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Nguyen JP, Gaillard H, Suarez A, Terzidis-Mallat É, Constant-David D, Van Langhenhove A, Evin A, Malineau C, Tan SVO, Mhalla A, Lefaucheur JP, Nizard J. Bicentre, randomized, parallel-arm, sham-controlled trial of transcranial direct-current stimulation (tDCS) in the treatment of palliative care patients with refractory cancer pain. BMC Palliat Care 2023; 22:15. [PMID: 36849977 PMCID: PMC9972710 DOI: 10.1186/s12904-023-01129-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/10/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Pain is a common symptom in palliative care cancer patients and is often insufficiently relieved. In recent years, transcranial direct-current stimulation (tDCS) of the motor cortex has been shown to be effective to treat chronic pain, essentially neuropathic pain. We propose to test the efficacy of tDCS in patients experiencing cancer pain in the palliative care setting. METHOD/DESIGN This article describes the protocol of a bicentre, randomized, parallel-arm, sham-controlled clinical trial evaluating tDCS in the treatment of palliative care patients with refractory cancer pain. Seventy patients between the ages of 18 and 80 years experiencing refractory pain with a pain score of 4/10 on a numerical rating scale (NRS) ranging from 0 to 10 will be enrolled in this trial. The main exclusion criteria are patients unable to fill in the various rating scales and life expectancy less than 3 weeks. Treatment consists of 5 consecutive tDCS sessions targeting the motor cortex (one daily session for 5 days) on the contralateral side to the pain. After randomization (1:1 ratio), 35 patients will receive active stimulation and 35 patients will receive sham stimulation. The primary endpoint is the NRS score and the primary objective is a significant improvement of this score between the baseline score recorded between D-3 and D-1 and the score recorded 4 days after stopping treatment (D8). The secondary objectives are to evaluate whether this improvement is maintained 16 days after stopping treatment (D21) and whether the following scores are improved on D14 and D21: Brief Pain Inventory, Edmonton Symptom Assessment System, Hospital Anxiety and Depression scale, State-Trait Anxiety Inventory and Medication Quantification Scale. DISCUSSION Positive results of this trial would indicate that tDCS can improve pain and quality of life of cancer patients in the palliative care setting. Reduction of analgesic consumption and improvement of activities of daily living should allow many patients to return home with a decreased workload for caregivers.
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Affiliation(s)
- Jean-Paul Nguyen
- Unité de Stimulation Transcrânienne, Clinique Bretéché, Groupe Elsan, Nantes, 44000 France ,grid.277151.70000 0004 0472 0371UIC22 et Service Douleur Soins Palliatifs et Soins de Support, Centre Hospitalo-Universitaire (CHU), Nantes, 44930 France
| | - Hélène Gaillard
- grid.277151.70000 0004 0472 0371UIC22 et Service Douleur Soins Palliatifs et Soins de Support, Centre Hospitalo-Universitaire (CHU), Nantes, 44930 France
| | - Alcira Suarez
- Unité de Stimulation Transcrânienne, Clinique Bretéché, Groupe Elsan, Nantes, 44000 France
| | | | - Diane Constant-David
- grid.277151.70000 0004 0472 0371UIC22 et Service Douleur Soins Palliatifs et Soins de Support, Centre Hospitalo-Universitaire (CHU), Nantes, 44930 France
| | - Aurélien Van Langhenhove
- grid.277151.70000 0004 0472 0371UIC22 et Service Douleur Soins Palliatifs et Soins de Support, Centre Hospitalo-Universitaire (CHU), Nantes, 44930 France
| | - Adrien Evin
- grid.277151.70000 0004 0472 0371UIC22 et Service Douleur Soins Palliatifs et Soins de Support, Centre Hospitalo-Universitaire (CHU), Nantes, 44930 France
| | - Catherine Malineau
