care services on patient satisfaction with QoL.

Patient reporting and doctor recognition of dyspnoea in a comprehensive cancer centre

The aim of this study was to examine different aspects of dyspnoea in an Australian acute cancer care population, specifically prevalence, recognition, reporting, symptom control methods and prognostic significance. Patients and treating hospital medical officer were concurrently asked to evaluate the experience of dyspnoea. The prevalence of dyspnoea was 33%, with discrepancies observed between patient and doctor reporting of the presence of dyspnoea (P = 0.021), as well as its intensity and distress. Symptomatic methods for the relief of cancer-related dyspnoea are underused, particularly opioids. The medical underestimation of dyspnoea is consistent with previous studies and potentially detracts from effective management of this symptom.

Discussion of quality and audit in health

Attaining quality health care has long been a social policy priority for countries internationally. This discussion considers issues important to understanding quality, and audit implementation in particular. The paper covers, first, the principles and practice of audit and, second, broader implementation issues, which together point to the further development of quality initiatives in health in the United Kingdom health care context. To close, the future of audit as a means of improving health care is elaborated.

A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease

Little attention has been paid to the symptom management needs of patients with life-threatening diseases other than cancer. In this study, we aimed to determine to what extent patients with progressive chronic diseases have similar symptom profiles. A systematic search of medical databases (MEDLINE, EMBASE, and PsycINFO) and textbooks identified 64 original studies reporting the prevalence of 11 common symptoms among end-stage patients with cancer, acquired immunodeficiency syndrome (AIDS), heart disease, chronic obstructive pulmonary disease, or renal disease. Analyzing the data in a comparative table (a grid), we found that the prevalence of the 11 symptoms was often widely but homogeneously spread across the five diseases. Three symptoms-pain, breathlessness, and fatigue-were found among more than 50% of patients, for all five diseases. There appears to be a common pathway toward death for malignant and nonmalignant diseases. The designs of symptom prevalence studies need to be improved because of methodological disparities in symptom assessment and designs.

Low dose diamorphine reduces breathlessness without causing a fall in oxygen saturation in elderly patients with end-stage idiopathic pulmonary fibrosis

There is very little evidence regarding the safety and efficacy of opioids for the control of dyspnoea in the terminal stages of idiopathic pulmonary fibrosis (IPF). We conducted an open case series study of 11 elderly opioid-naive patients referred for management of severe breathlessness before and after their first injection of 2.5 mg diamorphine subcutaneously. Subjective breathlessness, measured by a 100 mm visual analogue scale, fell by a mean of 47 mm in the first 15 min (P < 0.0001) and the mean heart rate fell by 12/min (P = 0.007). There were small non-significant falls in the mean respiratory rate (2/min), systolic blood pressure (6 mmHg) and oxygen saturation (1%). These changes were maintained at 30 min. Follow up treatment with oral morphine remained effective in reducing the symptom of breathlessness and no patient showed signs of respiratory depression. Low dose opioids are effective and safe in the palliative management of IPF in frail elderly patients.

Morphine for dyspnea control in terminal cancer patients: is it appropriate in Taiwan?

Morphine for dyspnea control usually arouses ethical controversy in terminal cancer care. This study prospectively assessed the use of morphine for dyspnea control in terminal cancer patients in terms of two characteristics: the extent to which medical staff, family, and patients found morphine to be ethically acceptable and efficacious, and the influence of morphine on survival. One hundred and thirty-six palliative care patients meeting specific eligibility criteria were enrolled. A structured data collection form was used daily to evaluate clinical conditions, which were analyzed at the time of admission and 48 h before death. Sixty-six (48.6%) of the 136 patients had dyspnea on admission. The intensity was mild in 14.0% and moderate or severe in 34.6%. The intensity of dyspnea became worse 48 h before death (4.29+/-2.55 vs. 4.94+/-2.60, P < 0.001, range 0-10). Twenty-seven (40.9%) of 66 patients with dyspnea received morphine on admission for the control of dyspnea; the routes of administration were oral (59.3%) and subcutaneous (40.7%). Fewer than two-thirds (59.3%) of the patients were given morphine with the consent of both patient and family. More than one-third (40.7%) on admission and about one-half (52.8%) in the 48 h before death had the consent of family alone. Positive ethical acceptability and satisfaction with using morphine for dyspnea control were found in both medical staff and family in this study. Multiple Cox regression analysis showed that using morphine for dyspnea, both on admission and in the 48 h before death, did not significantly influence the patients' survival (HR: 0.015, 95% CI: 0.00-4.23; HR: 1.76, 95% CI: 0.73-4.24). In this population, the use of morphine for dyspnea control in the terminal phase of cancer was effective and ethically validated in the study. Research efforts to find the most appropriate route and dosage of morphine for dyspnea, based on the patient's situation, remain worthwhile.

Management of dyspnea

Patients with cancer frequently report dyspnea, the uncomfortable awareness of breathing. Lung involvement with cancer does not predict its occurrence. Patients describe it as one of the most frightening and distressing symptoms, and patient self-report is the only reliable measure. Measurements of respiratory rate, oxygen saturation, and arterial blood gases do not measure dyspnea. Opioids in modest doses have been demonstrated to give effective relief of dyspnea, whether or not identifiable reversible causes exist. Medical management of dyspnea can be directed at the underlying cause when the potential benefits outweigh the burdens of such treatment. In rare cases where symptomatic treatment is unable to control dyspnea to the patient's satisfaction, sedation is an effective, ethical option.

