Congruity of cancer pain perceptions between Taiwanese patients and family caregivers: relationship to patients' concerns about reporting pain and using analgesics

Barriers to Pain Management: Incongruence in Black Cancer Caregiving Dyads

CONTEXT

To effectively manage cancer pain, there is a need to understand how caregiving dyads appraise symptoms. Dyadic appraisal of symptoms influences whether the dyad perceives the patient's pain is managed well and whether they are on the same page with their appraisal. Beliefs can act as barriers to the dyadic appraisal.

OBJECTIVES

This secondary data analysis examined incongruence within Black cancer caregiving dyads regarding beliefs about pain management and potential medication side effects using the Barriers Questionnaire-13. Associated factors were also examined.

METHODS

Guided by the Theory of Dyadic Illness Management, dyadic multilevel modeling was conducted with data from 60 Black cancer caregiving dyads to determine the dyadic appraisal of beliefs about pain management and potential medication side effects, which includes the average perception of barriers within the dyad (i.e., dyadic average) and the dyadic incongruence (i.e., gap between patient and caregiver).

RESULTS

On average, Black cancer caregiving dyads reported moderate barriers regarding pain management (2.262 (SE=0.102, P<0.001) and medication side effects (2.223 (SE=0.144, P<0.001). There was significant variability across dyads regarding barriers to pain management and medication side effects. Lower patient education and higher patient-reported pain interference were significantly associated with more perceived barriers to pain management and potential medication side effects. Incongruence within dyads regarding barriers to pain management and medication side effects were significantly associated with the caregiver's report of patient's pain interference.

CONCLUSION

Findings suggest the importance of appraisal that includes both members of Black cancer caregiving dyads regarding pain management.

Congruence of cancer pain experience between patients and family caregivers and associated factors: a multicenter cross-sectional study in China

PURPOSE

The purposes of this study were to determine whether there were differences in the cancer pain experience between patients and family caregivers (FCGs) and to explore the associated factors that influence cancer pain experience congruence.

METHODS

A multicenter cross-sectional study was conducted. A total of 410 patient-family caregiver dyads completed face-to-face surveys, including information about basic characteristics, the Patient Pain Questionnaire (PPQ), and the Family Pain Questionnaire (FPQ). The difference in cancer pain experience between patients and family caregivers was analyzed using a paired t test. Indicators for the congruence of cancer pain experience were analyzed using the chi-square test and two independent-sample t tests for bivariate analysis and multivariate binary logistic regression analysis.

RESULTS

Of the patients, 57.1% were men, and 60.7% perceived moderate performance status. The majority of the family caregivers was female (54.9%). The mean (SD) score on the pain experience subscale was 4.82 (1.66) for 410 patients and 5.02 (1.66) for 410 family caregivers. The difference was significant (P < 0.01). Additionally, 87 (21.2%) dyads were in the congruent group, and 323 (78.8%) dyads were in the incongruent group. Patients' self-perceived moderate performance status (OR = 2.983, P < 0.01) and family caregivers' pain knowledge (OR = 1.171, P < 0.05) were the main factors influencing the congruence of cancer pain experience.

CONCLUSION

The findings of this study indicate that family caregivers reported significantly worse cancer pain experiences than patients. Family caregivers' pain knowledge was a primary influencing factor. It is suggested that educational interventions aimed at teaching family caregivers and patients how to communicate their pain experience and improving the knowledge of family members regarding pain and its management may help in aligning their perceptions and thereby contribute to better quality of life and pain management outcomes.

Cancer pain management needs and perspectives of patients from Chinese backgrounds: a systematic review of the Chinese and English literature

Objective

More than half of all cancer patients experience unrelieved pain. Culture can significantly affect patients’ cancer pain-related beliefs and behaviors. Little is known about cultural impact on Chinese cancer patients’ pain management. The objective of this review was to describe pain management experiences of cancer patients from Chinese backgrounds and to identify barriers affecting their pain management.

Method

A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported pain management experiences of adult cancer patients from Chinese backgrounds. Five databases were searched for peer-reviewed articles published in English or Chinese journals between1990 and 2015. The quality of included studies was assessed using Joanna Briggs Institution's appraisal tools.

