Quality of life measurement in the palliative management of advanced cancer

Body image dissatisfaction: A novel predictor of poor quality of life in epilepsy

OBJECTIVE

People with epilepsy have long reported reduced quality of life (QoL) compared to healthy peers. This initial study seeks to broaden our understanding of QoL in adults with epilepsy, by examining the adverse impact of body image dissatisfaction for the first time. This aim stems from the observation that both seizures and their medical treatment can cause unwanted changes to physical appearances, such as weight change, hirsutism, and acne.

METHOD

Sixty-three adults with epilepsy and 48 age- and gender-matched healthy controls were recruited from a tertiary epilepsy program and targeted social media. Participants completed an online suite of well-validated questionnaires canvassing state (current) and trait (long-term) aspects of body image dissatisfaction, mood, QoL, and medical history.

RESULTS

People with epilepsy reported significantly elevated levels of trait body image dissatisfaction compared to controls across the dimensions of appearance evaluation, body areas satisfaction, and self-classified weight (p = 0.02); but did not differ from controls on state body image dissatisfaction (p > 0.05). All facets of body image dissatisfaction in participants with epilepsy were strongly associated with reduced QoL, together with heavier body weight, depressive symptoms, medical comorbidities, and a belief that epilepsy hindered their ability to attain a healthier physique. Multiple regression revealed that body image dissatisfaction was the strongest unique contributor to poor QoL in the epilepsy group (β = 0.46, p ≤ 0.001), above and beyond the contribution of current depressive symptoms (β = 0.34, p ≤ 0.01).

SIGNIFICANCE

This is the first study to highlight the high rates of body image dissatisfaction among adults with epilepsy, and the significantly detrimental impact it has on patient well-being. It also opens novel avenues for psychological interventions in epilepsy, that focus on enhancing positive body image as a means of holistically improving the often-poor psychological outcomes for people with this condition.

Palliative Oncological Patients with Insomnia: Concerns of the Patients and Their Relatives' Perception

Insomnia is one of the most frequent symptoms and usually generates significant stress in 60% of patients with advanced cancer. Worries from the patients' and relatives' perspective are crucial to improve the patients' quality of life but have received limited attention. The aims were to identify the concerns of patients with insomnia in the terminal illness stage in a palliative care unit and the relatives' perception, and to compare both. Here, 63 patients and 53 relatives answered a questionnaire about worries in the personal, spiritual, family-related and economic area, as well as a quality-of-life uniscale. The results showed that the relatives' most frequent concern was "Having lived life to the fullest" (100%), and the most intense was "The possible suffering during the process" (9.2/10). The patients' most expressed concern was: "Having unfinished business" (100%), and the most intense was "Suffering during the process" (9.3/10). Quality of life showed an average value of 6.95 out of 10. Relatives only coincided significantly in: "Not knowing what happens after death" (r = 0.600; p = 0.000). These results bring visibility to concerns during the final stage of oncological palliative patients with insomnia from the patients' and relatives' perspective. Knowing both is useful for professionals to foster the well-being for a short, yet very important, period for patients, relatives and the caregiving team.

Ayurveda: between religion, spirituality, and medicine

Ayurveda is playing a growing part in Europe. Questions regarding the role of religion and spirituality within Ayurveda are discussed widely. Yet, there is little data on the influence of religious and spiritual aspects on its European diffusion. Methods. A survey was conducted with a new questionnaire. It was analysed by calculating frequency variables and testing differences in distributions with the χ (2)-Test. Principal Component Analyses with Varimax Rotation were performed. Results. 140 questionnaires were analysed. Researchers found that individual religious and spiritual backgrounds influence attitudes and expectations towards Ayurveda. Statistical relationships were found between religious/spiritual backgrounds and decisions to offer/access Ayurveda. Accessing Ayurveda did not exclude the simultaneous use of modern medicine and CAM. From the majority's perspective Ayurveda is simultaneously a science, medicine, and a spiritual approach. Conclusion. Ayurveda seems to be able to satisfy the individual needs of therapists and patients, despite worldview differences. Ayurvedic concepts are based on anthropologic assumptions including different levels of existence in healing approaches. Thereby, Ayurveda can be seen in accordance with the prerequisites for a Whole Medical System. As a result of this, intimate and individual therapist-patient relationships can emerge. Larger surveys involving bigger participant numbers with fully validated questionnaires are warranted to support these results.