Guidelines on the role of the specialist nurse in supporting patients with lung cancer

Recently, there has been a significant increase in the number of nurse specialist posts working with patients with lung cancer in the UK. This has been in response to a recognized need to improve lung cancer services. However, there is concern that these posts have been developed quickly with little strategic planning or evaluation. This paper is a collaborative project by the members of The London and South East Lung Cancer Forum for Nurses and aims to offer guidelines to managers and practitioners on areas where improvements may be made in the care of patients with lung cancer. Recommendations are based on Government guidelines, evidence from recent research studies and the experience of the members of the Forum.

Validation of a symptom measure suitable for use among palliative care patients in the community: CAMPAS-R

The purpose of the study was to investigate psychometric properties of CAMPAS-R, an instrument for prospectively monitoring patients' symptoms and needs during palliative care at home. CAMPAS-R was piloted for face and content validity and then administered alongside criterion measures to a home care sample. Cronbach's alpha was used to test internal consistency and criterion-related validity was tested by non-parametric correlation with Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS) and EORTC QLQ-C30. Predictive validity was assessed by relating CAMPAS-R scores to survival. One hundred and nine patients were recruited to the study. Good reliability and high correlations between CAMPAS-R and criterion measures were found. Predictive validity was demonstrated by significant differences in symptom scores between groups differing in length of survival. CAMPAS-R is acceptable to patients, families and primary care professionals and is a valid, reliable instrument, which has the benefit of being easy to score.

The use of oxygen in the palliation of breathlessness. A report of the expert working group of the scientific committee of the association of palliative medicine

Dyspnoea is a common, distressing symptom and difficult to control with medical treatment. The role of oxygen in reducing the severity of the symptoms and improving quality of life is still unclear. A working party of the Association of Palliative Medicine Science Committee set out to examine the evidence concerning the use of oxygen for the palliation of breathlessness in COPD, advanced cancer and chronic heart failure and to make recommendations for clinicians working in palliative care. There were very few randomised controlled trials available for any of these conditions. There was no evidence available for heart failure, very little for advanced cancer and although there were a number of trials on the use of oxygen in COPD very few, until recently, used reduction of breathlessness as an outcome measure. Recommendations are made on the basis of the evidence available and expert opinion such as the Royal College of Physicians report on the use of domiciliary oxygen. Oxygen use has to be tailored to the individual and a formal assessment made of its efficacy for reducing breathlessness and improving quality of life for that person [corrected].

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.

The Last Forty-Eight Hours of Life in a Portuguese Palliative Care Unit: Does it Differ from Elsewhere?

The last few days of life have received significant attention in the literature. Reports have shown similarities and differences between programs. As a palliative care service in a cultural context that has not been reported on, we thought that an audit of our own experience in the care of patients in the last 48 hours of life and a comparison with other programs would be important. A prospective audit was designed to record data for four general domains: general demographic information, symptom prevalence, patient performance status, and perceived level of comfort. The inclusion criteria of patients were: older than 15 years of age (an admission criterion for patients of the unit), diagnosis of cancer, no active cancer-direct treatments, and patients who were on the unit for longer than 48 hours. The audit was completed when the 300th eligible patient died in the unit. Twenty-nine of 300 patients (9.6%) required sedation and the most common cause was delirium. Morphine was the most widely prescribed medication (85% of patients). The subcutaneous route was utilized extensively. Only 12% of the patients received parenteral fluids, usually via hypodermoclisis. Death was considered by staff to have been peaceful in 86% of cases. Our practice appears to mirror that of other palliative care groups.

Breathlessness in cancer and chronic obstructive pulmonary disease: Using a qualitative approach to describe the experience of patients and carers

Objective: To investigate and document the effects of breathlessness on the everyday lives of patients with cancer and COPD and their carers. This subject has been little researched, although dyspnoea is recognized as a disabling, distressing symptom. The number of breathless people is increasing as patients with all types of cardio-respiratory disease live longer.

Methods: Patients with severe COPD and cancer and their carers were interviewed at home using a semistructured format to record their perceptions of the impact of breathlessness, the help they had received from medical and caring services, and their ideas on how these could be improved.

Results: 10 patients with COPD (6 male) and 10 with cancer (6 male) and their spouses were interviewed. All patients found breathlessness frightening, disabling, and restricting. Patients developed a stoical, philosophical approach in order to live with dyspnoea and the difficulties it imposed: this was also an important way of reducing the emotional impact of breathlessness. Patients' spouses suffered significantly, experiencing severe anxiety and helplessness as they witnessed their partners' suffering and felt powerless to reduce it. The restrictions imposed by breathlessness affected their lives profoundly. Support of all kinds, practical, medical, and psychosocial was highly valued but was provided inconsistently and sporadically. Where help was given it came most frequently from general practitioners (GPs, family physicians) and specialist respiratory nurses.

Significance of results: This study is the first to document the psychosocial needs of carers, which are not adequately recognized or addressed at present. Patients and carers may feel most isolated and need support outside the working hours of most services and future provision needs to reflect this. Patients with cancer experience a more rapid onset of breathlessness. More clinicians need to be educated in the management of chronic breathlessness so known helpful strategies are more widely employed.