Results

Of 3,904 identified records, 23 articles met criteria and provided primary data from 6,110 patients. Suboptimal analgesic use, delays in receiving treatment, reluctance to report pain, and/or poor adherence to prescribed analgesics contributed to the patients’ inadequate pain control. Patient-related barriers included fatalism, desire to be good, low pain control belief, pain endurance beliefs, and negative effect beliefs. Patients and family shared barriers about fear of addiction and concerns on analgesic side effects and disease progression. Health professional–related barriers were poor communication, ineffective management of pain, and analgesic side effects. Healthcare system–related barriers included limited access to analgesics and/or after hour pain services and lack of health insurance.

Significance of results

Chinese cancer patients’ misconceptions regarding pain and analgesics may present as the main barriers to optimal pain relief. Findings of this review may inform health interventions to improve cancer pain management outcomes for patients from Chinese backgrounds. Future studies on patients’ nonpharmacology intervention-related experiences are required to inform multidisciplinary and biopsychosocial approaches for culturally appropriate pain management.

Mediating Effect of Family Caregivers' Hesitancy to Use Analgesics on Homecare Cancer Patients' Analgesic Adherence

CONTEXT

Family caregivers play an increasingly critical role in cancer patients' symptom management as the number of cancer patients receiving home care grows. However, there is a lack of research measuring the impact of the family caregivers' hesitancy to use analgesics on analgesic adherence and the resulting influence on patient pain intensity.

OBJECTIVES

To examine whether family caregivers' hesitancy to use analgesics is a mediator that influences patient adherence and investigate how analgesic regimen adherence affects pain intensity.

METHODS

This study used a cross-sectional and descriptive design. One hundred seventy-six patient-family caregiver dyads (N = 352) were recruited from one local hospital in southern Taiwan. Instruments included the Short Version of the Barriers Questionnaire-Taiwan, the Morisky Medication Adherence Measure-Taiwan, the Brief Pain Inventory-Chinese, and demographic and illness questionnaires. A one-way analysis of variance and post hoc comparisons were performed to assess the influence of analgesic regimen adherence on pain intensity. Sobel tests were used to examine mediating effects.

RESULTS

Family caregivers' hesitancy to use analgesics was a significant mediator between patient barriers to use analgesics and patient analgesic regimen adherence (P < 0.0001). Patients with low and moderate adherence levels reported significantly higher levels of pain severity (F = 3.83, P < 0.05).

CONCLUSION

This study showed that family caregivers' hesitancy to use analgesics was a significant mediator associated with their hesitancy to use analgesics and the patients' analgesic adherence. It is important for health care providers to consider family caregivers' hesitancy to use analgesics when attempting to improve adherence to pain management regimens in clinical practice.

Patterns and predictors of symptom incongruence in older couples coping with prostate cancer

PURPOSE

Prostate cancer survivors (PCSs) may experience persistent symptoms following treatment. If PCSs and spouses differ in their perceptions of symptoms, that incongruence may cause mismanagement of symptoms and reduced relationship quality. The purpose of this study was to examine symptom incongruence and identify the PCS and spouse characteristics associated with symptom incongruence in older couples coping with prostate cancer.

METHODS

Participants in the study were older PCSs (>60 years) and their spouses (N=59 couples). Symptom incongruence was determined by comparing patient and spouse independent ratings of the severity of his cancer-related symptoms. Predictor variables included PCS age, time since diagnosis, PCS comorbidity, PCS and spouse depressive symptoms, and spouse caregiving strain.

RESULTS

PCS and spouse ratings of his symptom severity and the amount of incongruence over his symptoms varied significantly across couples. Overall, couples rated a moderate level of PCS symptom severity, but PCSs and their spouses significantly differed in their perceptions of PCS symptom severity with spouses rating severity higher (t=-2.66, df=51, p<0.01). PCS younger age and high spouse caregiver strain accounted for 29 % of incongruence in perceptions of PCS symptom severity.

CONCLUSIONS

This study is among the first to show that PCSs and spouses may perceive cancer-related persistent symptoms differently. Among this older sample, younger PCS age and spouse caregiver strain were associated with incongruence in symptoms perceptions in couples. These and other factors may inform future interventions aimed at preserving relationship quality in older couples who have experienced prostate cancer.

Postural stability in patients with knee osteoarthritis: comparison with controls and evaluation of relationships between postural stability scores and International Classification of Functioning, Disability and Health components

OBJECTIVES

To assess the differences in postural stability between patients with knee osteoarthritis and controls without knee osteoarthritis, and to evaluate possible relations between postural stability scores and International Classification of Functioning, Disability and Health (ICF) components.