Single- vs. multiple-item instruments in the assessment of quality of life in patients with advanced cancer

Although multidimensional instruments are usually used to measure quality of life in advanced cancer patients, recent research suggests that single-item assessments can provide a reliable measure. Using the Functional Assessment of Cancer Therapy-General (FACT-G) instrument as a gold standard, we assessed the performance of the Edmonton Symptom Assessment System "feeling of well-being" (ESAS WB) item. We reviewed the data from 213 patients enrolled in six clinical trials. We determined the association between baseline ESAS WB and FACT-G total and subscale domain scores (Physical Well-being [PWB], Social/Family Well-being [SWB], Emotional Well-being [EWB], and Functional Well-being [FWB]. We also calculated the association between baseline (T1) and second (T2) observations of ESAS WB and of FACT-G total score. In addition, we predicted the change in FACT-G predicted by the ESAS WB score using regression analysis. Mean age was 60 (SD 12) years and 48% were female. The Spearman correlation coefficient of ESAS WB and FACT-G was -0.48 (P<0.0001). Correlations with FACT-G subscale domains were also highly significant, except for the SWB domain (P=0.08). The Pearson correlation coefficient for T1-T2 in ESAS WB and FACT-G for 146 patients was -0.36 (P<0.0001). The change in ESAS WB corresponding to FACT-G published minimally important difference was -0.24 for 3, -1.55 for 5, and -2.87 for 7, respectively. These results suggest that the single-item measure ESAS WB best reflects the total score on the FACT-G and PWB, EWB, and FWB domains but not on the SWB domain.

The geriatric cancer experience at the end of life: testing an adapted model

PURPOSE/OBJECTIVES

To test an adapted end-of-life conceptual model of the geriatric cancer experience and provide evidence for the validity and reliability of the model for use in practice and research.

DESIGN

Nonexperimental and cross-sectional using baseline data collected within 24-72 hours of admission to hospice.

SETTING

Two hospices in the southeastern United States.

SAMPLE

403 hospice homecare patients; 56% were men and 97% were Caucasian with a mean age of 77.7 years.

METHODS

Confirmatory factor analyses using structural equation modeling with AMOS statistical software.

MAIN RESEARCH VARIABLES

Clinical status; physiologic, psychological, and spiritual variables; and quality of life (QOL).

FINDINGS

A three-factor model with QOL as an outcome variable showed that 67% of the variability in QOL is explained by the patient's symptom and spiritual experiences.

CONCLUSIONS

As symptoms and associated severity and distress increase, the patient's QOL decreases. As the spiritual experience increases (the expressed need for inspiration, spiritual activities, and religion), QOL also increases.

IMPLICATIONS FOR NURSING

The model supports caring for the physical and metaphysical dimensions of the patient's life. It also highlights a need for holistic care inclusive of physical, emotional, and spiritual domains.

Measuring outcomes in randomized prospective trials in palliative care

Palliative care aims to improve the quality of life of patients and their families and reduce suffering from life-threatening illness. In assessing palliative care efficacy, researchers must consider a broad range of potential outcomes, including those experienced by the patient's family/caregivers, clinicians, and the health care system. The purpose of this article is to summarize the discussions and recommendations of an Outcomes Working Group convened to advance the palliative care research agenda, particularly in the context of randomized controlled trials. These recommendations address the conceptualization of palliative care outcomes, sources of outcomes data, application of outcome measures in clinical trials, and the methodological challenges to outcome measurement in palliative care populations. As other fields have developed and refined methodological approaches that address their particular research needs, palliative care researchers must do the same to answer important clinical questions in rigorous and credible ways.

Prevalence and Predictors of Symptoms in the Terminal Stage of Lung Cancer

BACKGROUND

There is little knowledge concerning the prevalence and predictors of symptoms in the terminal stage of lung cancer.

METHODS

We examined, retrospectively, all cases of lung cancer diagnosed from 1990 to 1996 in a defined hospital area in Norway. All medical records from general practitioners, nursing homes, and hospitals were investigated. A total of 271 cases were diagnosed, and 247 of 253 deaths (98%) were analyzed.

RESULTS

In the terminal 8 weeks, pain was recorded in 85% of the patients, psychological symptoms (anxiety, insomnia, and/or depression) in 71%, dyspnea in 54%, neurologic symptoms in 28%, cough in 24%, nausea in 21%, and hemoptysis in 9%. Young age (p = 0.02) and small cell lung carcinoma (p = 0.03) were risk factors for psychological symptoms. Terminal dyspnea was more frequent in patients with stage III (p = 0.002) and nausea in stage IV (p = 0.02) at the time of diagnosis, while cough (p = 0.04) occurred more often in non-small cell lung carcinoma. Terminal pain was independent of gender, age, performance status, stage, and histology.

CONCLUSION

In a community health service encompassing all lung cancer patients, pain, psychological symptoms, and dyspnea were frequent complaints in the terminal phase. Terminal dyspnea and nausea were associated with staging at the time of diagnosis, and terminal cough and nausea were associated with histology.