Effect of nebulized furosemide in terminally ill cancer patients with dyspnea

We evaluated the effect of ultrasonically nebulized furosemide (20 mg) on dyspnea uncontrollable by standard therapy in patients with terminal cancer. Dyspnea was evaluated using the Cancer Dyspnea Scale (CDS) before and 60 min after inhalation. Changes in arterial blood gases, hemoglobin oxygen saturation (SpO2), heart rate (HR), and respiratory rate (RR) also were evaluated. In 12 of 15 patients (80%), total dyspnea scores by CDS improved significantly after inhalation of furosemide (P = 0.007), especially concerning a reduced sense of effort (P = 0.013) and reduced anxiety (P = 0.04). No significant changes were observed in the partial pressure of oxygen in arterial blood (PaO2), the partial pressure of carbon dioxide in arterial blood (PaCO2), SpO2, HR, or RR. Inhalation of nebulized furosemide appears to be effective against dyspnea in terminally ill cancer patients.

Breathlessness clinics within specialist palliative care settings can improve the quality of life and functional capacity of patients with lung cancer

This paper is a development on recent research that proved the value of non-pharmacological techniques and strategies in the management of breathlessness in lung cancer. It evaluates the intervention in a specialist palliative care setting using an outpatient clinic at Lewis-Manning House. Referrals were made by the patients' physician or specialist nurse. Patients (n = 30) were assessed and treated by the senior physiotherapist in charge of the clinic over three sessions. A number of outcomes were measured at various stages of the patients' treatment. The results have confirmed and strengthened the previous published results. Highly significant improvements in patients' breathlessness, functional capacity, activity levels and distress levels have been shown. For example, the percentage of patients experiencing breathlessness several times or more per day was reduced from 73% to 27% four weeks later. In addition, this project has been able to demonstrate significant improvements in quality of life and high levels of satisfaction with the interventions. Qualitative data enhanced the findings of objective measurements.

The use of opioids and sedatives at the end of life

Opioids and sedative drugs are commonly used to control symptoms in patients with advanced cancer. However, it is often assumed that the use of these drugs inevitably results in shortening of life. Ethically, this outcome is excused by reference to the doctrine of double effect. In this review, we assess the evidence for patterns of use of opioids and sedatives in palliative care and examine whether the doctrine of double effect is needed to justify their use. We conclude that patients are more likely to receive higher doses of both opioids and sedatives as they get closer to death. However, there is no evidence that initiation of treatment, or increases in dose of opioids or sedatives, is associated with precipitation of death. Thus, we conclude that the doctrine of double effect is not essential for justification of the use of these drugs, and may act as a deterrent to the provision of good symptom control.

Research into practice: the reality of implementing a non-pharmacological breathlessness intervention into clinical practice

The work of Corner and colleagues in the non-pharmacological management of breathlessness in patients with lung cancer has aroused considerable interest. Cancer and palliative care nurses are encouraged to incorporate the breathlessness intervention into their clinical practice but this has not always proved easy or straightforward. This paper draws on the authors' experience as lung cancer nurse specialists to explore some of the difficulties nurses in clinical practice may encounter when attempting to translate the research findings into their own areas and suggests ways these difficulties may be overcome.

Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers?

Palliative care provision varies widely, and the effectiveness of palliative and hospice care teams (PCHCT) is unproven. To determine the effect of PCHCT, 10 electronic databases (to 2000), 4 relevant journals, associated reference lists, and the grey literature were searched. All PCHCT evaluations were included. Anecdotal and case reports were excluded. Forty-four studies evaluated PCHCT provision. Teams were home care (22), hospital-based (9), combined home/hospital care (4), inpatient units (3), and integrated teams (6). Studies were mostly Grade II or III quality. Funnel plots indicated slight publication bias. Meta-regression (26 studies) found slight positive effect, of approximately 0.1, of PCHCTs on patient outcomes, independent of team make-up, patient diagnosis, country, or study design. Meta-analysis (19 studies) demonstrated small benefit on patients' pain (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.23-0.64), other symptoms (OR: 0.51, CI: 0.30-0.88), and a non-significant trend towards benefits for satisfaction, and therapeutic interventions. Data regarding home deaths were equivocal. Meta-synthesis (all studies) found wide variations in the type of service delivered by each team; there was no discernible difference in outcomes between city, urban, and rural areas. Evidence of benefit was strongest for home care. Only one study provided full economic cost-benefit evaluation. This is the first study to quantitatively demonstrate benefit from PCHCTs. Such comparisons were limited by the quality of the research.

End-of-life care in patients with lung cancer

Evidence-based practice guidelines for end-of-life care for patients with lung cancer have been previously available only from the British health-care system. Currently in this setting, there has been increasing concern in attaining control of the physical, psychological, social, and spiritual distress of the patient and family. This American College of Chest Physicians'-sponsored multidisciplinary panel has generated recommendations for improving quality of life after examining the English-language literature for answers to some of the most important questions in end-of-life care. Communication between the doctor, patient, and family is central to the active total care of patients with disease that is not responsive to curative treatment. The advance care directive, which has been slowly evolving and is presently limited in application and often circumstantially ineffective, better protects patient autonomy. The problem-solving capability of the hospital ethics committee has been poorly utilized, often due to a lack of understanding of its composition and function. Cost considerations and a sense of futility have confused caregivers as to the potentially important role of the critical care specialist in this scenario. Symptomatic and supportive care provided in a timely and consistent fashion in the hospice environment, which treats the patient and family at home, has been increasingly used, and at this time is the best model for end-of-life care in the United States.

Communication in end-of-life cancer care: a comparison of team assessments in three European countries

PURPOSE

To compare team assessments of end-of-life communication in three European countries, and to identify factors associated with problematic communication.