- Unité de Stimulation Transcrânienne, Clinique Bretéché, Groupe Elsan, Nantes, 44000 France
| | - Son V. O. Tan
- Service de Neurochirurgie, University Hospital, Ho Chi Minh ville, Vietnam
| | - Alaa Mhalla
- grid.410511.00000 0001 2149 7878EA43910, Faculté de Médecine, Université Paris-Est, Créteil, 94000 France ,grid.50550.350000 0001 2175 4109Unité Douleur et Soins Palliatifs intégrés, DMU Cancer et spécialités, CHU Henri Mondor-Albert Chenevrier, APHP, Créteil, 94000 France
| | - Jean-Pascal Lefaucheur
- grid.410511.00000 0001 2149 7878EA43910, Faculté de Médecine, Université Paris-Est, Créteil, 94000 France ,grid.412116.10000 0004 1799 3934Unité de Neurophysiologie clinique, Hôpital Henri Mondor, APHP, Créteil, 94000 France
| | - Julien Nizard
- UIC22 et Service Douleur Soins Palliatifs et Soins de Support, Centre Hospitalo-Universitaire (CHU), Nantes, 44930, France. .,EA43910, Faculté de Médecine, Université Paris-Est, Créteil, 94000, France.
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Müller E, Mayer-Steinacker R, Gencer D, Keßler J, Alt-Epping B, Schönsteiner S, Jäger H, Couné B, Elster L, Keser M, Rauser J, Marquardt S, Becker G. Feasibility, use and benefits of patient-reported outcome measures in palliative care units: a multicentre observational study. Palliat Care 2023; 22:6. [PMID: 36641450 PMCID: PMC9839955 DOI: 10.1186/s12904-022-01123-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 12/19/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Research has shown that routinely assessed, patient-reported outcome measures (PROMs) have positive effects in patients with advanced oncologic diseases. However, the transferability of these results to specialist palliative care is uncertain because patients are more impaired and staff doubt the feasibility and benefits. The aim of this study is to evaluate the feasibility of patient self-assessment of PROMs, their use by staff and the benefits in palliative care wards. METHOD A multicentre observational study was conducted in the context of the implementation of the Integrated Patient Outcome Scale (IPOS) in three specialist palliative care wards at university hospitals in Germany. All admitted patients who screened positive regarding their ability to complete questionnaires were asked to participate and complete the IPOS on paper weekly, with assistance if necessary. Feasibility of questionnaire completion (e.g. proportion of patients able to complete them), use (e.g. involvement of different professional groups) and benefit (e.g. unexpected information in IPOS as rated by treating physicians) were assessed. Staff members' opinion was obtained in a written, anonymous evaluation survey, patients' opinion in a short written evaluation. RESULTS A total of 557 patients were screened for eligibility, 235 were assessed as able to complete the IPOS (42.2%) and 137 participated in the study (24.6%). A majority needed support in completing the IPOS; 40 staff members and 73 patients completed the evaluation. Unexpected information was marked by physicians in 95 of the 137 patient questionnaires (69.3%). The staff differed in their opinions on the question of whether this also improved treatment. A majority of 32 staff members (80.0%) were in favour of continuing the use of IPOS (4 against continuation, 4 no answer); 43 (58.9%) patients rated their overall experience of IPOS use as 'positive', 29 (39.7%) as 'neutral' and 1 (1.4%) as 'negative'. CONCLUSIONS While most staff wished to continue using IPOS, it was a challenge to integrate the effort to support the completion of IPOS into daily practice. Digital implementation was not successful, despite various attempts. To explore the effects on care and patient outcomes, multicentre cluster-randomised trials could be employed. TRIAL REGISTRATION German Clinical Trials Register DRKS-ID: DRKS00016681 (24/04/2019).
