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Schwonke I, Freitag N, Aschendorf P, Wucharz K, Thieme J, Appelmann I, Schumann M, Elsner F. Feasibility of a physical exercise intervention for patients on a palliative care unit: a critical analysis. BMC Palliat Care 2024; 23:58. [PMID: 38418974 PMCID: PMC10900709 DOI: 10.1186/s12904-024-01388-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 02/15/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Recent exercise intervention studies have shown promising results in improving quality of life (QoL) and physical function (PF) in diverse chronic disease and advanced cancer patients. However, the effects of structured exercise in palliative care patients, having different therapeutic needs, lower life expectancies and PFs remain unknown. This study primarily aimed to assess the feasibility of an exercise intervention with follow-up by analysing recruitment numbers, screening procedures, acceptability, preferences, and safety of the exercise intervention as well as retention in follow-up. Our secondary aims related to changes in QoL and PF. METHODS This study comprised of a one-arm design without a control group. Over 6 months, every in-hospital palliative care unit (PCU) patient was screened for eligibility. Eligible patients were asked to participate in a 2-week exercise intervention consisting of resistance training and/or endurance training with moderate or high intensity based on personal preferences and a 4-week follow-up. Before and after the exercise intervention, QoL and PF were assessed and a qualitative interview after the intervention addressed expectations and experiences of the exercise intervention. For follow-up, patients were provided with information on independent training and after 1 and 4 weeks a QoL assessment and qualitative interview were conducted. RESULTS Of 124 patients screened, 10 completed the intervention with an adherence rate of (80 ± 25%), of which 6 patients completed follow-up. Endurance training was the most performed training type and only a few minor adverse events occurred in certain or likely connection to the exercise intervention. While physical QoL and PF measured by arm curl strength and time up and go performance improved, mental QoL and the other PF tests remained unchanged. CONCLUSION Despite the challenges that were faced in our screening and testing process, that are specific to the palliative patient population with their unique therapeutic requirements and varying mental-/ physical capabilities, we discovered the 2-week exercise intervention to be feasible, safe, and well tolerated by palliative care patients. Moreover, it seems that short-term improvements in QoL and PF are possible. Further full scale studies are required to confirm our findings. TRIAL REGISTRATION The study was retrospectively registered on 25.01.2022 in the German Clinical Trials Register (DRKS00027861).
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Affiliation(s)
- Inken Schwonke
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - Nils Freitag
- Olympic Training Centre Berlin, Berlin, Germany
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Paula Aschendorf
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Kerstin Wucharz
- Department of Physiotherapy, Franziska-Schervier Educational Center, Bethlehem Hospital, Stolberg, Germany
- Department of Physiotherapy, RWTH Aachen University Hospital, Aachen, Germany
| | - Johanna Thieme
- Pro Sanum Health and Therapy Center Eifel, Nettersheim, Germany
- Department of Physiotherapy, RWTH Aachen University Hospital, Aachen, Germany
| | - Iris Appelmann
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Moritz Schumann
- Department of Sports Medicine and Exercise Therapy, Chemnitz University of Technology, Chemnitz, Germany
| | - Frank Elsner
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Phongtankuel V, Czaja S, Park T, Dignam R, Adelman R, Shah S, Vasquez F, Reid MC. Assessing the feasibility, acceptability, and preliminary efficacy of a novel symptom management care delivery intervention for caregivers receiving home hospice care: The I-HoME protocol. Contemp Clin Trials 2024; 136:107389. [PMID: 37972753 PMCID: PMC10922463 DOI: 10.1016/j.cct.2023.107389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/17/2023] [Accepted: 11/11/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Terminally ill patients experience high symptom burden at the end of life (EoL), even when receiving hospice care. In the U.S., family caregivers play a critical role in managing symptoms experienced by patients receiving home hospice services. Yet, most caregivers don't receive sufficient support or formal training in symptom management. Therefore, providing additional visits and education to caregivers could potentially improve outcomes for both patient and caregiver. In response, we developed the Improving Home hospice Management of End-of-life issues through technology (I-HoME) intervention, a program designed for family caregivers of home hospice patients. This paper describes the intervention, study design, and protocol used to evaluate the intervention. METHODS The I-HoME study is a pilot randomized controlled trial aimed at reducing patient symptom burden through weekly tele-visits and education videos to benefit the patient's family caregiver. One hundred caregivers will be randomized to hospice care with (n = 50) or without (n = 50) the I-HoME intervention. Primary outcomes include intervention feasibility (e.g., accrual, attrition, use of the intervention) and acceptability (e.g., caregivers' comfort accessing the tele-visits and satisfaction). We will also examine preliminary efficacy using validated patient symptom burden and caregiver outcome measures (i.e., burden, depression, anxiety, satisfaction). CONCLUSION The trial is evaluating a novel symptom management intervention that supports caregivers of patients receiving home hospice services. The intervention employs a multi-pronged approach that provides needed services at a time when close contact and support is crucial. This research could lead to advances in how care gets delivered in the home hospice setting.