PATIENTS AND METHODS

Three prospective cohort studies used similar standardized procedures, and included patients referred to palliative care services in the United Kingdom, Ireland, and Italy. Palliative team care staff assessed three components of communication in the last week of the patient's life-between the patient and family (or those close to them), between professionals and patient and family, and between professionals-using a validated measure. Univariate and multivariate analyses explored the data and tested for relationships between possible explanatory variables and communication.

RESULTS

Data were collected on 1,326 patients, 416 in the United Kingdom, 411 in Ireland, and 499 in Italy. Mean age was 68 years (range, 19 to 95 years), 55% were male, and almost two thirds were married. Team members assessed that communication between patient and family was a moderate or severe problem in the last week of life for 30% to 40% of patients; 10% to 20% had moderate or severe problems recorded for the other two communication items. Problematic communication was associated with respiratory and breast cancers, a shorter time in care, and hospice death. It was also associated with greater spiritual need, need for care planning, and poorer patient and family insight (Spearman's rho > 0.4), but not especially with pain and symptom control, in both univariate and multivariate analyses, both within countries and for all data combined.

CONCLUSION

Severe communication problems were reported by team assessments in up to 40% of patients at the end of life. A multiprofessional approach is needed to recognize and improve this.

Sedation, the doctrine of double effect and the end of life

The blurring of boundaries between appropriate symptom control and hastening death is a matter of concern in palliative care. The use of sedation at the end of life is a key example and Beel and colleagues provide an excellent review of the research available in this area and the difficulties in definition that need to be addressed (Beel et al, 2002).

Clinical nurse specialists in palliative care. Part 1. A description of the MacMillan Nurse caseload

Macmillan Nurses play a significant role in specialist palliative care services in the UK, providing direct and indirect services to patients with complex palliative care needs and to their families. Existing literature shows a developing understanding of the role; however, little detailed data exist regarding the clinical work that they undertake. This paper provides evidence from a major evaluation study, commissioned by Macmillan Cancer Relief. It reports the methods of data collection for the study and then goes on to use data from the evaluation to describe the caseload of Macmillan Nurses. Between September 1998 and October 1999, a team of researchers worked alongside 12 Macmillan teams for a period of 8 weeks with each team. Prospective data were gathered on all new referrals to the services within the 8-week period. This included demographic details, timing of referral, the nature and purpose of contacts, and interventions, recorded from case notes and Macmillan Nurse records. Where possible, a date of death was obtained for all patients. A total of 814 new patients were referred during the study period (range 45-114 per site). The most common reasons for referral were emotional care for the patient (57%), pain control (27%), and other physical symptoms (33%). Thirteen per cent of the patients referred to the services died within 1 week of referral while 40% died within 6 weeks; thus, a significant proportion of patient work is focused on care at the end of life. It is also noteworthy that one-third of patients were still alive, indicating that some patients are being cared for earlier in the illness trajectory. On average, each new patient referral received two or more 'face-to-face' visits and two follow-up phone calls within the 8-week period. It would appear that Macmillan Nurse teams have been successful in getting access to relevant patients. As with any service that provides a complex set of interventions, the Macmillan teams have to adapt and develop the services in each setting. Whilst it is clearly important for the development of a Macmillan service to be tailored to the local conditions, the evidence on diversity suggests that in some cases, stronger guidance, in partnership with both Macmillan Cancer Relief and core providers, may be justified.

Prevalence and screening of dyspnea interfering with daily life activities in ambulatory patients with advanced lung cancer

This study aimed to identify 1) the prevalence of "clinical dyspnea," defined here as dyspnea interfering with any daily life activities, 2) the impact of dyspnea on daily life activities, and 3) the screening ability of the Cancer Dyspnea Scale (CDS) and the Dyspnea Numeric Scale (DNS). A total of 157 outpatients with advanced lung cancer completed the two scales (CDS and DNS) along with a questionnaire about interference with daily life activities (normal work, walking, sleep, mood, relation with other people, enjoyment of life, and general activities). Over half of this population (55%) experienced "clinical dyspnea." Dyspnea interfered with not only physical domain (52%), such as walking and work, but also with psychological domain (23%), such as mood and enjoyment. Both scales were feasible for screening of clinical dyspnea. Applying a screening protocol may contribute to avoiding underestimation of clinical dyspnea and lead to appropriate interventions for it.

Factors correlated with dyspnea in advanced lung cancer patients: organic causes and what else?

This study aimed to investigate factors correlated with dyspnea in cancer patients among a broad range of medico-psycho-social factors. A total of 171 consecutive outpatients with advanced lung cancer were recruited. Dyspnea was evaluated by using the Cancer Dyspnea Scale, a valid, reliable 12-item self-rating scale developed to assess the multidimensional nature of dyspnea in cancer patients. Possible correlates, including 1) medical (clinical stage, Performance Status, SpO(2), organic causes of dyspnea, other symptoms, such as cough and pain, etc.), 2) psychological (anxiety and depression), and 3) social (education, marital status, existence of confidants, etc.), factors were collected from medical charts, interviews, and self-rating questionnaires. Multiple regression analysis revealed that psychological distress, presence of organic causes, cough, and pain were significantly correlated with dyspnea (P < 0.05, multiple R(2) = 0.303). The present study confirms that dyspnea is multifactorial and that a beneficial therapeutic strategy might include intervention for psychological distress and pain.