DESIGN

An age-matched, case-controlled trial with a cross-sectional design.

SETTING

A teaching hospital.

PARTICIPANTS

Patients with knee osteoarthritis (n=73) and age-matched controls (n=60).

INTERVENTIONS

Data on patients' postural stability and additional health-related variables were collected using various instruments. These included the Hospital Anxiety and Depression Scale, the Multidimensional Fatigue Inventory, the World Health Organization Quality of Life Brief Version, the physical function test (chair-rising time), the Chinese version of the Western Ontario and McMaster Universities Osteoarthritis Index, the Chinese version of the Knee Injury and Osteoarthritis Outcome Score, and the Biodex Stability System.

MAIN OUTCOME MEASURES

A comparison of postural stability in patients with knee osteoarthritis versus that of controls was performed. The relation between postural stability scores for patients with knee osteoarthritis and ICF components was evaluated. Pearson correlation tests were used to determine the variables that correlated with postural stability among these patients.

RESULTS

Patients with knee osteoarthritis displayed lower overall postural stability than controls (scores of 0.7 vs. 0.5, P=.006) and scored lower on the environmental domain of the World Health Organization Quality of Life Brief Version (62.2 vs 66.8, P=.014). For patients with knee osteoarthritis, postural stability was weakly associated with the ICF components of body functions and structures, including pain (r=.33-.34, P=.004), physical fatigue (r=.28, P=.016), and reduced motivation (r=.30, P=.011). Weak to moderate associations between postural stability and the ICF components of activities and participation were found; the relevant ICF variables included reduced activity (r=.38, P=.001), physical domain and function (r=.34-.48, P=.001 to P<.004), activities of daily living (r=.51, P<.001), and sports and recreation (r=.35, P=.003). A moderate association between postural stability and the ICF components of personal and environmental factors was observed, including age (r=.52, P<.001) and quality of life (r=0.4, P=.001).

CONCLUSIONS

Patients with knee osteoarthritis displayed lower postural stability and achieved lower scores in the environmental domain of quality-of-life measures than did controls. The postural stability of patients with knee osteoarthritis was weakly to moderately associated with the following ICF components: body functions and structures, activities and participation, and personal and environmental factors.

Meta-analysis of cultural differences in Western and Asian patient-perceived barriers to managing cancer pain

PURPOSE

barriers to managing cancer pain contribute to cancer patients' reluctance to report pain and use prescribed analgesics, resulting in inadequate pain control. Patients' perceived barriers to managing cancer pain may be influenced by culture. This meta-analysis compared differences in Western and Asian patient-perceived barriers to managing cancer pain.

METHODS

the literature was systematically reviewed to compare pain barriers in Western and Asian cancer patients in 22 studies that used Ward's Barrier Questionnaire. Differences in weighted barrier scores were compared by meta-regression analysis.

RESULTS

Asian cancer patients had higher barrier scores than Western patients, except for barriers of 'good patient', 'side effects', 'distract physician', 'fear of injections', and 'addiction'. Meta-regression analysis indicated that Asian patients' perceived pain barriers differed significantly from those of Western patients for disease progression (weighted mean difference [WMD] = 1.32; 95% confidence interval [CI] 0.80, 1.84, p < 0.0001), tolerance (WMD = 1.63; 95% CI 0.91, 2.36, p < 0.0001), fatalism (WMD = 0.89; 95% CI 0.28, 1.52, p = 0.004), and total score (WMD = 0.82; 95% CI 0.36, 1.28, p < 0.0001).

CONCLUSION

Asian patients' perceived barriers to managing cancer pain were significantly higher than those for Western patients (especially for concerns about disease progression, tolerance, and fatalism). Asian cancer patients need to be assessed and carefully treated for perceived barriers to optimize cancer pain management.

The cancer family caregiving experience: an updated and expanded conceptual model

OBJECTIVE

The decade from 2000 to 2010 was an era of tremendous growth in family caregiving research specific to the cancer population. This research has implications for how cancer family caregiving is conceptualized, yet the most recent comprehensive model of cancer family caregiving was published ten years ago. Our objective was to develop an updated and expanded comprehensive model of the cancer family caregiving experience, derived from concepts and variables used in research during the past ten years.

METHODS

A conceptual model was developed based on cancer family caregiving research published from 2000 to 2010.

RESULTS

Our updated and expanded model has three main elements: 1) the stress process, 2) contextual factors, and 3) the cancer trajectory. Emerging ways of conceptualizing the relationships between and within model elements are addressed, as well as an emerging focus on caregiver-patient dyads as the unit of analysis.