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Affiliation(s)
- Veerawat Phongtankuel
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, 525 E 68th St, Box 39, New York, NY, USA
| | - Sara Czaja
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, 525 E 68th St, Box 39, New York, NY, USA
| | - Taeyoung Park
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, 525 E 68th St, Box 39, New York, NY, USA.
| | | | - Ronald Adelman
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, 525 E 68th St, Box 39, New York, NY, USA
| | - Shivani Shah
- VNS Health, 220 E 42nd St, New York, NY 10017, USA
| | | | - M C Reid
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, 525 E 68th St, Box 39, New York, NY, USA
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3
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Park T, Sloan DH, Cruz-Oliver DM, Reid MC, Czaja S, Adelman RD, Dignam R, Phongtankuel V. Black Caregivers' Symptom Management, Cultural, and Religious Experiences With Home Hospice Care. J Pain Symptom Manage 2023; 66:116-122.e1. [PMID: 37084826 PMCID: PMC10524479 DOI: 10.1016/j.jpainsymman.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
CONTEXT Informal Black or African American (Black/AA) caregivers are at high risk for caregiver burden due to both greater caregiving responsibilities and unmet needs. However, there has been minimal research on the challenges Black/AA caregivers face after hospice enrollment. OBJECTIVES This study seeks to address this knowledge gap by applying qualitative methods to understand Black/AA caregivers' experiences around symptom management, cultural, and religious challenges during home hospice care. METHODS Data from small group discussions with 11 bereaved Black/AA caregivers of patients who received home hospice care were qualitatively analyzed. RESULTS Caregivers struggled most with managing patients' pain, lack of appetite, and decline near end of life (EoL). Cultural needs (e.g., knowing their language, having familiarity with foods) were perceived as not on top of mind for many Black/AA caregivers. However, there was a concern of stigma around mental health preventing care recipients from sharing their mental health concerns and seeking resources. Many caregivers relied on their personal religious networks rather than services provided by hospice chaplains. Lastly, caregivers reported increased burden during this phase of caregiving but were satisfied with the overall hospice experience. CONCLUSION Our results suggest that tailored approaches that target mental health stigma in the Black/AA community and reduce caregiver distress around end of life symptoms may improve hospice outcomes among Black/AA hospice caregivers. Hospice spiritual services should consider offering services complementary to caregivers' existing religious networks. Future qualitative and quantitative studies should examine the clinical implications of these results in terms of patient, caregiver, and hospice outcomes.
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Affiliation(s)
- Taeyoung Park
- Division of Geriatrics and Palliative Medicine (T.P., M.C.R., S.C., R.D.A., V.P.), Department of Medicine, Weill Cornell Medicine, New York, New York, USA.
| | - Danetta H Sloan
- Department of Health, Behavior, and Society (D.H.S.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dulce M Cruz-Oliver
- Division of General Internal Medicine (D.M.C-O.), Department of Medicine, Palliative Medicine Section, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Manney Cary Reid
- Division of Geriatrics and Palliative Medicine (T.P., M.C.R., S.C., R.D.A., V.P.), Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sara Czaja
- Division of Geriatrics and Palliative Medicine (T.P., M.C.R., S.C., R.D.A., V.P.), Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Ronald D Adelman
- Division of Geriatrics and Palliative Medicine (T.P., M.C.R., S.C., R.D.A., V.P.), Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Veerawat Phongtankuel
- Division of Geriatrics and Palliative Medicine (T.P., M.C.R., S.C., R.D.A., V.P.), Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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4
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Joseph A, Vemula B, Smith TJ. Symptom Management in the Older Adult: 2023 Update. Clin Geriatr Med 2023; 39:449-463. [PMID: 37385696 DOI: 10.1016/j.cger.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
In the older adult with a serious illness, the goal of palliative medicine and symptom management is to optimize quality of life. Frailty has become an overarching finding in many older adults with serious illness. Symptom management options need to be considered in the lens of increasing frailty along an illness trajectory. Here, the authors emphasize literature updates and best practices for the most common symptoms experienced by the older adult with a serious illness.
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Affiliation(s)
- Augustin Joseph
- Department of Medicine, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA.
| | - Balakrishna Vemula
- Department of Medicine, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA; Department of Emergency Medicine, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA
| | - Thomas J Smith
- Department of Medicine, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA; Department of Oncology, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA
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5
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Gerlach LB, Zhang L, Strominger J, Kim HM, Teno J, Bynum JPW, Maust DT. Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies. J Gen Intern Med 2022; 37:3814-3822. [PMID: 35469359 PMCID: PMC9640505 DOI: 10.1007/s11606-022-07604-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/06/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Benzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies. OBJECTIVE Examine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice. DESIGN Retrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice. PARTICIPANTS Medicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment. MAIN MEASURES The primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics. KEY RESULTS A total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing. CONCLUSIONS The pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Lan Zhang
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Joan Teno
- Department of General Internal Medicine and Geriatrics, Oregon Health and Sciences University, Portland, OR, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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The Impact of an Electronic Prescribing Template with Decision Support upon the Prescribing of Subcutaneous Infusions at the End of Life in a Community Setting: A Future Vision for Community Palliative Care. PHARMACY 2022; 10:pharmacy10050112. [PMID: 36136845 PMCID: PMC9498806 DOI: 10.3390/pharmacy10050112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/31/2022] [Accepted: 09/06/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives: To assess the impact of an electronic prescribing template with decision support upon the frequency of prescription errors, guideline adherence (relating to dose ranges), and prescription legality when prescribing continuous subcutaneous infusions (CSCI) in a palliative demographic. Design, setting, and participants: Before-and-after study across a large UK city utilizing local prescribing data taken from patients receiving end-of-life care. Intervention: An electronic prescribing template with decision support. Main outcome measures: The following were assessed: (1) the rate of prescription errors; (2) the proportion of prescriptions specifying a dose range and if the specified range complied with local recommendations; and (3) the proportion of prescriptions specifying legal mixing directions. Results: The intervention was associated with a significant reduction in errors of omission, with all prescriptions clearly stating drug indication, route of administration, drug dose, and infusion duration. The numbers of continuous subcutaneous infusion prescriptions that specified dose ranges were similar at baseline and post-intervention, at 71% (n = 122) and 72% (n = 179), respectively. At baseline, 69% (n = 84) of CSCI prescriptions specifying a dose range were deemed safe, and post-intervention, 97% (n = 173) were determined to be safe. At baseline, mixing directions were not specified correctly on any continuous subcutaneous infusion prescriptions, while post-intervention, such directions were correct on 75% (n = 157; p < 0.05) of the prescriptions. Conclusions: The intervention eliminated errors of omission, ensured the safety of prescribed dose ranges, and improved compliance with legislation surrounding the mixing of multicomponent infusions. Overall, the intervention has the potential to improve patient safety at the end of life and to increase the efficiency of community services.