Impact of dyspnea, pain, and fatigue on daily life activities in ambulatory patients with advanced lung cancer

This study aimed to compare the impact of dyspnea, pain, and fatigue on daily life activities in ambulatory patients with advanced lung cancer. One hundred seventy-one outpatients with advanced lung cancer completed a questionnaire about symptom severity and whether symptoms interfered with daily life activities (normal work, walking, sleep, mood, relation with other people, enjoyment of life, and general activities). The results indicated that 1) dyspnea and fatigue interfered with at least one daily life activity in more than half the patients, and pain in about 40%, 2) dyspnea and fatigue interfered predominantly with physical activities, such as walking and work, whereas pain interfered with all activities almost equally, and 3) symptoms rated as low severity (1 to 3 on a 0-10-point numerical scale) were severe enough to interfere with at least one daily life activity. To recognize the impact of symptoms may contribute to provide better management.

Attitudes of terminally ill cancer patients about euthanasia and assisted suicide: predominance of psychosocial determinants and beliefs over symptom distress and subsequent survival

PURPOSE

Although euthanasia and physician-assisted suicide (PAS) are controversial issues, the views of those most affected, terminal patients, are seldom explored. Our objective was to assess whether the attitudes about euthanasia/PAS of terminally ill cancer patients were determined by their symptomatic distress.

PATIENTS AND METHODS

We conducted a survey of 100 patients with terminal cancer. Statements related to the legalization of euthanasia/PAS were scored using Likert scales. We also asked patients how often they had considered ending their lives. Their responses were analyzed in relation to disease characteristics, including an assessment of symptomatic severity, sociodemographic features, general beliefs about the suffering of cancer patients, and survival.

RESULTS

Most patients (69%) supported euthanasia or PAS for one or more situations. The association between these attitudes and symptoms was weak, consistent in univariate analysis only for shortness of breath. No significant associations were observed with pain, nausea, well-being, loss of appetite, depression, or subsequent survival. Agreement with euthanasia was significantly related to male sex, lack of religious beliefs, and general beliefs about the suffering of cancer patients and their families. In multivariate analysis, the only characteristics that remained statistically associated with support were the strength of religious beliefs and the perception that patients with cancer are a heavy burden on their families. Frequency of suicidal ideation was associated with poor well-being, depression, anxiety, and shortness of breath, but not with other somatic symptoms such as pain, nausea, and loss of appetite.

CONCLUSION

Symptom intensity had limited impact on the attitudes about euthanasia of terminally ill cancer patients. Our findings suggest that patient views are primarily determined by psychosocial traits and beliefs, as opposed to disease severity or symptomatic distress.

Clinical management of dyspnoea

Dyspnoea, defined as a sensation of an uncomfortable awareness of breathing, is one of the most frightening and distressing symptoms for patients with cancer. It is very common in cancer patients with and without direct lung involvement. The gold standard of diagnosis and assessment is the patient's self-report. Measurements of respiratory rate, oxygen saturation, and arterial blood gases do not measure dyspnoea. Fast, safe, and effective relief of the symptom is possible whether or not identifiable reversible causes exist. Opioids are the first line of therapy for such relief. Medical management can be directed at the underlying cause when the potential benefits outweigh the burdens of such treatment. In rare cases for which symptomatic treatment does not control dyspnoea to the patient's satisfaction, sedation is an effective, ethical option.

Symptomatology of cancer patients in palliative care: content validation of self-assessment questionnaires against medical records

To elucidate which symptoms or problems to measure when evaluating palliative care, we assessed the content validity of selected patient self-assessment questionnaires used to evaluate palliative care: the European Organization for Research and Treatment of Cancer-Quality of Life-Core 30 (EORTC QLQ-C30), the Edmonton Symptom Assessment System (ESAS), the Palliative Care Outcome Scale (POS), the McGill Quality of Life Questionnaire (MQOL) and the Memorial Symptom Assessment Scale (MSAS). The content of the questionnaires was compared against the symptoms and problems noted in the medical records of 171 consecutive cancer patients on their first admission to a department of palliative medicine. From the records, 63 different symptoms were listed. Two questionnaires covered almost all of the prevalent symptoms/problems: the EORTC QLQ-C30 covered 10 and the MSAS 11 of the 12 most frequent problems. Researchers selecting instruments for evaluating palliative care may use the present study and other reviews to examine to what degree a given selection of instruments cover the symptoms/problems targeted by palliative care physicians.

Improving the management of breathlessness using a clinical effectiveness programme

Breathlessness represents a significant problem for the person with advanced cancer. Uncontrolled breathlessness ranks highly in terms of uncomfortable symptoms experience, causing pain and distress to the patient and resulting in significant anxiety to their carers. The key to the provision of effective care lies in the informed application of the nursing process, underpinned by a sound knowledge base in relation to the nursing management of breathlessness. Theoretical knowledge enables nursing staff to offer appropriate interventions for the management of breathlessness in collaboration with other members of the multidisciplinary team. This article will discuss the cause and management of breathlessness in the person with advanced cancer; the discussion focuses on the application of research-based interventions and the evaluation of clinical outcomes in a UK clinical governance context.

Do hospital-based palliative teams improve care for patients or families at the end of life?