CONCLUSIONS

Cancer family caregiving research has grown dramatically since 2000 resulting in a greatly expanded conceptual landscape. This updated and expanded model of the cancer family caregiving experience synthesizes the conceptual implications of an international body of work and demonstrates tremendous progress in how cancer family caregiving research is conceptualized.

Development and psychometric testing of a short version of the Barriers Questionnaire-Taiwan form for cancer patients

BACKGROUND

A comprehensive assessment of patient hesitancy to use analgesics and accurate knowledge related to the promotion of analgesic adherence is necessary for effective pain management. Unfortunately, there has been a lack of a short and concise questionnaire to assess patients' hesitancy to use analgesics in clinical practice.

OBJECTIVE

This paper is a report of the development and psychometric properties of the short version of the Barriers Questionnaire-Taiwan form (S-BQT).

DESIGN

This study employed a descriptive design.

SETTING

A convenience sample was recruited from oncology clinics at two medical centers in Taiwan.

PARTICIPANTS

One hundred and eighty-three (N=183) patients receiving analgesics for cancer pain participated in the study.

METHODS

Instruments included the Barriers Questionnaire-Taiwan form (BQT), the Taiwanese version of the Morisky Medication Adherence Measure-Taiwan form (MMAM-T). Two self-administered questionnaires were performed at the same time, and the ratio of analgesic usage was computed over a two-week period. Reliability was established by calculating Cronbach's α and test-retest reliability. The validity was estimated by construct validity, criterion-related validity, and known group validity.

RESULTS

To develop the S-BQT, we used reliability analysis to extract nine items from nine subscales. Internal consistency of the S-BQT was indicated by a Cronbach's alphas score of 0.86. Test-retest reliability was assessed as 0.83 over a two-week interval. Factor analysis revealed two factor structures. Criterion-related validity was examined by correlating the S-BQT score, and MMAM-T score, and the ratio of analgesic use. Known group validity was examined by comparing the S-BQT scores of patients with hesitancy to report pain and take analgesics vs. patients demonstrating no such hesitancy in the previous week. Known group validity was also established by comparing the S-BQT scores among patients with low, moderate, and high adherence to the usage of medication.

CONCLUSIONS

The S-BQT shows excellent reliability and validity. The use of this instrument can help to improve communication between patients and clinicians regarding the use of analgesics in the management of pain.

The prevalence and impact of pain among Taiwanese oncology outpatients

The purpose of this study was to report the prevalence and impact of pain among Taiwanese oncology outpatients who had experienced moderate pain. Ninety-two cancer outpatients in two teaching hospitals in the Taipei area of Taiwan were enrolled in a descriptive cross-sectional study. Outpatients aged ≥18 years who had been prescribed opioid analgesics for cancer-related pain completed the Brief Pain Inventory-Chinese questionnaire. Results of this study highlighted an important issue: undertreatment of cancer pain in the Taiwanese outpatients. Patients in this study reported that in the preceding 24 hours they had experienced a mean worst pain of 6.91 (SD 2.06, range 0-10). The average pain intensity in the preceding 24 hours was 5.21 (SD 1.69, range 0-10). Around 50% of the patients had pain most of the time and 25% of the patients had pain all of the time. In the preceding 24 hours the average pain relief experienced was 62.6% (SD 22.2%, range 0%-100%). Only 10.9% of patients experienced good pain relief (defined as 90%-100% of pain relief in the past 24 hours), whereas 45.7% experienced poor pain relief (defined as 0%-60% of pain relief in the past 24 hours). The mean pain interference with the patients' daily activities was 5.69 (SD 2.33, range 0-10). The findings of this study indicate the need for better programmatic efforts to improve relief of cancer pain in Taiwanese outpatients.

Symptoms experienced by cancer patients during the first year from diagnosis: patient and informal caregiver ratings and agreement

OBJECTIVE

The aim of this study was to explore the symptom experience of patients with cancer, identify changes in symptoms over time, and explore the congruence of symptom reports between patients and their informal caregivers.

METHOD

This was a prospective longitudinal evaluation of symptoms over 1 year from start of treatments (T1) using the Memorial Symptom Assessment Scale. Assessments and follow up took place at 3 months (T2), 6 months (T3) and 12 months (T4). A heterogeneous sample of 100 patients with cancer participated, providing 325 assessments over time. Furthermore, 82 caregivers also participated, providing 238 dyadic patient-caregiver assessments over the same time.