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Abstract
Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.
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Affiliation(s)
- Farrah N Daly
- EvenBeam Neuropalliative Care, Leesburg, VA, United States.
| | - Usha Ramanathan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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8
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Sousa MS, Davis W, Blanchard M, Razmovski-Naumovski V, Agar M, Daveson B, Hsm D, Currow DC. Appetite-Related Distress Is Burdensome in the Last Sixty Days of Life of People Receiving Palliative Care: A National Longitudinal Consecutive Cohort Study. J Palliat Med 2021; 25:636-642. [PMID: 34978898 DOI: 10.1089/jpm.2021.0462] [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: 11/12/2022] Open
Abstract
Background: People with life-limiting illnesses experience a range of distressing symptoms. Appetite-related symptoms are common, but studies have found varied prevalence and the distress caused has had limited quantification. Objectives: To examine the clinicodemographic factors and trajectory of appetite-related distress in the last 60 days of life. Design/Setting/Subjects: Consecutive cohort of 109,385 patients (359,038 data points) using specialist palliative care services in the Australian Palliative Care Outcomes Collaboration (PCOC). Measurements: Patient-reported appetite-related distress using the PCOC Symptom Assessment Scale. Results: Diagnoses included cancer (75%), end-stage organ failure (11%), neurodegenerative disease (4%), dementia (3%), and other noncancer (7%). Fifty-eight percent reported some degree of appetite-related distress at least once in the last 60 days of life. Daily mean distress scores did not vary greatly by diagnosis and the distributions of symptom severity were not linked with performance status. There was a sharp decline in mean distress for all diagnostic groups around 7-10 days before death. Moderate to severe distress was associated with nausea-, bowel-, pain-, and breathing-related distress, controlling for key baseline factors. Conclusion: Appetite-related distress is prevalent and burdensome in the 60 days before death and is strongly associated with distress from other cardinal symptoms.
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Affiliation(s)
- Mariana S Sousa
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Walter Davis
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Megan Blanchard
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Valentina Razmovski-Naumovski
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Meera Agar
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | | | - Dip Hsm
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - David C Currow
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,Wolfson Palliative Care Research Centre, University of Hull, Hull, England
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9
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Corona AGDL, Chin J. Olfactory Distraction for Management of Nausea in Palliative Care Patients. Am J Hosp Palliat Care 2021; 39:388-393. [PMID: 33955274 DOI: 10.1177/10499091211015957] [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
Nausea is one of the most common and debilitating symptoms Palliative Care patients experience. This can be caused by the life-limiting illness itself, its complications, or its treatments. While there are many options for management, including anti-emetics and motility agents, patients may develop refractory nausea or even intolerance to these treatments. Drug interactions, sedation, extrapyramidal effects, serotonin syndrome, and prolonged QT intervals with risk factors for Torsades de Pointes may all preclude use of these medications. Olfactory distraction using alcohol swabs has supporting literature in the emergency care setting as a means of alleviating nausea in a safe and effective way. We present a case series of 3 patients admitted to a Northwell facility who were referred to the Palliative Care consult service for severe nausea. The patients had nausea of varying etiology and were successfully managed with inhalation of alcohol swabs. This is the first case series that looks into applying this intervention to the Palliative Care population as an easy-to-use, readily-available, and safe method to manage nausea.
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Affiliation(s)
- Antonio Gabriel De Leon Corona
- Division of Geriatrics and Palliative Medicine, Donald and Barbara Zucker School of Medicine, Northwell Health, New York, NY, USA
| | - Jessica Chin
- Division of Geriatrics and Palliative Medicine, Donald and Barbara Zucker School of Medicine, Northwell Health, New York, NY, USA
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10
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Mochamat, Cuhls H, Sellin J, Conrad R, Radbruch L, Mücke M. Fatigue in advanced disease associated with palliative care: A systematic review of non-pharmacological treatments. Palliat Med 2021; 35:697-709. [PMID: 33765888 DOI: 10.1177/02692163211000628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Fatigue is a common complaint reported by patients with advanced disease, impacting their daily activities and quality of life. The pathophysiology is incompletely understood, and evidence-based treatment approaches are needed. AIM This systematic review aims to evaluate the efficacy of non-pharmacological interventions as treatment for fatigue in advanced disease. DESIGN The review design follows the Cochrane guidelines for systematic reviews of interventions. DATA SOURCES We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PubMed, ClinicalTrials.gov and a selection of journals up to February 28th 2019, for randomised controlled trials (RCTs) investigating the effect of non-pharmacological treatments for fatigue in advanced disease associated with palliative care. Further potentially relevant studies were identified from the reference lists in relevant reviews, and in studies considered for this review. RESULTS We screened 579 publications; 15 met the inclusion criteria, with data from 1179 participants: 815 were treated with physical exercise, 309 with psycho-educational therapy and 55 with an energy restoration approach. Sources of potential bias included lack of description of blinding and allocation concealment methods, and small study sizes. Physical exercise as treatment for fatigue in patients with advanced cancer was supported by moderate-quality evidence. CONCLUSION Physical exercise should be considered as a measure to reduce fatigue in patients with advanced cancer, but data on other advanced diseases is lacking. Due to the differences between studies, no clear recommendations can be made with respect to the best type of physical therapy. Restoration exercise and psycho-educational therapy are promising treatment options, although further research is needed.