To determine whether hospital-based palliative care teams improve the process or outcomes of care for patients and families at the end of life, a systematic literature review was performed employing a qualitative meta-synthesis and quantitative meta-analysis. Ten databases were searched. This was augmented by hand searching specific journals, contacting authors, and examining the reference lists of all papers retrieved. Studies were included if they evaluated palliative care teams working in hospitals. Data were extracted by two independent reviewers. Studies were graded using two independent hierarchies of evidence. A Signal score was used to assess the relevance of publications. Two analyses were conducted. In a qualitative meta-synthesis data were extracted into standardized tables to compare relevant features and findings. In quantitative meta-analysis we calculated the effect size of each outcome (dividing the estimated mean difference or difference in proportions by the sample's standard deviation). Nine studies specifically examined the intervention of a hospital-based palliative care team or studies. A further four studies considered interventions that included a component of a hospital or support team, although the total intervention was broader. The nature of the interventions varied. The studies were usually in large teaching hospitals, in cities, and mainly in the United Kingdom. Outcomes considered symptoms, quality of life, time in hospital, total length of time in palliative care, or professional changes, such as prescribing practices. Only one of the studies was a randomized controlled trial and this considered a hospital team as part of other services. Most method scores indicated limited research quality. Comparison groups were subject to bias and the analyses were not adjusted for confounding variables. In addition, there were problems of attrition and small sample sizes. Nevertheless, all studies indicated a small positive effect of the hospital team, except for one study in Italy, which documented deterioration in patient symptoms. The Signal scores indicated that the studies were relevant. No study compared different models of hospital team. This review suggests that hospital-based palliative care teams offer some benefits, although this finding should be interpreted with caution. The study designs need to be improved and different models of providing support at the end of life in hospital need comparison. Standardized outcome measures should be used in such research and in practice.

Determinants of place of death for terminal cancer patients

Approximately two-third of cancer patients, when asked about the preferred place of death, wish to die in their own homes. However, the majority of deaths from cancers in most western countries occur in a hospital. When a person dies from other than sudden or traumatic causes, the death appears to be a function of a complex interplay of personal and cultural values and physical and medical factors, as well as various health care systems forces. This article reviews the determinants of place of death for terminal cancer patients from published studies in hopes of shedding light on the difficulties of dying patients to realize their preferences for place of death. These insights may contribute to modification of hospice care systems so health professionals will be more responsive to the needs of their dying patients to retain control and die with dignity and help health professionals achieve the proposed outcome of hospice care.

Physiological changes and clinical correlations of dyspnea in cancer outpatients

The purposes of this cross-sectional study of 75 outpatients of a general oncology clinic were to assess the subjective and objective factors associated with dyspnea in cancer patients and to characterize factors that might contribute to respiratory muscle weakness demonstrated in a previous study. Patients with moderate to severe shortness of breath completed visual analogue scales (VAS) of shortness of breath (SOB) and anxiety; other data were acquired from pulmonary function tests, including maximum inspiratory pressure (MIP) and expiratory pressures; chest radiography; arterial blood gases; measurement of hemoglobin, serum potassium, phosphate, calcium, albumin, and magnesium; and ultrasound study of the diaphragm for thickness and excursion. The correlation coefficient between SOB VAS and anxiety VAS was 0.26 (P = 0.03). In stepwise multiple regression analyses, only the regression coefficient for anxiety remained significant at P < 0.05 in the multivariate model with SOB VAS as the dependent variable. The multivariate model using MIP (a measure of respiratory muscle strength) as the dependent variable, found significance for total diaphragmatic excursion, hemoglobin, phosphate, residual volume over total lung volume, vital capacity, percent predicted total lung capacity, oxygen saturation, and forced vital capacity. The regression coefficients for these variables were significant at P < 0.05 and the model accounted for 58% of the variance of MIP.

Chronic critically ill dyspneic patients: mechanisms and clinical measurement

Dyspnea is a multidimensional, subjective perception of breathing difficulty commonly seen in patients who are critically or terminally ill. Understanding the mechanisms and assessment of dyspnea will help nurses in advanced practice roles to successfully manage these patients. Major mechanisms of dyspnea include stimulation of the chemoreceptors, stimulation of chest wall and intrapulmonary receptors, and increased sense of effort (also termed increased respiratory motor command). The causes of dyspnea are multifactorial, including numerous clinical conditions and aggravating situations that promote dyspnea. Assessment of dyspnea includes an accurate history of timing, precipitating factors, associated symptoms, alleviating factors, intensity and quality of the symptom. Measurement tools for dyspnea include both unidimensional and multidimensional tools, as well as tools that measure changes in the perception of dyspnea. Most tools have been tested for reliability and validity on healthy subjects or on patients with chronic obstructive pulmonary disease and, therefore, should be used with caution in critically or terminally ill patients.

Dyspnea in cancer patients: prevalence and associated factors

The objectives of this study were to determine the prevalence of dyspnea in the general cancer population, the intensity of the symptom as perceived by the patient, and the patient characteristics associated with the presence of dyspnea. Nine hundred and twenty-three cancer outpatients completed visual analogue scales (VAS) and verbal rating scales (VRS-D) to assess the intensity of their dyspnea. Baseline data included variables that were known covariates of dyspnea. Forty-six percent of the patients had some shortness of breath. Only 4% had a diagnosis of lung cancer and 5.4% lung metastases. Risk factors found to be significantly related to the presence of dyspnea were history of smoking; asthma or chronic obstructive pulmonary disease (COPD); lung irradiation; or a history of exposure to asbestos, coal dust, cotton dust or grain dust (P values from 0.001 to 0.038). The prevalence of dyspnea was strongly related to the number of risk factors a patient had (P < 0.0001). The VAS and VRS-D were significantly correlated, establishing concurrent validity for the VRS-D.