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Affiliation(s)
- Evelyn Müller
- grid.5963.9Department of Palliative Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch Str. 3, 79106 Freiburg, Germany
| | - Regine Mayer-Steinacker
- grid.410712.10000 0004 0473 882XDepartment of Hematology and Oncology, Comprehensive Cancer Center, University Medical Center Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany ,Competence Centre Palliative Care of Baden-Wuerttemberg, Baden-Wuerttemberg, Robert-Koch Str. 3, 79106 Freiburg, Germany
| | - Deniz Gencer
- grid.411778.c0000 0001 2162 1728Department of Hematology and Oncology, Mannheim Cancer Center, Mannheim University Hospital, Mannheim Faculty of Medicine, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany ,Competence Centre Palliative Care of Baden-Wuerttemberg, Baden-Wuerttemberg, Robert-Koch Str. 3, 79106 Freiburg, Germany
| | - Jens Keßler
- grid.5253.10000 0001 0328 4908Department of Anaesthesiology, Devision of Pain Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 131, 69120 Heidelberg, Germany ,Competence Centre Palliative Care of Baden-Wuerttemberg, Baden-Wuerttemberg, Robert-Koch Str. 3, 79106 Freiburg, Germany
| | - Bernd Alt-Epping
- Competence Centre Palliative Care of Baden-Wuerttemberg, Baden-Wuerttemberg, Robert-Koch Str. 3, 79106 Freiburg, Germany ,grid.5253.10000 0001 0328 4908Department of Palliative Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 305, Heidelberg, 69120 Germany
| | - Stefan Schönsteiner
- grid.410712.10000 0004 0473 882XDepartment of Hematology and Oncology, Comprehensive Cancer Center, University Medical Center Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany ,Competence Centre Palliative Care of Baden-Wuerttemberg, Baden-Wuerttemberg, Robert-Koch Str. 3, 79106 Freiburg, Germany
| | - Helga Jäger
- grid.5963.9Department of Palliative Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch Str. 3, 79106 Freiburg, Germany
| | - Bettina Couné
- grid.5963.9Department of Palliative Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch Str. 3, 79106 Freiburg, Germany
| | - Luise Elster
- grid.5963.9Department of Palliative Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch Str. 3, 79106 Freiburg, Germany
| | - Muhammet Keser
- grid.411778.c0000 0001 2162 1728Department of Hematology and Oncology, Mannheim Cancer Center, Mannheim University Hospital, Mannheim Faculty of Medicine, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Julia Rauser
- grid.410712.10000 0004 0473 882XDepartment of Hematology and Oncology, Comprehensive Cancer Center, University Medical Center Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Susanne Marquardt
- grid.5253.10000 0001 0328 4908Department of Anaesthesiology, Devision of Pain Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 131, 69120 Heidelberg, Germany
| | - Gerhild Becker
- grid.5963.9Department of Palliative Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch Str. 3, 79106 Freiburg, Germany ,Competence Centre Palliative Care of Baden-Wuerttemberg, Baden-Wuerttemberg, Robert-Koch Str. 3, 79106 Freiburg, Germany
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3
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Cho MC, Yang PC, Wang YH, Chang HT, Lin MH. Association between the Development of Hospice and Palliative Care and Government-Funded Research Priority: Taiwan-Based Example. Healthcare (Basel) 2022; 10:healthcare10061125. [PMID: 35742174 PMCID: PMC9222240 DOI: 10.3390/healthcare10061125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/11/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Abstract
In recent years, hospice and palliative care (HPC) has grown, developed, and changed in response to the humanistic and social needs for supporting those with incurable illnesses. As a relatively new discipline, research is needed in HPC, and the priority setting of research is essential to help direct finite resources to support research. To promote creative research in different fields including HPC, the Taiwan government subsidized institutions to conduct research. In this study, we obtained data from the Government Research Bulletin, an open-source online system containing complete information about government subsidized studies since 1993 to investigate the development of research priority in HPC in Taiwan. In total, 552 studies were recorded during 1993–2021, with a continued upward trend. An association was found between research priority and the promulgation of new HPC regulations. The type of diseases in research extended from cancer to all advanced chronic conditions. The increased diversity in out-of-hospital settings of palliative research was also observed. Numerous studies have focused on education, and the theme gradually shifted from “training and education for healthcare professionals” to “public education”. Here, the results may serve as a basis to understand the commonalities of research and enhance dialog in HPC research.