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Affiliation(s)
- Mochamat
- Department of Anesthesiology and Intensive Therapy, University of Diponegoro/Kariadi Hospital, Semarang, Indonesia.,Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Henning Cuhls
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Julia Sellin
- Centre for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
| | - Rupert Conrad
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany.,Center for Palliative Care, Malteser Hospital Bonn/Rhein-Sieg, Bonn, Germany
| | - Martin Mücke
- Centre for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
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11
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Gerlach LB, Kales HC, Kim HM, Zhang L, Strominger J, Covinsky K, Teno J, Bynum JPW, Maust DT. Prevalence of psychotropic and opioid prescribing among hospice beneficiaries in the United States, 2014-2016. J Am Geriatr Soc 2021; 69:1479-1489. [PMID: 33683703 DOI: 10.1111/jgs.17085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/26/2021] [Accepted: 02/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVES Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes. DESIGN Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016. SETTING Beneficiaries enrolled in the Medicare hospice benefit. PARTICIPANTS Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022). MAIN OUTCOME Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing. RESULTS 70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics. CONCLUSIONS Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Helen C Kales
- Department of Psychiatry, University of California, Davis, California, USA
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Lan Zhang
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Kenneth Covinsky
- Department of Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Joan Teno
- Department of Internal Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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12
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LeBaron V, Bennett R, Alam R, Blackhall L, Gordon K, Hayes J, Homdee N, Jones R, Martinez Y, Ogunjirin E, Thomas T, Lach J. Understanding the Experience of Cancer Pain From the Perspective of Patients and Family Caregivers to Inform Design of an In-Home Smart Health System: Multimethod Approach. JMIR Form Res 2020; 4:e20836. [PMID: 32712581 PMCID: PMC7481872 DOI: 10.2196/20836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/11/2020] [Accepted: 07/25/2020] [Indexed: 01/20/2023] Open
Abstract
Background Inadequately managed pain is a serious problem for patients with cancer and those who care for them. Smart health systems can help with remote symptom monitoring and management, but they must be designed with meaningful end-user input. Objective This study aims to understand the experience of managing cancer pain at home from the perspective of both patients and family caregivers to inform design of the Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C) smart health system. Methods This was a descriptive pilot study using a multimethod approach. Dyads of patients with cancer and difficult pain and their primary family caregivers were recruited from an outpatient oncology clinic. The participant interviews consisted of (1) open-ended questions to explore the overall experience of cancer pain at home, (2) ranking of variables on a Likert-type scale (0, no impact; 5, most impact) that may influence cancer pain at home, and (3) feedback regarding BESI-C system prototypes. Qualitative data were analyzed using a descriptive approach to identity patterns and key themes. Quantitative data were analyzed using SPSS; basic descriptive statistics and independent sample t tests were run. Results Our sample (n=22; 10 patient-caregiver dyads and 2 patients) uniformly described the experience of managing cancer pain at home as stressful and difficult. Key themes included (1) unpredictability of pain episodes; (2) impact of pain on daily life, especially the negative impact on sleep, activity, and social interactions; and (3) concerns regarding medications. Overall, taking pain medication was rated as the category with the highest impact on a patient’s pain (=4.79), followed by the categories of wellness (=3.60; sleep quality and quantity, physical activity, mood and oral intake) and interaction (=2.69; busyness of home, social or interpersonal interactions, physical closeness or proximity to others, and emotional closeness and connection to others). The category related to environmental factors (temperature, humidity, noise, and light) was rated with the lowest overall impact (=2.51). Patients and family caregivers expressed receptivity to the concept of BESI-C and reported a preference for using a wearable sensor (smart watch) to capture data related to the abrupt onset of difficult cancer pain. Conclusions Smart health systems to support cancer pain management should (1) account for the experience of both the patient and the caregiver, (2) prioritize passive monitoring of physiological and environmental variables to reduce burden, and (3) include functionality that can monitor and track medication intake and efficacy; wellness variables, such as sleep quality and quantity, physical activity, mood, and oral intake; and levels of social interaction and engagement. Systems must consider privacy and data sharing concerns and incorporate feasible strategies to capture and characterize rapid-onset symptoms.
