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

The impact of different models of specialist palliative care on patients' quality of life: a systematic literature review

This study set out to systematically review the research evidence about the impact of alternative models of specialist palliative care on the quality of life of patients. Eighty-six relevant papers were identified and reviewed, including 22 descriptive and 27 comparative studies. We found few comparative trials of reasonable quality. There was some evidence that in-patient palliative care provided better pain control than home care of conventional hospital care, but this research was dated and open to criticism. Research on palliative home care teams and co-ordinating nurses has demonstrated limited impact on quality of life over conventional care for patients dying at home. These negative findings may be due to the limitations of the assessment tools used. There is a need for larger studies to provide clear evidence as to whether specialist palliative care services provide improvements in patients' quality of life. This review does not exclude the possibility that models of care might be justifiable on other grounds such as patient preference or cost-effectiveness.

The relationship between patients' concerns and psychological distress in a hospice setting

A total of 87 patients admitted to two hospices during a 9 month period were assessed by trained nurses to determine their current concerns. These assessment interviews were tape recorded. A trained researcher then administered a semi structured concerns interview using the Concerns Checklist, the Hospital Anxiety and Depression Scale and the Spielberger State Anxiety Inventory. Patients reported an average of 6.5 concerns. Concerns about loss of independence and the family were most common. Although a third of the patient sample died within a short time after the interview, concerns about cancer, the future and dying were infrequent. Using a threshold score on the Hospital Anxiety and Depression Scale of > 19 to allow for the effect of disease, 17% of the sample were judged to be probable cases of clinical anxiety and/or depression. There was a strong association between the number of concerns patients experienced and psychological distress (p < 0.001). Concerns about pain and treatment were particularly associated with anxiety whereas concerns about disability were linked with depressed mood. Concerns about cancer were linked with both anxious and depressive changes in mood (p < 0.001). The study highlights the diverse nature of hospice patients' concerns and shows a clear link between psychological distress and number of concerns expressed by patients.

Symptoms and functional status of patients with disseminated cancer visiting outpatient departments

Considerable research has focused on pain and other symptoms in terminal cancer patients referred to hospices and palliative care services. These patients differ from Dutch cancer patients in the palliative stage of their disease because the latter are cared for by general practitioners at home and medical specialists in outpatient departments. To clarify the experience of these Dutch patients, a study was started to investigate the prevalence and severity of pain and other symptoms as well as the functional status of consecutive patients visiting oncology outpatient departments for follow-up. After randomization, one group (I) of patients was interviewed at home by a general practitioner using structured questionnaires. The other group (II) received the questionnaires by mail, and scored the symptoms independently. The results of the symptom assessment show that patients in groups I and II suffered 2.4 (SD = 1.7) and 2.8 (SD = 2.0) symptoms, respectively. Between 30% and 40% of all patients reported constipation, nausea, loss of appetite, coughing, and dyspnea. These percentages were 50% lower when only moderate, severe, or extremely distressing symptoms were included. Sixty percent of all patients had pain, and 20% indicated a daytime pain score of 5 or greater on a scale of 0 to 10. Functional status was measured by the COOPWONCA charts; the mean score for the charts "physical fitness" and "daily activities" was 1.5 points lower for cancer patients than a random sample from the community of the same age and gender. The findings of this study should motivate doctors to put more energy in symptom assessment and interventions in palliative care.

The palliation of dyspnea in terminal disease

Dyspnea is a complex subjective experience that is common in terminal illness. Patients may present at any time during the course of their illness, although prevalence increases with disease progression. Dyspnea has physical, psychological, social and spiritual components; without recognizing how each of these contributes to the total suffering of dyspnea, management is unlikely to be successful. The management of dyspnea involves both pharmacological and non-pharmacological treatment. The main pharmacological palliative treatments are oxygen, opioids, and benzodiazepines, but the evidence to support these treatments is limited. More research is urgently needed to establish the efficacy of current treatments and to identify new ones.