Care of the dying: setting standards for symptom control in the last 48 hours of life

The hospice model of care of the dying patient is regarded as a model of excellence; however, outcomes of this care have been poorly demonstrated. Integrated Care Pathways (ICPs) provide a method of recording and measuring outcomes of care. The ICP document replaces all previous documentation and is a multiprofessional record of patient care. The aim of this study was to implement an ICP in an inpatient hospice setting in order to set standards of care for symptom control in the dying phase of a patient's life. ICPs were analyzed from 168 inpatients who died over a one-year period. Symptoms of pain, agitation, and respiratory tract secretions (RTS) were monitored every four hours by nursing staff as either present or absent. For each symptom, 80% of patients had one episode or complete control of the symptom, 10% had two episodes, and 10% had three episodes or more recorded. As death neared, there was a statistically significant increase in the number of patients whose pain was controlled. The ICP has provided a means to measure symptom control in the dying patient and set standards of care, which is integrated into clinical practice.

Cancer nursing practice development: understanding breathlessness

This paper considers methodological and philosophical issues that arose during a multi-centre, randomized controlled trial of a new nursing intervention to manage breathlessness with patients with primary lung cancer. Despite including a diverse range of instruments to measure the effects of the intervention, the uniqueness of individuals' experiences of breathlessness were often hidden by a requirement to frame the study within a reductionist research approach. Evidence from the study suggests that breathlessness is only partly defined when understood and explored within a bio-medical framework, and that effective therapy can only be achieved once the nature and impact of breathlessness have been understood from the perspective of the individual experiencing it. We conclude that to work therapeutically we need to know how patients interpret their illness and its resultant problems and that this demands methodological creativity.

Behavioral interventions for lung cancer-related breathlessness

PURPOSE

The purpose of this report is to present behavioral interventions to assist persons with lung cancer in the management of feelings of breathlessness and, thus, also to enhance their quality of life.

OVERVIEW

Breathlessness is a serious symptom that adversely affects the quality of life of persons with lung cancer. A review of the literature points to the value of exercises in assisting patients to breathe more effectively and to manage related anxiety. However, the professional literature frequently does not describe these basic interventions in enough detail to enable oncology professionals to learn them. Instructional materials, found in the popular wellness and self-help literature, are included in this article to more easily facilitate acquisition of these skills. Interventions described include exercises that enhance the use of the diaphragm when breathing and those that help to alter the breathing rhythm and to exhale more effectively.

CLINICAL IMPLICATIONS

All oncology professionals should be aware of the importance of breathlessness as a problem that diminishes the quality of life for patients with lung cancer. Addressing breathlessness through the use of psychosocially oriented behavioral interventions can act as an adjunct to the medical management of this debilitating symptom.

Perceptions of health care need in lung cancer. Can prospective surveys provide nationally representative data?

This paper considers the potential of a prospective questionnaire survey to provide nationally representative data of perceptions of health care need. The paper focuses on methodological problems encountered during the study, reserving the discussion of key findings to further publications. Data were gathered from patients with lung cancer, lay carers and professionals from 24 randomly selected hospitals throughout the UK. A number of factors had an impact on the survey's potential to provide nationally representative data. These included an unanticipatedly high death rate of patients registered in hospitals as being in receipt of treatment or follow-up care. Of a potential sample of 785 patients identified as being alive by the participating hospitals prior to data collection, 319 (41%) were found to have died after checking with general practitioner surgeries. As a consequence of consultants declining to participate, or where they did not reply to any correspondence, eight hospitals were withdrawn from the study on the grounds of inability to gain access to a representative sample of patients. In conclusion, a retrospective design, supplemented by the views of patients would have ensured greater success in terms of patient response rate (45%) and representativeness of data. Nevertheless, the survey represents a first attempt at undertaking a national assessment of patients with lung cancer and has provided rich data drawn from patients' experiences of living with a diagnosis of lung cancer and its treatment.

Pain and symptom control in terminally ill children

The management of pain in terminally ill pediatric patients has incalculable benefits to patients, their families, and physicians and nurses. A therapeutic management plan is dependent on a thorough understanding of the causes of pain in these patients, on pain assessment, and on the myriad drugs and drug strategies that are essential in pain treatment. Aggressive symptom control of treatment-related side effects can ensure successful implementation of such a plan.

The frequency and correlates of dyspnea in patients with advanced cancer

Dyspnea is a devastating symptom in patients with advanced cancer. Unfortunately, very limited research has been done on the frequency and correlates of dyspnea in this particular patient population. The purpose of this prospective study was to assess the frequency of moderate to severe dyspnea and the correlates of dyspnea in a population of ambulatory terminally ill cancer patients. One hundred thirty-five consecutive patients attending a multidisciplinary pain clinic were tested for respiratory function (vital capacity, peak flow, maximal inspiratory pressure, and oxygen saturation). All patients gave their rating of dyspnea, anxiety, and fatigue/tiredness using visual analogue scales (VAS). Lung involvement by the tumor (primary or metastatic) was determined from the patient's chart. Moderate dyspnea occurred in 74/135 (55%) patients with terminal cancer. Lung involvement (r = 0.285, P = 0. 0009), anxiety (r = 0.306, P = 0.0003), fatigue/tiredness (r = 0.211, P = 0.0146), and vital capacity (r = -0.189, P = 0.0444) were significantly correlated with the intensity of dyspnea. Multivariate analysis demonstrated that lung involvement (P = 0.0016) and anxiety (P = 0.0027) were independently correlated with the intensity of dyspnea. In the subgroup of patients with moderate to severe dyspnea, multivariate analysis found anxiety (P = 0.0318) and maximal inspiratory pressure (P = 0.0187) to be independent correlates of the intensity of dyspnea. Dyspnea is a frequent symptom in patients with advanced cancer. The presence of cancer in the lungs, anxiety, and maximal inspiratory pressure are correlates of the intensity of dyspnea in this patient population. Possible treatments addressing low maximal inspiratory pressure and anxiety are needed, as well as further research in finding new correlates of dyspnea in advanced cancer patients.