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Affiliation(s)
- Virginia LeBaron
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Rachel Bennett
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Ridwan Alam
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Leslie Blackhall
- University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Kate Gordon
- Virginia Commonwealth University Health, Richmond, VA, United States
| | - James Hayes
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Nutta Homdee
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Randy Jones
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Yudel Martinez
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Emmanuel Ogunjirin
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Tanya Thomas
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - John Lach
- The George Washington University School of Engineering & Applied Science, Washington, DC, United States
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13
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Abstract
BACKGROUND A large number of the hospice patients have been reported to be with symptoms of pain. Thus, managing the patient's pain is one aspect of hospice care provision. The delivery of pain care services could be facilitated through effective communication. However, little has been done to explore the interactional details of the delivery of pain care services in palliative care. METHODS Conversation analysis is a useful method to explore the interactional details of interaction by hospice care providers and terminally ill patients. Using the method of Conversation Analysis (CA), this study aims to demonstrate how the hospice care provider employs different types of interactional practices to address the patient's pain concerns. The data showed in this study are collected from the Alexander St website http://ctiv.alexanderstreet.com , an educational resource presenting a large collection of psycho-therapeutic videos. RESULTS In this study, an illustrative analysis is demonstrated to show the potential of conversation analysis for research on pain talk in palliative care. It has been shown that conversation analysis could contribute to unfolding the interactional details regarding "pain talk" in hospice care settings. Specifically, conversation analysis could provide a detailed description and interpretation of the conversational practices, which are used to construct hospice care provider participation in delivering pain talk. In addition, conversation analysis could also demonstrate the interactional resources by which patients disclose their experiences of physical or spiritual pain to the hospice care provider and the way how the hospice care provider responds to the patient's troubles talk or feelings talk. CONCLUSIONS This study identifies five types of interactional resources which are used to deal with the patient's pain concerns in hospice care setting. A conversation analytical study of pain talk in hospice care could provide a turn-by-turn description of how the hospice care provider communicates with the terminally ill patient in terms of the patient's pain concerns. The findings in this study could inform how the hospice care provider initiates, delivers and develops a pain talk with the terminally ill patient effectively.
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Affiliation(s)
- Yijin Wu
- School of Translation Studies/Center for Medical Humanities in the Developing World, Qufu Normal University, No.5, Yantai Road, Donggang District, Rizhao, 250100, Shandong, China.
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14
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Singh N, Batra A, Yang L, Boyne DJ, Harper A, Ghatage P, Cuthbert CA, Cheung WY. Patient-Reported Symptom Burden Near the End of Life in Patients With Gynaecologic Cancers. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:26-33. [PMID: 32967796 DOI: 10.1016/j.jogc.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE There are limited data on patient-reported outcomes near the end of life in patients with gynaecologic cancers. This study aimed to assess the symptom burden in the last 6 months of life in a real-world cohort. METHODS Patients diagnosed with metastatic gynaecologic malignancies from 2016 to 2019 who completed the revised Edmonton Symptom Assessment System (ESASr) questionnaire within 6 months of death in a large Canadian province were identified. Patient-reported symptom scores were categorized as none to mild (0-3) and moderate to severe (4-10). Individual symptoms were subsequently grouped into physical, psychological, and total subscores. The severity of symptoms was further analyzed for any associations with age, time to death, and primary tumour site (ovarian vs. uterocervical and vulvovaginal). RESULTS We identified 107 patients with gynaecologic malignancies including 59 ovarian, 29 uterocervical, and 19 vulvovaginal cancers. The median ages at diagnosis and questionnaire completion were 64 and 65 years, respectively. The median time from completing the ESASr questionnaire to death was 65 days. Overall, physical and psychological symptoms were moderate to severe in 57.9% and 40.2% of patients, respectively. Among the individual symptoms, tiredness was the most commonly reported moderate to severe symptom (74.9%), while shortness of breath was least commonly reported (31.6%). While physical (P < 0.001) and total symptom (P = 0.009) subscores were more likely to be moderate to severe in intensity as death approached, the psychological subscore (P = 0.744) had no relationship with time to death. Longer time to death was predictive of lower physical (P = 0.002) and total symptom (P = 0.002) subscores, while a primary uterocervical cancer site was associated with a lower psychological symptom subscore (P = 0.042). CONCLUSIONS In the real-world setting, unique symptom trajectories can emerge for patients with gynaecologic cancer near the end of life. Knowledge of these specific symptom patterns can help inform the development and delivery of targeted palliative interventions to improve quality of life for these patients.
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Affiliation(s)
| | | | - Lin Yang
- Tom Baker Cancer Centre, Calgary, AB
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15
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Curry A. Psychiatric Issues in Hospice and Palliative Medicine. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Benítez-Rosario MA, Ascanio-León B. Palliative sedation: beliefs and decision-making among Spanish palliative care physicians. Support Care Cancer 2020; 28:2651-2658. [PMID: 31637516 DOI: 10.1007/s00520-019-05086-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/16/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe physician attitudes to deep palliative sedation. METHODS A nationwide e-survey of Spanish palliative care specialists was performed using vignettes which described patients close to death with intractable symptoms. Sedation levels were defined according to the Richmond Agitation-Sedation Scale. Multivariate analyses were performed to assess the explanatory factors involved in decision-making. RESULTS Responses of 292 palliative care specialists were analyzed (response rate 40%). Ninety-four percent, 87%, and 81% of the respondents supported the use of palliative sedation in cases of irreversible refractory symptoms as hyperactive delirium and dyspnea at rest secondary to lung cancer and GOLD stage IV COPD; 60% agreed with the use of palliative sedation in cases of existential suffering. Logistic regression analysis found as the explanatory factor in not performing palliative sedation the physicians' belief that sedation therapy constitutes undercover euthanasia (OR = 12, p < 0.01). Around 80% of physicians who decided on palliative sedation chose deep/complete sedation for every vignette; there were no common explanatory factors for decision-making for every vignette. The belief that sedation therapy equates to undercover euthanasia justifies not performing deep sedation in cases of irreversible refractory agitated delirium (OR = 7) and irreversible intractable dyspnea (OR = 6). Physician background in palliative care and sedation were associated with the selection of deep/complete sedation in cases of refractory delirium and cancer-associated dyspnea. CONCLUSIONS Spanish palliative physicians generally agree with the use of deep sedation as a proportionate treatment in dying patients with refractory symptoms. Decision-making is associated with physician beliefs regarding euthanasia and with the physician's background in palliative care and sedation.