Dyspnea in the advanced cancer patient

Optimal management of dyspnea in terminal cancer patients requires an understanding of the responsible pathophysiological mechanisms. This prospective study assessed visual analogue scales (VAS) of shortness of breath (SOB) and anxiety, bedside spirometry, maximum inspiratory pressure (MIP), chest radiography, arterial blood gases, hemoglobin, and electrocardiogram, if indicated, in 100 terminally ill cancer patients. Forty-nine percent of the patients had lung cancer. The median VAS scores for SOB and anxiety were 53 mm and 29 mm, respectively. Spirometry was abnormal in 93% of patients, with 5% having obstructive, 41% restrictive, and 47% mixed patterns. The median MIP was 16 cm H2O. Sixty-five percent of the patients had parenchymal or pleural involvement on chest radiograph. Twenty-nine percent had evidence of cardiac ischemia, recent or current myocardial infarction or atrial fibrillation. Patients had a median of five different abnormalities that could have contributed to their shortness of breath. Only anxiety (p = 0.001), a history of smoking (p = 0.02), and pCO2 levels were statistically significantly correlated with SOB VAS scores. The potentially correctable causes of dyspnea included hypoxia (40%), anemia (20%), and bronchospasm (52%). The finding of very low MIPs suggests severe respiratory muscle weakness may contribute significantly to dyspnea in this patient population. Further studies are needed to confirm this finding and characterize the underlying pathophysiology.

Do hospital palliative care teams improve symptom control? Use of a modified STAS as an evaluation tool

The support team assessment schedule (STAS) has previously been validated as an evaluation tool for community palliative care teams and inpatient units. This study reports on use of an expanded STAS (E-STAS) to determine symptom prevalence and outcome for inpatients and outpatients referred to a multiprofessional hospital palliative care team. E-STAS forms were completed on patients at referral and twice weekly thereafter. Between August 1996 and May 1997, 352 patients had one or more E-STAS forms completed; 122 of this group had three or more assessments. One-hundred-and-eighty-two patients were male and 170 were female, the median age was 68.5 years (range 26-101 years) and all but 27 (8%) had malignant disease. Of the symptoms assessed on referral, the most common were psychological distress 93%, anorexia 73%, pain 59%, mouth discomfort 59%, depression 40%, constipation 36%, breathlessness 32%, nausea 24% and vomiting 13%. In the 122 patients where three or more assessment were completed, statistically significant improvements from first to last assessment were seen in all symptoms except depression. This study suggests that E-STAS may be a useful tool to evaluate interventions by a hospital palliative care team in patients with advanced disease.

Sedation for intractable distress in the dying--a survey of experts

Terminal sedation is a phrase that has appeared in the palliative care literature in the last few years. There has not been a clear definition proposed for this term, nor has there been any agreement on the frequency with which the technique is used. A postal survey of 61 selected palliative care experts (59 physicians, two nurses) was carried out to examine their response to a proposed definition for 'terminal sedation', to estimate the frequency of this practice and the reasons for its use, to identify the drugs and dosages used, to determine the outcome, and to explore the decision-making process. Opinions on physician-assisted suicide and voluntary euthanasia were also sought. Eighty-seven per cent of the experts responded from eight countries, although predominantly from Canada and the United Kingdom. Forty per cent agreed unequivocally with the proposed definition, while 4% disagreed completely. Eighty-nine per cent agreed that 'terminal sedation' is sometimes necessary and 77% reported using it in the last 12 months--over half of these for up to four patients. Reasons for using this method included various physical and psychological symptoms. The most common drugs used were midazolam and methotrimeprazine. Decision making usually involved the patient or family, and varied with respect to the ease with which the decision was made. The use of sedation was perceived to be successful in 90 out of 100 patients recalled. Ninety per cent of respondents did not support legalization of euthanasia. In conclusion, sedating agents are used by palliative care experts as tools for the management of symptoms. The term 'terminal sedation' should be abandoned and replaced with the phrase 'sedation for intractable distress in the dying'. Further research into the management of intractable symptoms and suffering is warranted.

The uses of psychotropics in symptom management in advanced cancer

Approximately 50% of patients diagnosed with cancer die because of progressive disease. Psychotropic drugs are frequently used for the management of physical and psychosocial symptoms in these patients. Thalidomide, cannabinoids and melatonin are emerging agents for the management of cachexia. Psychostimulants have a defined role in the management of opioid-induced sedation. Haloperidol, tricyclic anti-depressants and newer anti-depressants also have an established role in the management of neuropsychiatric symptoms such as delirium or depression. Cancer patients present unique challenges for successful psychotropic therapy including older age, malnutrition, autonomic failure, borderline cognition, opioid and psychotropic therapy. A practical clinical approach which defines a specific target symptom, an outcome latency period, expected side effects, and reviews possible drug interactions, and frequent monitoring is outlined. Continued research is needed to further define the role of psychotropics in the management of the different physical and psychosocial symptoms in advanced cancer patients.