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Affiliation(s)
- Ming-Chieh Cho
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (M.-C.C.); (Y.-H.W.)
| | - Po-Chin Yang
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan; (P.-C.Y.); (H.-T.C.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Yueh-Hsin Wang
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (M.-C.C.); (Y.-H.W.)
| | - Hsiao-Ting Chang
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan; (P.-C.Y.); (H.-T.C.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Ming-Hwai Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan; (P.-C.Y.); (H.-T.C.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Correspondence: ; Tel.: +886-2-28757460
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4
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van Esch HJ, Prins SD, van de Vathorst S, van der Rijt CCD, van der Heide A, van Zuylen L. Reflections on Including Patients in a Randomized Placebo-Controlled Multicentre Trial in the Dying Phase - the SILENCE Study. J Pain Symptom Manage 2022; 63:e545-e552. [PMID: 34954069 DOI: 10.1016/j.jpainsymman.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/25/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022]
Abstract
A need exists for studies investigating symptom relief at the end of life. Randomised controlled trials (RCTs) are the gold standard for demonstrating efficacy of medication, but they are difficult to perform at the end of life due to barriers such as the vulnerability of patients, and gatekeeping by healthcare professionals. We analyzed and reflected on recruitment, participation, and strategies used in an RCT at the end of life. The SILENCE study, performed in six inpatient hospice facilities, was a placebo-controlled trial to study the effect of ScopolamIne butyLbromidE giveN prophylactiCally for dEath rattle in dying patients. We addressed patients' vulnerability by using an advance consent procedure, and potential gatekeeping by extensive training of health care professionals and the appointment of hospice doctors as daily responsible researchers. In almost three years, 1097 patients were admitted of whom 626 were eligible at first assessment. Of these, 119 (19%) dropped out because of physical deterioration before they could be informed about the study (44) or sign informed consent (75). Twenty-five (4%) patients were not asked to participate. In 24 cases (4%), relatives advised against the patient participating. Overall, 229 patients (37%) gave informed consent to participate. The vulnerability of patients was the most important barrier in this medication study at the end of life. Gatekeeping by HCPs and relatives occurred in a small number of patients. The robust design and applied strategies to facilitate patient recruitment in this study resulted in a successful study with sufficient participants.
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Affiliation(s)
- Harriëtte J van Esch
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands; Laurens Cadenza, Oosterhagen 239, 3078 CL Rotterdam, The Netherlands; Department of Public Health, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands.
| | - Sanne D Prins
- Department of Public Health, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Suzanne van de Vathorst
- Department of Medical ethics,philosophy and history, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam UMC, Amsterdam University Medical Centers, Cancer Center Amsterdam, 1007 MB Amsterdam, The Netherlands
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5
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Young MJ, Regenhardt RW, Sokol LL, Leslie-Mazwi TM. When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative? AMA J Ethics 2021; 23:E783-793. [PMID: 34859772 PMCID: PMC8684539 DOI: 10.1001/amajethics.2021.783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.