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Affiliation(s)
- Miguel Angel Benítez-Rosario
- Palliative Care Unit, La Candelaria Hospital, Canary Health Service, Facultad de Medicina, Universidad de La Laguna, Crtra del Rosario 145, 38010, Santa Cruz de Tenerife, Spain.
| | - Belén Ascanio-León
- Palliative Care Unit, La Candelaria Hospital, Canary Health Service, Facultad de Medicina, Universidad de La Laguna, Crtra del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
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17
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Phongtankuel V, Teresi JA, Eimicke JP, Kong JX, Adelman RD, Prigerson HG, Czaja SJ, Shalev A, Dignam R, Baughn R, Reid MC. Identifying the Prevalence and Correlates of Caregiver-Reported Symptoms in Home Hospice Patients at the End of Life. J Palliat Med 2019; 23:635-640. [PMID: 31873053 PMCID: PMC7232637 DOI: 10.1089/jpm.2019.0324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Symptoms (e.g., pain, shortness of breath, and fatigue) at the end of life (EoL) are common. Although symptoms can contribute to poor quality of life at the EoL, much remains unknown regarding their prevalence and correlates in home hospice care. Objectives: To determine the prevalence and correlates of caregiver-reported symptoms in home hospice patients during the last week before discharge using the Edmonton Symptom Assessment Scale (ESAS). Design: This is a cross-sectional study measuring perceived patient symptoms using caregiver proxy data. Bivariate and multivariate analyses were conducted to examine patient and caregiver characteristics associated with ESAS scores. Setting/Subjects: Subjects were from an urban nonprofit home hospice organization. Measurements: Symptoms were measured using the ESAS. Results: The mean ESAS score was 51.2 (SD ±17.4). In bivariate analyses, higher perceived symptom score was associated with younger patient age (p < 0.001), younger caregiver age (p < 0.001), having a cancer diagnosis (p = 0.006), and lower caregiver comfort level managing symptoms (p < 0.001). Regression model analyses showed that younger patient age (p = 0.0009, p = 0.0036) and lower caregiver comfort level managing symptoms (p = 0.0047, p < 0.0001) were associated uniquely with higher symptom scores. Conclusions: Multiple symptoms of high severity were perceived by caregivers in the last week on home hospice. Patient age and caregiver comfort level in managing symptoms were associated with higher symptom scores. Further work is needed to improve management and treatment of symptoms in this care setting.
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Affiliation(s)
- Veerawat Phongtankuel
- Department of Medicine, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Jeanne A Teresi
- Research Division, Hebrew Home at Riverdale, New York, New York, USA.,Columbia University Stroud Center at New York State Psychiatric Institute, New York, New York, USA
| | - Joseph P Eimicke
- Research Division, Hebrew Home at Riverdale, New York, New York, USA
| | - Jian X Kong
- Research Division, Hebrew Home at Riverdale, New York, New York, USA
| | - Ronald D Adelman
- Department of Medicine, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Holly G Prigerson
- Department of Medicine, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sara J Czaja
- Department of Medicine, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Ariel Shalev
- Department of Medicine, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Ritchell Dignam
- Department of Hospice and Palliative Care, Visiting Nurse Service of New York, New York, New York, USA
| | - Rosemary Baughn
- Department of Hospice and Palliative Care, Visiting Nurse Service of New York, New York, New York, USA
| | - M Cary Reid
- Department of Medicine, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
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18
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Washington KT, Oliver DP, Smith JB, Kruse RL, Meghani SH, Demiris G. A Comparison of Rural and Urban Hospice Family Caregivers' Cancer Pain Knowledge and Experience. J Pain Symptom Manage 2019; 58:685-689. [PMID: 31325546 PMCID: PMC6754759 DOI: 10.1016/j.jpainsymman.2019.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Family caregivers play a vital role in managing the pain of hospice patients with cancer; however, caregivers' knowledge of pain management principles and experiences as pain managers vary widely. Differences in cultural values and access to resources suggest that rural and urban hospice family caregivers may differ with regard to their pain knowledge and experience, but this has not been empirically investigated. OBJECTIVES We sought to determine if rural and urban hospice family caregivers differed in terms of their knowledge of cancer pain management principles and their experiences managing cancer pain. METHODS Our study consisted of a secondary analysis of baseline, cross-sectional data from hospice family caregivers (N = 196) participating in an ongoing cluster randomized crossover pragmatic trial. We performed multivariable regression to model associations between caregivers' demographic characteristics and their scores on the Family Pain Questionnaire (FPQ), which included subscales measuring pain knowledge and experience. RESULTS When controlling for other demographic variables, rural caregivers' scores on the FPQ knowledge subscale were worse (P = 0.01) than their urban counterparts. FPQ experience subscale scores and FPQ total scores were not statistically significantly different between the two groups. CONCLUSION Rural hospice family caregivers report greater pain knowledge deficits than urban hospice family caregivers, although the two groups report comparable pain management experiences. Additional research is needed to better explain observed differences.