Palliative care in chronic obstructive airways disease: a needs assessment

The view that palliative care should move beyond cancer is widely endorsed, however, there remains a lack of clarity about the level at which this should occur. In order to target the palliative approach effectively, the value of more detailed and localized needs assessment becomes apparent. This paper provides evidence from a study commissioned by a department of public health, where the focus was the palliative care needs of an individual with chronic obstructive airways disease (COAD). Over a six-month period, 63 individuals in the district were interviewed about their experiences of living with COAD and the services utilized, using a combination of qualitative and quantitative research methods. The findings revealed a poor quality of life, relating to a high degree of social isolation and emotional distress, associated with low physical functioning and disability, and physical symptoms. Current service provision focused on acute exacerbations. Consequently, there is a need to manage the health and social care interface more effectively, with a shift in emphasis from reactive ad hoc provision, which is where the palliative approach to care could be best suited to meet the needs identified.

Developing the Cambridge palliative audit schedule (CAMPAS): a palliative care audit for primary health care teams

BACKGROUND

Problems with the provision of palliative care have been reported. Audit is one means of improving care. Earlier audits of primary care palliative care have been initiated by general practitioners (GPs) and are predominantly retrospective record reviews. Widely applicable methods for the audit of primary care palliative care do not exist.

AIM

To develop relevant palliative care standards and to devise an audit schedule (the Cambridge palliative audit schedule, CAMPAS) suitable for monitoring palliative care in diverse primary care settings.

METHOD

Primary health care team (PHCT) members collaborated at all stages. Reasonable outcomes and acceptable interventions for PHCTs were identified and standards developed. Each standard was constructed to ensure uniform interpretation, and CAMPAS was structured to collect data necessary for determining whether the standards were met.

RESULTS

Over 50% of PHCTs (n = 20) in the health district were recruited and trained to use CAMPAS. A total of 876 contacts with 29 patients was recorded by PHCTs using CAMPAS. Considerable inter- and intra-PHCT variation was found in the achievement of the standards.

CONCLUSIONS

The favourable participation rate suggests commitment to audit and improvement in patient care. Overall, the standards were reported to be suitable. Although 100% achievement of some standards may be unrealistic, the level of attainment for many suggests that it is possible. CAMPAS has been reported to be a useful structure for recording assessments and monitoring care, as well as a usable audit schedule. As an audit tool, it identified areas in need of improvement and facilitated feed-back to participants. Future audit is required to determine whether improvements in care have been effected.

Difficulty of symptom control and general practitioners' knowledge of patients' symptoms

The purpose of this study was to investigate barriers to adequate symptom control in palliative care within primary care by surveying health professionals' perceptions of their ability to control symptoms and awareness of their patients' symptoms. General practitioners (GPs) and district nurses were surveyed about general views of symptom control. Interviews with terminally ill patients were conducted, and GPs completed questionnaires about these specific patients. GPs and district nurses differed greatly in the symptoms they felt confident in controlling. There was generally low agreement between patients' and GP's reports of patients' symptoms. GPs were most likely to miss symptoms which were perceived to be difficult to control and which were less prevalent in the patient sample. As GPs and district nurses differ in the symptoms they feel confident in controlling, close teamwork between the two professions may enhance the prospects for adequate control of some symptoms. Perceived ability to control symptoms and the prevalence of symptoms may both influence which symptoms come to the attention of the GP. Unless GPs ask directly about symptoms, many symptoms are likely to be missed.

End-of-life care in cystic fibrosis

OBJECTIVE

End-of-life clinical care in cystic fibrosis (CF) differs substantially from terminal care in childhood cancer. To examine this difference, we reviewed the medical care of a cohort of CF patients treated at Children's Hospital, Boston, to document the use of preventive, therapeutic, and palliative care in the month preceding death.

PATIENTS

We reviewed the medical records of 44 patients older than 5 years who died of CF-related respiratory failure for the years 1984 to 1993.

RESULTS

Thirty-eight patients (86%) received opiates for the treatment of severe dyspnea and pain; the duration of opiate use varied from less than 1 hour to greater than 1 month. The dose of opiates varied from less than 5 mg per hour to greater than 30 mg per hour. Thirty-three patients (75%) continued to receive intravenous antibiotics in the last 12 hours of life; 32 (72%) continued to receive preventive or therapeutic oral medications in the last 12 hours of life. All patients were designated as do not resuscitate at the time of death; 43 of the patients died in the hospital with 1 patient dying at home under hospice care.