Quality of life in palliative care cancer patients: a literature review

AIMS AND OBJECTIVES

[corrected] This review of the literature intended to get insight into the international standards of quality of life assessment in palliative care, the conceptual and research literature addressing illness related quality of life and an examination of how nurse researchers define and assess this concept in the context of terminally ill cancer patients. Clearly stated goals for measuring quality of life as well as an understanding of the pragmatic and theoretical explanations for current trends in quality of life measurement are fundamental to this focus.

BACKGROUND

Most clinicians and researchers agree that the primary goal of palliative care is to optimize the quality of life of patients with advanced incurable diseases through control of physical symptoms and attention to the patient's psychological, social and spiritual needs. Palliative care therefore is the achievement of the best quality of life for patients and their families. Consequently, the outcomes of care should be measured in terms of the extent to which this goal is achieved. Quality of life is difficult to define and measure; it is a multidimensional, dynamic and subjective concept. During the past decade, multidisciplinary research measuring the impact of cancer and its treatment on the quality of people's lives escalated rapidly in international literature but not in the German speaking European countries. This international escalation was accompanied by a proliferation of measurement strategies and tools. Nursing shared this interest and began to generate substantive research of the phenomenon. In the oncology and palliative care nursing societies quality of life and numerous closely related areas of symptom management rank among the highest research priorities.

METHOD

This paper examines nursing literature published between 1990 and 2004, retrieved through a computer review of MEDLINE and Cumulative Index of Nursing and Allied Health Literature. The review includes reports that systematically describe or measure the quality of life of people with a terminal cancer in palliative care as a variable of interest. This article also describes conceptual and operational definitions of quality of life and explores the implicit and explicit goals of research.

RESULTS

Quality of life is a concept relevant to the discipline of nursing. Nurses, especially oncology and palliative care nurses, actively contributed to the development of the quality of life concept through instrument development and population description.

CONCLUSION

Nurses working in German palliative care settings do change the quality of life of patients they care for, but there are no systematic standards of assessing these outcomes.

RELEVANCE TO CLINICAL PRACTICE

There are challenges related to measuring quality of life in patient-focused palliative care and research. Systematic quality of life assessment in all palliative care settings will establish quality assurance and the further development of this very young discipline in Germany.

Use of strong opioids in advanced cancer pain: a randomized trial

The World Health Organization (WHO) guidelines for the treatment of cancer pain recommend nonopioid analgesics as first-line therapy, so-called "weak" analgesics combined with nonopioid analgesics as second-line therapy, and so-called "strong" opioids (with nonopioid analgesics) only as third-line therapy. However, these guidelines can be questioned with regard to the extent of efficacy as well as the rationale for not using strong opioids as first-line treatment, especially in terminal cancer patients. The purpose of this randomized study was to prospectively compare the efficacy and tolerability of strong opioids as first-line agents with the recommendations of the WHO in terminal cancer patients. One hundred patients with mild-moderate pain were randomized to treatment according to WHO guidelines or to treatment with strong opioids. Evaluated outcomes included pain intensity, need for change in therapy, quality of life, Karnofsky Performance Status, general condition of the patient, and adverse events. No between-treatment differences were observed for changes in quality of life or performance status, but patients started on strong opioids had significantly better pain relief than patients treated according to WHO guidelines (P=0.041). Additionally, patients started on strong opioids required significantly fewer changes in therapy, had greater reduction in pain when a change was initiated, and reported greater satisfaction with treatment than the comparator group (P=0.041). Strong opioids were safe and well-tolerated, with no development of tolerance or serious adverse events. These data suggest the utility of strong opioids for first-line treatment of pain in patients with terminal cancer.

Predicting the Trajectory of Will to Live in Terminally Ill Patients

Will to live has been shown to vary considerably during the final course of a terminal illness. The goal of this study was to identify illness-related and demographic variables predicting will to live among dying patients. Subjects were 168 patients with cancer who were admitted for palliative care. Will to live was measured twice daily for the duration of hospitalization by using a self-report 100-mm visual analogue scale. Will-to-live data for each patient were summarized into two statistics, intercept and slope, by using simple linear regression analyses. Intercept-slope pairs for all patients were classified into the following five clusters by using spatial and conceptual criteria: patients with sustained high will to live (58%), patients with sustained moderate will to live (11%), patients with sustained low will to live (3%), will-to-live relinquishers (18%), and will-to-live acquirers (10%). Discriminant analyses revealed seven variables that accounted for 69% of the variance in cluster membership: anxiety, shortness of breath, nausea, length of survival from time of admission, having a diagnosis of colon cancer, having no religion, and living with a spouse.