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Affiliation(s)
- Karla T Washington
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA.
| | - Debra Parker Oliver
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Jamie B Smith
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Salimah H Meghani
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Demiris
- Schools of Nursing and Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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19
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Hsu Y, Chu F, Chen T, Chou L, Chang H, Lin M, Hwang S. Lots of little ones: Analysis of charitable donations to a hospice and palliative care unit in Taiwan. Int J Health Plann Manage 2019; 34:e1810-e1819. [DOI: 10.1002/hpm.2897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/13/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Ya‐Chuan Hsu
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
| | - Feng‐Yuan Chu
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
| | - Tzeng‐Ji Chen
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Li‐Fang Chou
- Department of Public Finance National Chengchi University Taipei Taiwan
| | - Hsiao‐Ting Chang
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Ming‐Hwai Lin
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Shinn‐Jang Hwang
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
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20
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Kozlov E, Phongtankuel V, Prigerson H, Adelman R, Shalev A, Czaja S, Dignam R, Baughn R, Reid MC. Prevalence, Severity, and Correlates of Symptoms of Anxiety and Depression at the Very End of Life. J Pain Symptom Manage 2019; 58:80-85. [PMID: 31004771 PMCID: PMC6726373 DOI: 10.1016/j.jpainsymman.2019.04.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 10/27/2022]
Abstract
CONTEXT Rates of psychological symptoms for patients with serious illness are high, but there has been limited research investigating psychological symptoms at the very end of life (EOL). OBJECTIVES To better understand the prevalence, severity, and correlates of psychological distress at the very EOL. METHODS This retrospective cross-sectional study utilized caregiver proxy interviews. Caregivers were contacted after their care recipient recently died while receiving home hospice care and invited to participate in a brief interview with a trained research assistant. Patient, caregiver, and hospice utilization data were also abstracted from electronic medical records, and caregiver burden scores were assessed via interview. RESULTS A total of 351 caregivers were included in the study. According to caregivers, 46.4% of patients had moderate-to-severe anxiety, as assessed with a score of ≥4 on the Edmonton Symptom Assessment Scale and 43% had moderate-to-severe symptoms (Edmonton Symptom Assessment Scale score ≥ 4) of depression in the last week of life. Symptoms of anxiety and depression were significantly associated with caregiver burden scores and inversely associated with patient age. CONCLUSION Psychological symptom management at the very EOL is essential to providing comprehensive hospice care. Our study revealed that nearly half of all home hospice patients experience moderate-to-severe symptoms of anxiety and/or depression in the last week of life. Future research is needed to improve psychological symptom management at the very EOL to improve the quality of life for both patients and their families.
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Affiliation(s)
- Elissa Kozlov
- Weill Cornell Medicine, Division of Geriatric and Palliative Medicine, New York, New York, USA.
| | - Veerawat Phongtankuel
- Weill Cornell Medicine, Division of Geriatric and Palliative Medicine, New York, New York, USA
| | - Holly Prigerson
- Weill Cornell Medicine, Division of Geriatric and Palliative Medicine, New York, New York, USA
| | - Ronald Adelman
- Weill Cornell Medicine, Division of Geriatric and Palliative Medicine, New York, New York, USA
| | - Ariel Shalev
- Weill Cornell Medicine, Division of Geriatric and Palliative Medicine, New York, New York, USA
| | - Sara Czaja
- Weill Cornell Medicine, Division of Geriatric and Palliative Medicine, New York, New York, USA
| | | | | | - M Carrington Reid
- Weill Cornell Medicine, Division of Geriatric and Palliative Medicine, New York, New York, USA
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21
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Rocque GB, Williams CP, Miller HD, Azuero A, Wheeler SB, Pisu M, Hull O, Rocconi RP, Kenzik KM. Impact of Travel Time on Health Care Costs and Resource Use by Phase of Care for Older Patients With Cancer. J Clin Oncol 2019; 37:1935-1945. [PMID: 31184952 DOI: 10.1200/jco.19.00175] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Many community cancer clinics closed between 2008 and 2016, with additional closings potentially expected. Limited data exist on the impact of travel time on health care costs and resource use. METHODS This retrospective cohort study (2012 to 2015) evaluated travel time to cancer care site for Medicare beneficiaries age 65 years or older in the southeastern United States. The primary outcome was Medicare spending by phase of care (ie, initial, survivorship, end of life). Secondary outcomes included patient cost responsibility and resource use measured by hospitalization rates, intensive care unit admissions, and chemotherapy-related hospitalization rates. Hierarchical linear models with patients clustered within cancer care site (CCS) were used to determine the effects of travel time on average monthly phase-specific Medicare spending and patient cost responsibility. RESULTS Median travel time was 32 (interquartile range, 18-59) minutes for the 23,382 included Medicare beneficiaries, with 24% of patients traveling longer than 1 hour to their CCS. During the initial phase of care, Medicare spending was 14% higher and patient cost responsibility was 10% higher for patients traveling longer than 1 hour than those traveling 30 minutes or less. Hospitalization rates were 4% to 13% higher for patients traveling longer than 1 hour versus 30 minutes or less in the initial (61 v 54), survivorship (27 v 26), and end-of-life (310 v 286) phases of care (all P < .05). Most patients traveling longer than 1 hour were hospitalized at a local hospital rather than at their CCS, whereas the converse was true for patients traveling 30 minutes or less. CONCLUSION As health care locations close, patients living farther from treatment sites may experience more limited access to care, and health care spending could increase for patients and Medicare.