RESULTS

The most commonly occurring, and by far most distressing, symptom was "lack of energy." Common symptoms reported were lack of concentration, difficulties sleeping, shortness of breath, cough, pain, dry mouth, and feeling drowsy. Symptom occurrence and distress improved over time, particularly from T2 to T3 (p < 0.05), but the "chronicity" of some generic symptoms was notable. Caregivers tended to overestimate occurrence and distress compared to patients, particularly in symptoms of psychological nature; κ statistics had a highest coefficient of 0.45, suggesting moderate agreement between patients and caregivers at best.

SIGNIFICANCE OF RESULTS

More attention needs to be paid to the commonly reported symptoms by patients, as they have the potential of impacting on quality of life (QOL). As patient-caregiver reports had moderate agreement, effort should be directed to improving this agreement, as caregivers are often communicating patient symptoms to clinicians.

Use of the concordance correlation coefficient when examining agreement in dyadic research

BACKGROUND

The statistical measure used to quantify the degree of agreement or congruence between two research subjects has been the intraclass or the Pearson correlation coefficient; however, the concordance correlation coefficient (CCC) is another measure of agreement used to examine agreement between two observers or raters.

OBJECTIVES

The aims of this study were to (a) highlight the differences among three statistical measures used to quantify the degree of agreement or congruence, (b) demonstrate the use of the CCC in examining agreement between heart failure (HF) patients and their family members, and (c) provide nurse researchers another method for evaluating agreement.

METHODS

Symptom evaluation scores obtained from HF patients and their family members were used in the analysis of this study. To explain the use of the CCC in this analysis, a distinction between Pearson correlation coefficient and intraclass correlation coefficient is discussed. The CCC calculation is then described in detail.

RESULTS

The HF patients in this sample were 71 +/- 9.6 years in age, 40% male, and 41.4% African American. Most (75%) family members were female. There were several different categories of family members, but most were spouses. The CCC results indicated that no symptom achieved good agreement, and 8 of 14 symptoms were in moderate agreement (.4 <or= CCC <or= .7) within the dyads. Of the six symptoms with poor agreement (0<or= CCC < .4), HF patients and their family members agreed least on worsening cough (CCC = .152, 95% confidence interval = -.134 to .413) and bloated abdomen (CCC = .055, 95% confidence interval = -.224 to .325).

DISCUSSION

Applying the CCC to dyadic data from HF patients and family members, symptoms in which the patient and family member had the most and least agreement were identified. The six symptoms with poor agreement were symptoms that can show HF decline and may be important when examining future nursing interventions. Further study is needed using the CCC with dyadic data along with other family factors that influence agreement.

Barriers to pain management in a community sample of Chinese American patients with cancer

Barriers to cancer pain management can contribute to the undertreatment of cancer pain. No studies have documented barriers to cancer pain management in Chinese American patients. The purposes of this study in a community sample of Chinese Americans were to: describe their perceived barriers to cancer pain management; examine the relationships between these barriers and patients' ratings of pain intensity, pain interference with function, mood disturbances, education, and acculturation level; and determine which factors predicted barriers to cancer pain management. Fifty Chinese Americans with cancer pain completed the following instruments: Brief Pain Inventory (BPI), Karnofsky Performance Status (KPS) Scale, Barriers Questionnaire (BQ), Hospital Anxiety and Depression Scale (HADS), Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA), and a demographic questionnaire. The mean total BQ score was in the moderate range. The individual barriers with the highest scores were: tolerance to pain medicine; time intervals used for dosage of pain medicine; disease progression; and addiction. Significant correlations were found between the tolerance subscale and least pain (r=0.380) and the religious fatalism subscale and average pain (r=0.282). These two subscales were positively correlated with anxiety and depression levels: (tolerance: r=0.282, r=0.284, respectively; religious fatalism: r=0.358, r=0.353, respectively). The tolerance subscale was positively correlated with pain interference (r=0.374). Approximately 21% of the variance in the total BQ score was explained by patients' education level, acculturation score, level of depression, and adequacy of pain treatment. Chinese American cancer patients need to be assessed for pain and perceived barriers to cancer pain management to optimize pain management.

Quality of life, health satisfaction and family impact on caregivers of children with developmental delays

OBJECTIVE

To study the quality of life, health satisfaction and family impact on caregivers of children with developmental delays in Taiwan.