CONCLUSIONS

The model of comfort care developed in childhood cancer does not adequately describe the combination of preventive, therapeutic, and palliative care given at the end of life for CF at our institution. The majority of CF patients continued to receive intravenous antibiotics and/or oral vitamin preparations while being treated with opiates for terminal pain and dyspnea. Small doses of opiates seem to be effective in the treatment of the pain and dyspnea at the end of life in CF.

Oral morphine as symptomatic treatment of dyspnoea in patients with advanced cancer

We report an open, uncontrolled study to evaluate the effectiveness of regular oral morphine as symptomatic treatment of dyspnoea in patients with advanced cancer receiving standard clinical care. Fifteen patients were assessed initially, and then 48 h and 7-10 days after starting treatment with oral morphine or having their dose increased. Dyspnoea, measured on a visual analogue scale (0-100), fell by a median of 14 (95% confidence interval -1.5, 25.5; Wilcoxon statistic 32.0; P = 0.06) in the nine who completed all three assessments. The three patients who died during the study did not show symptomatic benefit and, like the three who withdrew, experienced increased sedation and/or dizziness. Sedation was significantly increased at 48 h; median rise 10.5 (95% confidence interval 7, 25; Wilcoxon statistic 74; P = 0.007). Baseline respiratory function (FEV1, FVC, peak flow) was poor and the patients' respiratory rate was unaffected. Regular, titrated oral morphine may improve dyspnoea in some patients with advanced cancer but can cause significant short-term adverse effects. Oral morphine should be given to these patients as a therapeutic trial. Patients should be advised about side-effects and carefully monitored. Larger studies are needed to establish which patients are most likely to benefit and optimal dosage regimens.

Nebulized morphine in the palliation of dyspnoea

Seventeen terminally ill cancer patients with primary or secondary intrathoracic malignancy complaining of breathlessness were treated with nebulized morphine in doses of 20 mg 4-hourly for 48 h. The effect on dyspnoea was evaluated using the Dyspnoea Assessment Questionnaire. Most patients felt less dyspnoeic after 24 h; the effect was maintained, but not improved upon, after 48 h.

Dyspnea: pathophysiology and assessment

Dyspnea is frequently a multicausal and devastating symptom among advanced cancer patients. It occurs in 21%-78.6% of patients days or weeks before death and is often difficult to control. The genesis and pathophysiology of dyspnea as a symptom still has not been well understood. Dyspnea is frequently associated with abnormalities in the mechanisms that regulate normal breathing; however, the actual expression of dyspnea by a patient results from a complex interaction between the abnormalities in breathing and the perception of those abnormalities in the central nervous system. The production of dyspnea has to be related to the activation of mechanoreceptors both in the respiratory muscles and in the lung, even in the absence of increased muscle respiratory activity. Respiratory muscle weakness appears to be an important cause of dyspnea in malnourished, asthenic, and cachectic cancer patients. This might also explain why about 24% of dyspneic cancer patients do not present cardiac/pulmonary disease. In addition, two other possible mechanisms of dyspnea have been proposed: chemoreceptor stimulation and efferent activity from the respiratory center by direct ascending stimulation. These factors and the assessment tools used in patients with chronic dyspnea are summarized in this review.

Residents' management of the symptoms associated with terminal cancer

The principal aim of palliative care is to bring symptomatic relief to patients with progressive disease. Residents graduating from a university general surgery training program should be competent to manage common symptoms associated with advanced cancer. This study used performance-based testing to evaluate the skills of resident physicians in managing common symptoms of a patient with advanced cancer. Thirty-three resident physicians (PGY 1 to 6) were presented with four clinical symptoms of a patient with advanced cancer: (1) nausea and vomiting associated with regular morphine use; (2) lack of appetite in the last weeks of life of a terminally ill patient; (3) constipation associated with codeine analgesia; and (4) dyspnea associated with diffuse lung metastases. The management plan for the symptom problems was evaluated by using a predefined checklist. A significant number of residents showed deficits in the management of common symptoms of advanced cancer. Scheduled dosing of antiemetics was infrequently prescribed for opioid-related nausea and vomiting. Most physicians inappropriately managed lack of appetite by using forced feeding. Opioids were infrequently used in the management of terminal dyspnea. The absence of difference in scores between junior and senior residents suggests that adequate management of the symptoms of terminal cancer is not being effectively taught in postgraduate training programs.

Non-pharmacological intervention for breathlessness in lung cancer

OBJECTIVE

To evaluate the effect of non-pharmacological intervention for breathlessness in lung cancer on breathlessness ratings and patient functioning.

DESIGN

Randomised controlled pilot study.