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Affiliation(s)
- Michael J Young
- Fellow in neurology at Massachusetts General Hospital and Brigham and Women's Hospital in Boston
| | - Robert W Regenhardt
- Neuroendovascular fellow and stroke scientist at Massachusetts General Hospital in Boston
| | - Leonard L Sokol
- Neurology resident physician at Northwestern University in Evanston, Illinois
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Weaver MS, Wiener L, Moon MM, Gordon B, Kelly KP, Hinds PS. Family Caregiver Partnerships in Palliative Care Research Design and Implementation. Pediatrics 2021; 148:peds.2020-049403. [PMID: 34103377 PMCID: PMC8276591 DOI: 10.1542/peds.2020-049403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Meaghann S. Weaver
- Division of Palliative Care, Department of Pediatrics, Children’s Hospital and Medical Center, Omaha, Nebraska,National Center for Ethics in Healthcare, Washington, District of Columbia
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Michelle M. Moon
- Parent, Division of Hospice and Palliative Medicine, Department of Internal Medicine, School of Medicine, University of Nevada, Reno, Nevada
| | - Bruce Gordon
- Department of Pediatrics, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Katherine Patterson Kelly
- Department of Nursing Science, Professional Practice and Quality, Children's National Hospital and Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Pamela S. Hinds
- Department of Nursing Science, Professional Practice and Quality, Children's National Hospital and Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
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7
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Oriani A, Fusi-Schmidhauser T, Guo P. Should end-of-life patients be enrolled as participants in clinical research? A best-fit framework synthesis. J Adv Nurs 2020; 77:1656-1666. [PMID: 33615566 DOI: 10.1111/jan.14712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 11/12/2020] [Accepted: 11/19/2020] [Indexed: 11/29/2022]
Abstract
AIM To identify and appraise evidence about ethical concerns regarding conducting medical research with end-of-life patients. DESIGN A best-fit framework synthesis of the literature regarding ethical issues in research involving adult patients at the end of life was conducted. DATA SOURCES Five databases were searched (Cumulative Index to Nursing and Allied Health Literature, Web of Science, Embase, MEDLINE, and PsychINFO) between January 2000-August 2019. REVIEW METHODS Data were synthesized and categorized according to the moral positions described by Foster. RESULTS In all, 18 papers that met the inclusion criteria were included in this review. These papers provided rich knowledge not only about various ethical objections to researching the end of life but also about the social, moral, and clinical requirements to perform rigorous studies on clinical interventions in this field. CONCLUSIONS Research on people at end of life is not an unsolvable ethical dilemma between providing the best possible care and enhancing new therapies. It is important to find a balance between the moral duties of providing care and achieving research outcomes that are rigorous and meaningful for service users. IMPACT Research ethics committees can be challenged by the evaluation of human research. This review provides up-to-date evidence on key challenges and ethical considerations about researching with end-of-life patients. SUMMARY STATEMENT This study is a review of relevant evidence and key ethical challenges and issues around palliative and end-of-life research. Our findings provided important recommendations for clinicians, research, and ethics committee members when evaluating clinical research with people at their end of life.
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Affiliation(s)
- Anna Oriani
- ASST Valle Olona, Palliative Care and Hospice, Regione Lombardia, Italy
| | - Tanja Fusi-Schmidhauser
- Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Ping Guo
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingha, Birmingham, UK.,Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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8
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Vinches M, Neven A, Fenwarth L, Terada M, Rossi G, Kelly S, Peron J, Thomaso M, Grønvold M, De Rojas T. Clinical research in cancer palliative care: a metaresearch analysis. BMJ Support Palliat Care 2020; 10:249-258. [PMID: 32209567 DOI: 10.1136/bmjspcare-2019-002086] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/30/2020] [Accepted: 02/10/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This metaresearch of the clinicaltrials.gov database aims to evaluate how clinical research on palliative care is conducted within the setting of advanced cancer. METHODS Clinicaltrials.gov was searched to identify registered studies recruiting patients with cancer, and investigating issues relevant to palliative care. The European Organisation for Research and Treatment of Cancer QLQ-C15-PAL (Quality of Life in palliative cancer care patients) questionnaire was taken into account to define the research domains of interest. Studies investigating cancer-directed therapy, management of cancer treatment-related adverse events and diagnostic tests were excluded. Publication status was crosschecked using PubMed. RESULTS Of 3950 identified studies, 514 were included. The most frequent reason for exclusion was cancer-directed therapy (2491). In 2007-2012, 161 studies were registered versus 245 in 2013-2018. Included studies were interventional (84%) or observational (16%). Most studies were monocentric (60%), sponsored by academia (79%), and conducted in North America (57%) or Europe (25%). Seventy-nine per cent of studies evaluated a heterogeneous population (>1 tumour type). Interventional studies most frequently investigated systemic drugs (34%), behavioural interventions (29%) and procedures for pain (24%). Pain, quality of life and physical function were the most frequently studied research domains (188, 95 and 52 studies, respectively). The most applied primary outcome measures were efficacy/symptom control (61%), quality of life (14%) and feasibility (12%). Only 16% of the closed studies had published results in PubMed. CONCLUSIONS Our study describes the heterogeneous landscape of studies conducted to address the issues of patients with advanced cancer in palliative care. Albeit the observed increase in the number of studies over the last decade, the generalisation of the results brought by the existing trials is limited due to methodological issues and lack of reporting. A greater effort is needed to improve clinical research that supports evidence-based palliative cancer care.