DESIGN

Cross-sectional study.

SUBJECTS

The caregivers of children with diagnoses of developmental delays recruited from a teaching hospital in northern Taiwan.

METHODS

The main caregivers of 48 male and 22 female children with developmental delays were recruited. WHOQOL-BREF for health-related quality of life (HRQOL), PedsQL-Health Satisfaction for health satisfaction, PedsQL-Family Impact Module and Impact on Family Scale for family impact were evaluated. The correlation of caregivers' HRQOL, health satisfaction and family impact were also studied.

RESULTS

Caregivers in nuclear families had higher health satisfaction scores (78.2 for nuclear families vs. 66.9 for extended families, P < 0.05) when assessed by the PedQL-Health Satisfaction questionnaire. Children's age was negatively correlated with family impact, including parent (-0.272, P = 0.023), family (-0.262, P = 0.029) and total scores (-0.281, P = 0.018) as assessed using the PedsQL-Family Impact Module.

CONCLUSION

A negative relation between impact of burden and child's age suggests that family members gradually adapt to the delayed developmental status in their children as they grow. Caregivers in nuclear families having higher health satisfaction than those in extended families may be due to Chinese cultural effects.

Factors influencing opioid-taking self-efficacy and analgesic adherence in Taiwanese outpatients with cancer

AIM

Although research has suggested that medication adherence rates are lower than what is needed to achieve optimal pain control, the role of patient beliefs and attitudes in influencing opioid adherence has rarely been examined. Perceived self-efficacy is reported to be an important construct in predicting and enhancing adherence behaviour. The purpose of this study was to explore the relationship between opioid-taking self-efficacy, opioid beliefs, adherence behaviours, and pain experience amongst Taiwanese cancer outpatients.

METHOD

The cross-sectional study included 92 oncology outpatients in two teaching hospitals in the Taipei area of Taiwan. The research instruments included the Opioid-Taking Self-Efficacy Scale-Cancer (OTSES-CA), the Pain Opioid Analgesic Beliefs Scale-Cancer (POABS-CA), opioid adherence, and the Brief Pain Inventory-Chinese (BPI-Chinese).

RESULTS

Opioid-taking self-efficacy demonstrated a significant positive relationship with patients' opioid adherence (r=0.22, p<0.05) and pain relief (r=0.35, p<0.01), while also demonstrating a significant positive correlation with worst pain (r=0.25, p<0.05). In addition, the more negative beliefs regarding opioids the patient had, the worse their adherence to around the clock analgesic regimen (r=-0.30, p<0.01). Multivariate analysis identified opioid-taking self-efficacy continued to have a significant independent influence on opioid adherence and pain relief, after controlling for key demographic variables. Self-efficacy accounted for 4% (R(inc) (2)=0.04, p=0.043) of the variance and opioid beliefs accounted for 8% (R(inc) (2)=0.08, p=0.007) of the variance in opioid adherence. Multivariate analysis also identified that opioid-taking self-efficacy accounted for 11% (R(inc) (2)=0.11, p=0.001) of the variance in pain relief, but opioid beliefs did not continue to have an independent effect for this outcome.

CONCLUSIONS

The study highlights the potential importance of a patient's self-efficacy beliefs in adherence to medication and key pain outcomes.

A Review of the Literature on the Pain Experience of Chinese Patients With Cancer

Over 2 million new cases of cancer are diagnosed annually in China. In addition, cancer is the leading cause of death in China. Because cancer is often diagnosed in more advanced stages in China, a higher percentage of patients will experience pain related to their disease or treatment. This article presents a review and critique of the studies that examined the experience of pain in Chinese cancer patients. Because pain is a subjective experience with multiple dimensions, this review used the multiple dimensions of cancer pain to describe the pain experience in adult Chinese patients with cancer. The results from 24 studies of cancer pain in Chinese patients are summarized. Most of these descriptive correlational studies evaluated the physiologic and sensory dimensions of the pain experience. Most of the patients reported moderate to severe pain and that pain interfered with their normal activities and mood. In contrast, little information is available about the impact of cancer pain on the cognitive and sociocultural dimensions of the pain experience for Chinese patients.