SETTING

A nurse led clinic in a specialist cancer centre.

SUBJECTS

20 patients with advanced small cell and non-small cell lung cancer.

INTERVENTION

Weekly sessions with a nurse research practitioner over 3-6 weeks using counselling, breathing re-training, relaxation and teaching coping and adaptation strategies.

MAIN OUTCOME MEASURES

Visual analogue scale ratings of breathlessness, distress caused by breathlessness, functional capacity, ability to perform activities of daily living and the Hospital Anxiety and Depression Scale.

RESULTS

Improvements in median scores on all measures were observed in the intervention group with the exception of depression, compared with the control group where median scores were static or worsened. Distress from breathlessness was improved by a median of 53%, breathlessness at worst by 35% and functional capacity by 21%. In contrast, distress in the control group worsened by a median of 10%. Significant improvements compared with the control group were observed in breathlessness at best (p < 0.02), breathlessness at worst (p < 0.05), distress caused by breathlessness (p < 0.01), functional capacity (p < 0.02) and ability to perform activities of daily living (p < 0.03) but were not observed for anxiety or depression.

CONCLUSION

Lung cancer patients suffering from breathlessness benefited from this rehabilitative approach to breathlessness management and strategies employed in this pilot study warrant further multicentre research. Macmillan nurses and palliative care teams are recommended to explore the potential of adopting similar approaches.

Prevalence of symptoms among patients with advanced cancer: an international collaborative study. Symptom Prevalence Group

The aims of this study were (a) to estimate the prevalence of pain and eight other common symptoms in a large population of patients with advanced cancer from different palliative care centers, and (b) to assess the differences in prevalence of the symptoms by primary site. In 1990-1991, the prevalence of eight major symptoms and performance status were assessed prospectively among 1840 cancer patients in seven hospices in Europe, the United States, and Australia. The data were collected at each institution using structured data collection sheets from the World Health Organization's (WHO) Cancer and Palliative Care Unit. The prevalence of moderate to severe pain was 51%, ranging from 43% in stomach cancer to 80% in gynecological cancers. Nausea was most prevalent in gynecological (42%) and stomach (36%) cancers, and dyspnea (46%) in lung cancer. There were statistically significant differences in the prevalence of most symptoms depending on the primary site of cancer and the hospice. Population-based follow-up studies are needed to document the incidence and prevalence of symptoms throughout the course of the disease.

Effect of home care on the place of death of advanced cancer patients

This study presents a prospective evaluation of the home care programme for patients with advanced cancer at the National Cancer Institute of Milan. Demographic, psychosocial and physical variables were evaluated. The Therapy Impact Questionnaire was used for symptom and quality of life assessment. The association of clinical and demographic variables with the place of death was investigated, considering that the aim of the home care programme is to follow up patients until death in their houses. Eighty-six per cent (86%) of patients died at home and 14% in hospitals. Multivariate analysis showed that only a higher degree of family support was associated with home death. Several changes in symptoms and quality of life items scores were seen, pain improved while physical debility and cognitive functions worsened throughout the home care duration to death. High intensity pain and dyspnoea were still present in, respectively, 23.8 and 15.3% of patients in the last week of life. Psychological distress was high at the end of life and did not seem to be affected by treatment. Home care is a feasible alternative for implementing palliative care in a selected population of patients with advanced cancer. Palliation of physical symptoms is more easily achieved than the control of psychological suffering. Family and economical issues implied by home care models should be part of the discussion in implementing palliative care for advanced cancer patients.

Pain and Symptom Management in Palliative Care

BACKGROUND: Pain, dyspnea, and anorexia are common symptoms experienced by patients with cancer and often are poorly managed. METHODS: The incidence and causes of these symptoms are described, as well as factors that exacerbate or ameliorate their impact. RESULTS: Pharmacologic management of cancer pain is based on the use of a sequential "ladder" that incorporates nonopioid, opioid, and adjuvant drugs, depending on the severity of the pain. This approach usually is effective. Other symptoms of advanced disease may be more difficult to control. CONCLUSIONS: Adherence to an adequate pain-control strategy will significantly enhance palliation of pain in patients with cancer.

A Circular Diagram for Representing Symptom Status in Advanced Cancer Patients

Symptom relief is the major goal of palliative care. Its assessment is essential and several methods have been described. To evaluate immediately the clinical situation, a circular diagram for a visual representation of the physical symptoms is proposed. Particular patterns derived from the given data emerge from the diagrams. Certain critical situations often observed in palliative care, especially in the last weeks of life, show specific patterns that are easily distinguished. Effective treatments may change the appearance of different pictures.