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Affiliation(s)
- Marie Vinches
- Medical Department, EORTC Headquarters, Brussels, Belgium .,Medical Oncology Department, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Anouk Neven
- Statistics Department, EORTC Headquarters, Brussels, Belgium
| | | | - Mitsumi Terada
- International Trials Management Section, Clinical Research Support Office, National Cancer Center Hospital, Chuo-ku, Japan
| | - Giovanna Rossi
- Medical Department, EORTC Headquarters, Brussels, Belgium
| | - Sarah Kelly
- Fellowship Program, SIOP Europe, Brussels, Belgium.,Data Management Department, EORTC Headquarters, Brussels, Belgium
| | - Julien Peron
- Medical Oncology Department, Cancer Institute of the "Hospices Civils" of Lyon, Lyon, France
| | - Muriel Thomaso
- Supportive Care Department, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Mogens Grønvold
- Department of Palliative Medicine, Bispebjerg Hospital, Copenhagen University Hospital, Kobenhavn, Denmark
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9
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Bickel KE, Kennedy R, Levy C, Burgio KL, Bailey FA. The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis. J Gen Intern Med 2020; 35:505-513. [PMID: 31792872 PMCID: PMC7018872 DOI: 10.1007/s11606-019-05538-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 08/06/2019] [Accepted: 10/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization. OBJECTIVES To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration. DESIGN Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center. SUBJECTS Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011. MAIN MEASURES Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life. KEY RESULTS Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194-2.138). CONCLUSIONS PTSD's association with increased end-of-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients. TRIAL REGISTRATION NCT00234286.
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Affiliation(s)
- Kathleen E Bickel
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA.
- Rocky Mountain Veterans Affairs Medical Center, Aurora, USA.
| | - Richard Kennedy
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cari Levy
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA
- Rocky Mountain Veterans Affairs Medical Center, Aurora, USA
| | - Kathryn L Burgio
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - F Amos Bailey
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
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10
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Kaiser KS, McGuire DB, Keay TJ, Haisfield-Wolfe ME. Methodological challenges in conducting instrumentation research in non-communicative palliative care patients. Appl Nurs Res 2019; 51:151199. [PMID: 31759841 DOI: 10.1016/j.apnr.2019.151199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/30/2019] [Accepted: 10/18/2019] [Indexed: 01/09/2023]
Abstract
Well-designed, rigorously implemented instrumentation studies are essential to develop valid, reliable pain assessment tools in non-communicative (non-self-reporting) palliative care patients. When conducting a pain instrumentation study, a research team identified methodologic challenges surrounding informed consent, eligibility criteria, acute pain operational definitions, patient recruitment, missing data, and study-related training during a run-in phase at the beginning of the project and during the conduct of the study. The team dealt with these challenges through identifying root causes, implementing remedial measures, and collecting data to demonstrate improvement or resolution. Effective strategies included obtaining Institutional Review Board (IRB) approval for a waiver of informed consent, modifying eligibility criteria, ensuring that operational definitions and study procedures were consistent with clinical practice, decreasing time from screening to data collection to improve recruitment, increasing study nurse staffing by re-budgeting grant funds, focusing time and resources on high accruing clinical units, revising processes to minimize missing data, and developing detailed training for users of the instrument. With these multi-pronged solutions, the team exceeded the patient accrual target by 25% within the funding period and reduced missing data. While pain instrumentation studies in non-communicative patients have similar challenges to other palliative care studies, some of the solutions may be unique and several are applicable to other palliative care studies, particularly instrumentation research. The team's experience may also be useful for funders and IRBs.