Risk Items Associated With Patient Falls in Oncology and Medical Settings

The aim of this study was to determine whether items on a falls risk-assessment tool, made up of brief cognitive and physical measures that nurses use in practice, differentiated fallers and nonfallers in oncology and medical settings. A measure of leg muscle strength clearly distinguished between fallers and nonfallers, with the latter having stronger leg muscles. For nursing practice, the assessment of patients' muscle strength seems to be the most useful scale for identifying potential fallers.

Older spouses' perceptions of partners' chronic arthritis pain: implications for spousal responses, support provision, and caregiving experiences

This study of older patients with osteoarthritis and their spouses examined concordance between patients' and spouses' reports of patients' pain severity and the association of concordance with support and caregiving outcomes. Patients and spouses independently viewed videotapes of the patient performing simulated household tasks and provided ratings of patients' pain. Spousal overestimation of patients' pain was the most common type of nonconcordance. Spouses who were accurate in their perceptions of their partner's level of pain during a log-carrying task responded less negatively and provided emotional support that was more satisfying to patients. In addition, spouses who were accurate in their perceptions of their partner's pain during the log-carrying task reported less stress from providing support and assistance. Future research that uses such observational methods may be highly useful for understanding the effects of chronic illness on older couples.

Symptom distress and quality-of-life assessment at the end of life: the role of proxy response

This study sought to advance understanding of the relationships among proxy and patient reports of symptom distress and quality of life (QOL). English-speaking adults (n=86), their nurses (n=86), and family caregivers (n=49) from 11 hospice/palliative care organizations completed the Memorial Symptom Assessment Scale (MSAS) and McGill Quality of Life Questionnaire (MQOL) at hospice/palliative care enrollment, at 1 week, 2 weeks, then monthly until death or discharge. Patients and proxies provided similar average reports of symptom distress, both physical and psychological, but MSAS correlations were generally poor. MQOL correlations were higher for nurse-patient than for patient-caregiver dyads. Based on small differences between ratings but only moderate levels of correlation, proxy response appears to be a fair substitute for patient response, suggesting that symptom and QOL reports should be obtained from all available respondents throughout the course of clinical care or research in the hospice/palliative care setting.

The Influence of Discordance in Pain Assessment on the Functional Status of Patients with Chronic Nonmalignant Pain

BACKGROUND

Chronic pain is a frequent cause of suffering and disability that seriously affects patients' quality of life and imposes a staggering socioeconomic toll on society. Little is known about the impact of patient-physician disagreement (discordance) regarding the assessment of chronic pain on patients' quality of life in primary care settings. This study evaluates the role of discordance and other potentially modifiable factors that affect the quality of life and functional status of chronic pain patients.

METHODS

We evaluated 436 patient-physician encounters at 12 academic medical centers in the United States. We surveyed chronic nonmalignant pain patients to understand their pain perceptions. We concurrently surveyed their physicians about their perceptions of their patient's pain in primary care settings.

RESULTS

More than 50% of physicians disagreed with their patient's pain. Thirty-nine percent of primary care physicians underestimated their patient's pain. In the multivariate analysis, this discordance was associated with poor physical functioning and worse bodily pain (P < 0.018 and P < 0.001 respectively). Patients with chronic, nonmalignant pain have reductions in physical function and bodily pain domains of the SF-36 compared to age-matched populations. Depression and obesity represented other associations.

CONCLUSION

Patients with chronic nonmalignant pain have poor physical functioning and worse bodily pain. Discordance, obesity, and depression are other modifiable factors. Prospective studies are needed to design interventions. However, a multifaceted approach appears to represent the best opportunity to reduce the pain and suffering of this challenging population.

Concordance of Quality-of-Life Assessments Between Terminally Ill Cancer Patients and Their Primary Family Caregivers in Taiwan

Physical or cognitive deterioration may hamper the ability or willingness of cancer patients to participate and remain in quality-of-life (QOL) research at the end of life. Use of family caregivers as proxy informants to report patients' QOL has been suggested as a way of resolving the problem of nonresponse bias and nonrandom missing data in end-of-life research. However, there is a dearth of information in the literature about the extent of concordance of QOL assessments between terminally ill patients and their family caregivers outside Western countries. A prospective and descriptive study was conducted to fill the gap in the literature. Results from 114 dyads of Taiwanese terminally ill cancer patients and their family caregivers indicated that QOL assessments from family informants agreed at least moderately well with patients' QOL reports. None of the standardized absolute mean differences for individual items and composite (sub)scales between the 2 respondents exceed the threshold of moderate (>0.50) set by Cohen. Generally, when discrepancies existed, family caregivers held a more negative view of patients' QOL than did patients. At the individual patient level, family caregivers were best able to assess functional dependency, followed by symptom distress, but were least reliable when evaluating the psychological-social-spiritual concerns of patients. The conclusion made by Western researchers that family caregivers can act as a not perfect but reliable alternative source of QOL data for terminally ill cancer patients who are no longer able to speak for themselves is cross-culturally confirmed in this study. It is suggested from the findings that, for family caregivers to function well in their role as proxy informants on the psychological reactions and social/spiritual domains of QOL as well as surrogate decision makers for terminally ill cancer patients in Asian countries, an open and frequent dialogue between terminally ill cancer patients and their family caregivers should become standard.