Management of dyspnea and cough in patients with cancer

The understanding and treatment of dyspnea in the cancer patient are where the science of pain management was 15 or 20 years ago. Very few studies have examined the pathophysiologic mechanisms that cause dyspnea in cancer patients, and few investigators have evaluated therapeutic strategies to control dyspnea in this patient group. The optimal therapy for dyspnea is treatment of the underlying cause. When this is not possible, opioids and phenothiazines provide effective symptomatic relief in most cases, but many unanswered questions remain. Are these the optimal drugs, and what are their optimal doses? What are the effects of chronic dosing? Which is the best route of administration? How serious are the risks of respiratory depression? A clear consensus supports the aggressive treatment of pain in terminally ill cancer patients, even if death is hastened as an unintended consequence. No such position has yet been reached in the management of dyspnea in the same population. As a result, dyspnea is addressed only very late in the course of the disease, perhaps reducing the patient's quality of life and function at earlier stages and resulting in a very small "therapeutic window" in the terminal phase. Clearly, a need exists for more research to determine the most effective management of this common and very distressing symptom.

Prognostic value of quality of life scores in terminal cancer patients

A multicenter cross-sectional study of 115 terminal cancer patients in eight home-care units assessed the prognostic value of quality of life scores, as measured by the Therapy Impact Questionnaire (TIQ). The analysis of the questionnaires completed by 100 patients revealed an association between survival and many of the scales: fatigue, gastrointestinal symptoms, global health status, functional impairment, emotional status, and cognitive status. This association was also observed for some specific physical symptoms, such as confusion, weakness, and loss of appetite, and the overall number of symptoms reported by the patient. Adjusting for some possible confounding factors, only confusion (among the physical symptoms), cognitive status, and global health status (among TIQ primary scales) showed independent prognostic value. As regards the latter two scales, median survival time was distributed differently for patients with no impairment of either (137 days), with impairment of one scale (50 days) and with impairment of both scales (17 days). The judgment expressed by the patient about subjective perception of general malaise and cognitive difficulties can give the clinician important prognostic information.

Nursing as therapy in the management of breathlessness in lung cancer

Breathlessness has been described as an unpleasant sensation, but if it encompasses suffering, as some argue, it is much more than this. Breathlessness is also a major issue for people with cancer. Much of the effort to manage breathlessness has thus far focused on the treatment of underlying causes or on pharmacological strategies. In this paper, broader rehabilitative goals of care and treatment for breathlessness in lung cancer are addressed. Breathing control techniques have been developed to help patients with non-malignant disease to avoid breathlessness at rest or on exertion. A study is described (Corner et al., 1995) which evaluated the effectiveness of breathing retraining and psychosocial support for breathlessness in lung cancer. Breathlessness can be a frightening and powerful experience. It can symbolize a threat to life itself. In these circumstances, the goal of therapy is to alleviate loss of function and to ease the psychological burden that so restricts the individual. An 'integrative' model of breathlessness is discussed, in which the emotional experience of breathlessness is considered inseparable from the sensory experience and the biological mechanisms. Evidence is presented from a small study of the experiences of nurses working in the experimental clinic for breathlessness which suggests that the emotional consequences of breathlessness have a profound influence on how it is managed in practice. Finally, it is argued that symptoms are sometimes generalized too much. Experience is particular, not universal, and an open, accepting and therapeutic approach to managing illness has to be involved with messy and sometimes frightening emotions.

Dyspnoea: a study of measurement instruments for the assessment of dyspnoea and their application for patients with advanced cancer

Dyspnoea or breathlessness is a problem commonly encountered in the palliative care of many patients with advanced cancer, although its impact on the patient is frequently under-estimated. In advanced cancer, the aim of effective management is to minimize the patient's perception of breathlessness which, in turn, depends on reliable assessment. Most of the knowledge and experience of dyspnoea has been acquired through working with patients with chronic pulmonary disease and there is a dearth of literature relating specifically to the assessment of dyspnoea in advanced cancer. A critical analysis of available literature was undertaken and measurement instruments available for assessing breathlessness and their application to dyspnoeic patients with advanced cancer were reviewed. Dyspnoea is a complex, multidimensional sensation and its subjectivity makes it difficult to quantify. For patients with advanced cancer, dyspnoea may be one of many symptoms and measurement instruments need to take this into account. No single measurement instrument takes into account the different components of dyspnoea and as the final choice will depend on the purpose of assessment, it is likely that more than one instrument will be required.