Does spirometry predict dyspnoea in advanced cancer?

This study explores the similarities and differences between subjective assessments of dyspnoea and objective spirometric indices of respiratory function in advanced cancer. Of 155 patients investigated, 71 (46%) were dyspnoeic and 108 (70%) had spirometry (94 post-salbutamol). Of the 94, 84 had height and weight measured to calculate predicted spirometry. Average dyspnoea levels over 24 h were measured by patient visual analogue scales (VASMe 24). Forced expiratory volume after 1 s (FEV1) and forced vital capacity (FVC) were almost always lower than predicted, indicating frequent impaired respiratory function. Mean spirometric increase post-salbutamol was 21% for FEV1 and 12% for FVC. Correlations between VAS dyspnoea scores and spirometry were low; hence, the latter cannot be relied upon as a measure of the former. Respiratory impairment tended to be obstructive (mean FEV1/FVC = 65%).

Is the presence of dyspnea a risk factor for morbidity in cancer patients?

Data collected from six home palliative care teams in Ireland were analyzed to determine the prevalence of dyspnea in the population studied and to identify factors associated with the presence of dyspnea that might impact on future care. The prevalence of mild, moderate, or severe dyspnea, as measured by the Support Team Assessment Schedule (STAS), fell from 39% at referral in 327 evaluable patients to 23%. The presence of dyspnea at referral was positively correlated with severity of patient spiritual distress (Spearman rho = 0.110, P = 0.042) and weakness (Spearman rho = 0.105, P = 0.008) at referral. In analysis of contingency tables, dyspnea was also significantly associated with low patient (chi 2 9.5, P = 0.002) and family (chi 2 50.78, P < 0.001) well-being, high staff anxiety (chi 2 4.14, P = 0.04), male sex (chi 2 8.9, P = 0.003), a diagnosis of lung cancer (chi 2 59.88, P < 0.001), and dying in hospital rather than hospice or nursing home (chi 2 18.03, P = 0.001). In adjusting for covariates using a logistic regression analysis, however, only the presence of low family well-being, a diagnosis of lung cancer, and increased likelihood of a hospital death remained significantly associated with the presence of dyspnea at referral. These data suggest that the presence of dyspnea may be associated with increased family distress, which may influence place of death.

Effect of nebulized morphine in cancer patients with dyspnea: a pilot study

BACKGROUND

It is known that opioids may decrease subjective dyspnea. The recent finding that opioid binding sites are present in the peripheral bronchus supports the possibility of a local action of opioids. However, the clinical benefit of nebulized morphine is controversial. The purpose of this study was to confirm the feasibility of nebulized morphine and to evaluate its clinical benefits.

PATIENTS AND METHODS

Fifteen cancer patients with dyspnea in the Thoracic Oncology Division and Palliative Care Unit in the National Cancer Center Hospital East were given 20 mg of morphine hydrochloride dissolved in 5 ml of normal saline through an ultranebulizer. The subjective effects were evaluated using a visual analog scale (VAS) immediately before and 60 min after inhalation. Respiratory rate (RR), hemoglobin oxygen saturation (SpO2) and blood pressure also were measured twice at these two time points. A questionnaire about adverse reactions was included.

RESULTS

No major adverse reactions such as respiratory depression, sleepiness, nausea or vomiting were observed. VAS was significantly decreased after nebulization (p = 0.005) without any significant change in RR or SpO2. In eight of 15 patients, dyspnea was improved as measured by a decrease in VAS of more than 10%. This correlated with the desire of the patients to continue its use.

CONCLUSION

Our preliminary data confirmed the feasibility of nebulized morphine and suggested its possible clinical benefit for dyspneic patients. A randomized controlled study is warranted to exclude a placebo effect and to compare the clinical benefits of nebulized morphine with those of other methods of treatment.

Fatigue in advanced cancer: a prospective controlled cross-sectional study

Uncontrolled studies have reported that fatigue is a common symptom among patients with advanced cancer. It is also a frequent complaint among the general population. Simply asking cancer patients whether or not they feel fatigued does not distinguish between the 'background' level of this symptom in the community and any 'excess' arising as a result of illness. The aim of this study was to determine the prevalence of fatigue among palliative care inpatients in comparison with a control group of age and sex-matched volunteers without cancer. In addition, the correlates of fatigue were investigated. The prevalence of 'severe subjective fatigue' (defined as fatigue greater than that experienced by 95% of the control group) was found to be 75%. Patients were malnourished, had diminished muscle function and were suffering from a number of physical and mental symptoms. The severity of fatigue was unrelated to age, sex, diagnosis, presence or site of metastases, anaemia, dose of opioid or steroid, any of the haematological or biochemical indices (except urea), nutritional status, voluntary muscle function, or mood. A multivariate analysis found that fatigue severity was significantly associated with pain and dypnoea scores in the patients, and with the symptoms of anxiety and depression in the controls. The authors conclude that subjective fatigue is both prevalent and severe among patients with advanced cancer. The causes of this symptom remain obscure. Further work is required in order to determine if the associations reported between fatigue and pain and between fatigue and dyspnoea are causal or coincidental.