Barriers to effective cancer pain management: a survey of Australian family caregivers

Cancer pain continues to be an important focus of health research and intervention development. The continuing shift of cancer care to the community increases the family caregiver's role in pain management and highlights the need to understand family experiences and also family barriers to effective pain management. This paper presents the findings of an Australian study exploring attitudinal barriers to effective pain management amongst 75 family caregivers of people with cancer attending an outpatient clinic. Approximately 75% of the caregivers demonstrated concerns or were unsure about addiction, a belief likely to impact on the use of prescribed opioids in the home. Caregivers demonstrated similar levels of concern about side-effects or whether the presence of pain indicated disease progression. These findings support research in other populations and are further evidence of the need to include family caregivers, along with patients, in intervention studies aimed at reducing the impact of these barriers on effective pain management.

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.

Online exclusive: family satisfaction with perception of and barriers to terminal care in Japan

PURPOSE/OBJECTIVES

To examine how families of patients with cancer perceive and are satisfied with terminal care given in a university hospital and to identify barriers to the best care for patients and proper support for their families.

DESIGN

Quantitative, descriptive.

SETTING

A Japanese national university hospital.

SAMPLE

Convenience sample of 73 family members of deceased patients with cancer (response rate was 55%).

METHODS

Completion of a questionnaire comprised of 23 items, including multiple-choice and open-ended questions.

MAIN RESEARCH VARIABLES

Satisfaction with terminal care, misunderstanding of narcotics use, recognition of disease signs and symptoms, and expectations for terminal care.

FINDINGS

Ninety percent of respondents were satisfied with nursing care. Eighty percent were satisfied with the information they received at admission, 70% were satisfied at the critical phase, and 63% were satisfied at the end of life. The main expected types of desirable terminal care were pain management and spiritual care. The bereaved had difficulty dealing with patients' pain, dyspnea, and appetite loss. Forty-four patients were treated with narcotics. Fifty-seven percent of the family members of these patients found pain to be the most difficult symptom to deal with. Fifty-eight percent of the respondents believed that if narcotics were used, patients would soon die.

CONCLUSIONS

Terminal cancer care given in Japanese university hospitals does not appear to be adequate in terms of patients' and families' quality of life. The findings indicate that insufficient current information is given throughout the terminal stage of cancer and patients and their families misunderstand the use of narcotics.

IMPLICATIONS FOR NURSING

Oncology nurses need to consider different cultural backgrounds when offering specific care to patients with terminal cancer. Patients and their families must be educated about the efficacy of narcotics in the care of terminally ill patients with cancer.

Judging the quality of care at the end of life: can proxies provide reliable information?

A major challenge in research into care at the end of life is the difficulty of obtaining the views and experiences of representative samples of patients. Studies relying on patients' accounts prior to death are potentially biased, as they only represent that proportion of patients with an identifiable terminal illness, who are relatively well and therefore able to participate, and who are willing to take part. An alternative approach that overcomes many of these problems is the retrospective or 'after death' approach. Here, observations are gathered from proxies, usually the patient's next of kin, following the patient's death. However, questions have been raised about the validity of proxies' responses. This paper provides a comprehensive review of studies that have compared patient and proxy views. The evidence suggests that proxies can reliably report on the quality of services, and on observable symptoms. Agreement is poorest for subjective aspects of the patient's experience, such as pain, anxiety and depression. The findings are discussed in relation to literature drawn from survey methodology, psychology, health and palliative care. In addition to this, factors likely to affect levels of agreement are identified. Amongst these are factors associated with the patient and proxy, the measures used to assess palliative care and the quality of the research evaluating the validity of proxies' reports. As proxies are a vital source of information, and for some patients the only source, the paper highlights the need for further research to improve the validity of proxies' reports.