Dying from cancer: results of a national population-based investigation

OBJECTIVE

To describe the quality of care received in the last year of life by people who die from cancer, focusing particularly on symptom control, communication with health professionals, and care in the community.

DESIGN

Interview survey of family members or others who knew about the last year of life of a random sample of people who died in the UK in 1990, based upon methods used in nationally representative surveys by Cartwright in 1969, and Cartwright and Seale in 1987.

SETTING

Twenty district health authorities from a range of inner city, outer urban and rural settings. Although self-selected, districts were nationally representative in terms of social characteristics and on many indicators of health service provision and usage.

PARTICIPANTS

Interviews were obtained for 2074 cancer deaths out of a random sample of 2915, a 71% response rate.

MAIN RESULTS

At some stage in the last year of life, 88% were reported to have been in pain, 66% were said to have found it to be 'very distressing', and 61% to have experienced it in their last week. Treatment that only partially controlled the pain, if at all, was said to have been received by 47% of those treated for pain by their GPs and by 35% of hospital patients. Other common symptoms experienced by more than half the sample in their last year were loss of appetite, constipation, dry mouth or thirst, vomiting or nausea, breathlessness, low mood, and sleeplessness. Half of the respondents (51%) were unable to get all the information they wanted about the patient's medical condition when they wanted it. Relatives bore the brunt of caring for 81% of the sample. Of respondents who had helped to care for the deceased, 65% said that their activities had been at least fairly restricted, but 53% had found it rewarding. District nurses had helped 60% of the deceased, 20% had had a home help, and 9% had received 'meals on wheels'. More help with activities of daily living was reported to have been needed by 31%; 24% were reported to have needed more help with domestic chores; 25% were reported to have needed more financial help, and 29% were reported to have needed either more care from district nurses (if had some) or some care (if had none).

CONCLUSION

There is still some way to go before all dying cancer patients receive high quality care. Education in the principles of palliative care is needed at all levels of the NHS if high standards are to be reached. In addition, adequate resources are required to meet the social and health care needs of cancer patients at home. There is, as yet, no room for complacency about the care of dying cancer patients.

The incidence of airflow obstruction in bronchial carcinoma, its relation to breathlessness, and response to bronchodilator therapy

Breathlessness is a common symptom in patients with primary bronchial carcinoma and is often not well-controlled. Most patients are ex- or current smokers, and therefore are at high risk for co-existing chronic obstructive pulmonary disease (COPD). The incidence of airflow obstruction in patients with bronchial carcinoma, its relation to breathlessness, and response to bronchodilator therapy was examined prospectively. Fifty-seven consecutive patients attending our outpatient clinic with bronchial carcinoma diagnosed in the preceding 12 months were studied (22 female, 35 male, mean age 68.4 years). Spirometry was performed and breathlessness rated. Those with airflow obstruction (FEV1:FVC < 65% and FEV1 < 70% predicted) and who judged themselves to have moderate or severe breathlessness, were offered a trial of bronchodilator therapy. The response to regular inhaled fenoterol and ipratropium bromide by metered dose inhaler (MDI) and large volume spacer, and to regular nebulized salbutamol and ipratropium bromide was assessed by home peak flow recordings, spirometry and two subjective scores: (a) rating of breathlessness on a simple four-point scale, and (b) activity score of the St George's Respiratory Questionnaire. There was very strong association between airflow obstruction and breathlessness. Twenty-eight patients (49%) had airflow obstruction, and we had breathlessness ratings on 26 of these patients of whom 18 (69%) had rated it as moderate or severe. Only four of the patients with airflow obstruction and breathlessness were using bronchodilator therapy. There was no significant difference in the mean age, time from diagnosis, tumour site, or smoking history between the groups with, and without, airflow obstruction. There was no association between cell type and the presence of airflow obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Developing a nursing approach to managing dyspnoea in lung cancer

Dyspnoea, or breathlessness, is a common problem in lung cancer and is frequently difficult to alleviate. Most studies exploring strategies for dyspnoea intervention have focused on pharmacological intervention. The approach described in this article has been developed through an evaluative study of a nursing clinic for lung cancer patients with breathlessness. It used an integrative model of dyspnoea and techniques derived from chronic pulmonary disease rehabilitation. Case examples suggest that this may offer a positive intervention approach in breathlessness management by nurses.