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Affiliation(s)
- Karen Snow Kaiser
- Corporate Education, University of Maryland Capital Region Health, 3001 Hospital Drive, Cheverly, MD 20785-1189, United States of America.
| | - Deborah B McGuire
- Professor Emeritus, Virginia Commonwealth University School of Nursing, 1100 East Leigh St., Richmond, VA 23298-0567, United States of America
| | - Timothy J Keay
- Formerly: Department of Family and Community Medicine, Palliative Care, University of Maryland School of Medicine Baltimore, MD 21201, United States of America
| | - Mary Ellen Haisfield-Wolfe
- Formerly: University of Maryland Baltimore School of Nursing, Baltimore, MD 21201, United States of America
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11
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Nicholson E, Murphy T, Larkin P, Normand C, Guerin S. Findings From a Thematic Synthesis of Key Messages From a Palliative Care Research Network: The KINDLE Project. Am J Hosp Palliat Care 2018; 36:241-248. [PMID: 30360632 DOI: 10.1177/1049909118806461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Effective palliative care requires a strong evidence base to advance clinical practice and policy-making. Calls for more collaborative and strategic approaches to research have resulted in the development of research networks at national and wider regional levels. AIM The aim was to synthesize the learning arising from the activities of the Palliative Care Research Network from the island of Ireland, in order to identify the overarching messages from these activities. The ultimate aim is to promote the communication of these messages to practice. DESIGN The study developed a systematic search process influenced by Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, with analysis of data adopting a qualitative critical interpretative synthesis approach using thematic synthesis. PARTICIPANTS In total, 142 dissemination products were sourced from 22 associated projects, including peer-reviewed publications, conference presentations, reports, and web/social media posts. RESULTS The synthesis of dissemination products identified 4 key themes relating to palliative care research and practice: (1) addressing the needs of patients while recognizing the caregiver role, (2) equal access to connected services, (3) general and specific needs in palliative care research, and (4) challenges in palliative care research. CONCLUSIONS The key themes identified relate to challenges in both practice and research, highlighting the complexity of palliative care provision that aims to support both patients and carers, and research in this area. However, an important implication is the need for a broader approach to dissemination (beyond traditional academic activities) to ensure that research in palliative care is well placed to inform both practice and policy.