A proposed matrix for organisational changes to improve quality of life in oncology

Educational and institutional changes are needed to improve the care of dying patients. There are four phases to a cancer control programme, and each phase stresses prevention. The fourth phase of a cancer control programme is concerned with the prevention of suffering, through impeccable management of physical and psychosocial distress. In practice, cancer control is usually addressed primarily as a biological problem, with less emphasis placed on behavioural aspects and the alleviation of suffering. The principles of symptom control and the management of psychosocial issues have been defined by the palliative care movement. However, this body of knowledge tends to be cocooned within palliative care programmes and associated journals and textbooks. As exemplified by recent advances in cancer pain management, symptom control research is a promising area for development. However, the promise is not matched by priority assignment and idea implementation. This article offers proposals for specific changes in the structure of university and cancer programmes, and revision of legislative policies which will enhance the care of patients who depend upon our interest in the fourth phase of cancer control, the prevention and relief of suffering.

Dyspnea in dying patients

Dyspnea is common in terminally ill patients and is often fairly difficult to control. If specific causes cannot be identified or treated, general measures to relieve symptoms should be used. Nondrug measures (eg, discussion and explanation with the patient) and drug measures (eg, morphine) can be used to control the dyspnea, although side effects, such as sedation, can be problematic.

Palliative care for people with HIV/AIDS: views of patients, carers and providers

This study compared the views of palliative care reported by patients, informal carers and the Community Care Team (CCT), a multidisciplinary team caring for people with late stage HIV/AIDS illness. Patients and their carers were interviewed at home, 3-4 weeks after referral to CCT. They rated nine items of the Support Team Assessment Schedule (STAS), a standardized measure of palliative care. Items included current problems such as pain and symptom control, anxiety and service needs. Satisfaction with health services was also recorded. CCT separately recorded the severity of 17 STAS items as part of a continuing audit of care. Relatively few patients (19) and carers (8) were interviewed. Main reasons for non-interview of (105) patients were: 57 too ill and 30 less than 4 weeks in care. CCT's audit showed that non-interviewed patients had significantly more severe problems for five out of 17 STAS items. Patients and CCT identified continuing problems with symptom control, pain control, patient and family anxiety, and communication from professionals. Agreement between patient, carer and CCT ratings was reasonable. Patients and CCT ratings were significantly correlated (Spearman rho = 0.66, p < 0.005). However, patients rated pain as significantly more severe than did CCT (p < 0.05, Wilcoxon Z = -2.45). All patients and seven carers rated the care given by CCT as good or excellent. There were negative comments about communication with other professionals. Studies of palliative care which rely on data gained by patient interview may be biased to include patients with fewer problems. To overcome this providers may wish to audit their care. This study indicates that the views of palliative teams are a reasonable reflection of patients' and carers' experiences, and that the STAS is a valid tool, which we hope will be useful for those wishing to audit their work.

Short terminal admissions to a hospice

Over a six-month period, 47 patients (9.8% of admissions) died within 48 hours of admission to St Christopher's Hospice and were included in this study. There was a high prevalence of symptoms on admission but many were amenable to treatment, even in the short time available. Respiratory symptoms were commonest and the most difficult to control. The majority of the patients required an opioid, although only low doses were needed. Almost all the relatives had no regrets about the place of death. Hospice staff felt that a number of patients transferred from hospital should not have been moved. The study confirmed the value of short terminal admissions to patients and families and suggested areas for further action.

Quality-of-life assessment during a palliative care programme

By means of a cross-sectional study, 115 terminal cancer patients (53 males, 62 females) who were no longer responsive to anticancer treatment, were investigated. The sample included all patients who had been undergoing palliative care (PC) during a single week (at the out-patient clinic, in hospital or at home). From the start of PC, the quality of the patients' lives was assessed by a weekly self-descriptive record comprising 32 items at four levels of intensity. The responses given on the questionnaire during the sample week were compared to those given by the same patients at the beginning of PC (T0). From T0 to time during treatment, figures show a significant increase in the percentage of patients who reported drowsiness, and a significant decrease in pain, weakness, functional impairment and psychological distress. The global judgment of not feeling well was reduced from 49% of the patients at TO to 31% during the period of treatment (p less than 0.01). This result shows that, although the disease progressively develops, PC can enhance the quality of the lives of patients during the terminal stages of illness. The subjective judgment of not feeling well was much more closely correlated with physical, functional and psychological symptoms. Of the physical symptoms, pain has the closest correlation with feeling bad. However, pain has a low number of statistically significant correlations with respect to the other items, in marked contrast to the high number of correlations regarding psychological and functional items.(ABSTRACT TRUNCATED AT 250 WORDS)