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Affiliation(s)
- Emma Nicholson
- All Ireland Institute of Hospice and Palliative Care, Education and Research Centre, Our Lady's Hospice and Care Services, Harold's Cross, DUB, Ireland
| | - Tara Murphy
- All Ireland Institute of Hospice and Palliative Care, Education and Research Centre, Our Lady's Hospice and Care Services, Harold's Cross, DUB, Ireland
| | - Philip Larkin
- UCD School of Nursing, Midwifery and Health Systems, UCD College of Health Sciences, Belfield, DUB, Ireland.,Palliative Care Research Network, All Ireland Institute for Hospice and Palliative Care, Harold's Cross, DUB, Ireland
| | - Charles Normand
- Palliative Care Research Network, All Ireland Institute for Hospice and Palliative Care, Harold's Cross, DUB, Ireland.,Trinity College Dublin, School of Medicine, DUB, Ireland
| | - Suzanne Guerin
- Palliative Care Research Network, All Ireland Institute for Hospice and Palliative Care, Harold's Cross, DUB, Ireland.,UCD School of Psychology, Newman Building, University College Dublin, Belfield, DUB, Ireland
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12
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Chidiac C. The evidence of early specialist palliative care on patient and caregiver outcomes. Int J Palliat Nurs 2018; 24:230-237. [DOI: 10.12968/ijpn.2018.24.5.230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Claude Chidiac
- Lecturer in Palliative Care, Saint Francis Hospice, Romford, UK and Course Director MSc Palliative and End of Life Care, School of Health and Social Care, London South Bank University, UK
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13
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Bloomer MJ, Hutchinson AM, Brooks L, Botti M. Dying persons' perspectives on, or experiences of, participating in research: An integrative review. Palliat Med 2018; 32:851-860. [PMID: 29235418 PMCID: PMC6144348 DOI: 10.1177/0269216317744503] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Conducting research with dying persons can be controversial and challenging due to concerns for the vulnerability of the dying and the potential burden on those who participate with the possibility of little benefit. AIM To conduct an integrative review to answer the question 'What are dying persons' perspectives or experiences of participating in research? DESIGN A structured integrative review of the empirical literature was undertaken. DATA SOURCES Cumulative Index Nursing and Allied Health Complete, PsycINFO, MEDLINE, Informit and Embase databases were searched for the empirical literature published since inception of the databases until February 2017. RESULTS From 2369 references, 10 papers were included in the review. Six were qualitative studies, and the remaining four were quantitative. Analysis revealed four themes: value of research, desire to help, expression of self and participation preferences. Dying persons value research participation, regarding their contribution as important, particularly if it provides an opportunity to help others. Participants perceived that the potential benefits of research can and should be measured in ways other than life prolongation or cure. Willingness to participate is influenced by study type or feature and degree of inconvenience. CONCLUSION Understanding dying persons' perspectives of research participation will enhance future care of dying persons. It is essential that researchers do not exclude dying persons from clinically relevant research due to their prognosis, fear or burden or perceived vulnerability. The dying should be afforded the opportunity to participate in research with the knowledge it may contribute to science and understanding and improve the care and treatment of others.
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Affiliation(s)
- Melissa J Bloomer
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong Waterfront Campus, Geelong, VIC, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong Waterfront Campus, Geelong, VIC, Australia
| | - Laura Brooks
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong Waterfront Campus, Geelong, VIC, Australia
| | - Mari Botti
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong Waterfront Campus, Geelong, VIC, Australia
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Abstract
There has been a paradigm shift in medicine away from tradition, anecdote and theoretical reasoning from the basic sciences towards evidence-based medicine (EBM). In palliative care however, statistically significant benefits may be marginal and may not be related to clinical meaningfulness. The typical treatment vs. placebo comparison necessitated by ‘gold standard’ randomised controlled trials (RCTs) is not necessarily applicable. The complex multimorbidity of end of life care involves considerations of the patient’s physical, psychological, social and spiritual needs. In addition, the field of palliative care covers a heterogeneous group of chronic and incurable diseases no longer limited to cancer. Adequate sample sizes can be difficult to achieve, reducing the power of studies and high attrition rates can result in inadequate follow up periods. This review uses examples of the management of cancer-related fatigue and death rattle (noisy breathing) to demonstrate the current state of EBM in palliative care. The future of EBM in palliative care needs to be as diverse as the patients who ultimately derive benefit. Non-RCT methodologies of equivalent quality, validity and size conducted by collaborative research networks using a ‘mixed methods approach’ are likely to pose the correct clinical questions and derive evidence-based yet clinically relevant outcomes.
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Affiliation(s)
- Claire Visser
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Gina Hadley
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Bee Wee
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
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