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Affiliation(s)
| | | | - Harold D Miller
- 2Center for Healthcare Quality and Payment Reform, Pittsburgh, PA
| | - Andres Azuero
- 1University of Alabama at Birmingham, Birmingham, AL
| | | | - Maria Pisu
- 1University of Alabama at Birmingham, Birmingham, AL
| | - Olivia Hull
- 1University of Alabama at Birmingham, Birmingham, AL
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Haywood A, Duc J, Good P, Khan S, Rickett K, Vayne-Bossert P, Hardy JR. Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. Cochrane Database Syst Rev 2019; 2:CD012704. [PMID: 30784058 PMCID: PMC6381295 DOI: 10.1002/14651858.cd012704.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Dyspnoea is a common symptom in advanced cancer, with a prevalence of up to 70% among patients at end of life. The cause of dyspnoea is often multifactorial, and may cause considerable psychological distress and suffering. Dyspnoea is often undertreated and good symptom control is less frequently achieved in people with dyspnoea than in people with other symptoms of advanced cancer, such as pain and nausea. The exact mechanism of action of corticosteroids in managing dyspnoea is unclear, yet corticosteroids are commonly used in palliative care for a variety of non-specific indications, including pain, nausea, anorexia, fatigue and low mood, despite being associated with a wide range of adverse effects. In view of their widespread use, it is important to seek evidence of the effects of corticosteroids for the management of cancer-related dyspnoea. OBJECTIVES To assess the effects of systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Science Citation Index Web of Science, Latin America and Caribbean Health Sciences (LILACS) and clinical trial registries, from inception to 25 January 2018. SELECTION CRITERIA We included randomised controlled trials that included adults aged 18 years and above. We included participants with cancer-related dyspnoea when randomised to systemic corticosteroids (at any dose) administered for the relief of cancer-related dyspnoea or any other indication, compared to placebo, standard or alternative treatment. DATA COLLECTION AND ANALYSIS Five review authors independently assessed trial quality and three extracted data. We used means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). We assessed the risk of bias and quality of evidence using GRADE. We extracted primary outcomes of sensory-perceptual experience of dyspnoea (intensity of dyspnoea), affective distress (quality of dyspnoea) and symptom impact (burden of dyspnoea or impact on function) and secondary outcomes of serious adverse events, participant satisfaction with treatment and participant withdrawal from trial. MAIN RESULTS Two studies met the inclusion criteria, enrolling 157 participants (37 participants in one study and 120 in the other study), of whom 114 were included in the analyses. The studies compared oral dexamethasone to placebo, followed by an open-label phase in one study. One study lasted seven days, and the duration of the other study was 15 days.We were unable to conduct many of our predetermined analyses due to different agents, dosages, comparators and outcome measures, routes of drug delivery, measurement scales and time points. Subgroup analysis according to type of cancer was not possible.Primary outcomesWe included two studies (114 participants) with data at one week in the meta-analysis for change in dyspnoea intensity/dyspnoea relief from baseline. Corticosteroid therapy with dexamethasone resulted in an MD of lower dyspnoea intensity compared to placebo at one week (MD -0.85 lower dyspnoea (scale 0-10; lower score = less breathlessness), 95% CI -1.73 to 0.03; very low-quality evidence), although we were uncertain as to whether corticosteroids had an important effect on dyspnoea as results were imprecise. We downgraded the quality of evidence by three levels from high to very low due to very serious study limitations and imprecision.One study measured affective distress (quality of dyspnoea) and results were similar between groups (29 participants; very low-quality evidence). We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Both studies assessed symptom impact (burden of dyspnoea or impact on function) (113 participants; very low-quality evidence). In one study, it was unclear whether dexamethasone had an effect on dyspnoea as results were imprecise. The second study showed more improvement for physical well-being scores at days eight and 15 in the dexamethasone group compared with the control group, but there was no evidence of a difference for FACIT social/family, emotional or functional scales. We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Secondary outcomesDue to the lack of homogenous outcome measures and inconsistency in reporting, we could not perform quantitative analysis for any secondary outcomes. In both studies, the frequency of adverse events was similar between groups, and corticosteroids were generally well tolerated. The withdrawal rates for the two studies were 15% and 36%. Reasons for withdrawal included lost to follow-up, participant or carer (or both) refusal, and death due to disease progression. We downgraded the quality of evidence for these secondary outcomes by three levels from high to very low due to serious study limitations, inconsistency and imprecision.Neither study examined participant satisfaction with treatment. AUTHORS' CONCLUSIONS There are few studies assessing the effects of systemic corticosteroids on cancer-related dyspnoea in adults with cancer. We judged the evidence to be of very low quality that neither supported nor refuted corticosteroid use in this population. Further high-quality studies are needed to determine if corticosteroids are efficacious in this setting.
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Affiliation(s)
- Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
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Abstract
BACKGROUND: Providing quality care to hospice and palliative care patients requires the ability to feel and demonstrate empathic behaviors. To acquire a heightened level of empathy, the learner needs to internalize a process of experiencing first-hand real-life symptom burdens common at end of life. Making this happen during new employee orientation is a challenge but with powerful outcomes. OBJECTIVE: To increase empathy levels in hospice and palliative care staff within the agency. METHODS: A mandatory class for all new employees and open sessions for existing employees in a hospice and palliative care setting. Subjecting participants to multiple disease process simulations. RESULTS: All new employees participated in a symptom simulation workshop during their orientation. CONCLUSIONS: Ninety-eight percent of the new employees found their experience in the workshop to dramatically positively affect their empathy levels and consequently formulate compassionate responses to patient situations based on their experiences of feeling empathy during the training.
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Do Physicians Underestimate Pain in Terminal Cancer Patients? A Prospective Study in a Hospice Setting. Clin J Pain 2018; 34:1159-1163. [PMID: 30028368 DOI: 10.1097/ajp.0000000000000641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Unrelieved pain is present in a majority of terminal cancer patients. However, the treatment of pain in palliative and hospice care is affected by the lack of validated pain assessment. The goal of this study was to evaluate differences in pain evaluation between terminal cancer patients and physicians and evaluate the pain levels as a survival biomarker. MATERIALS AND METHODS Patients were evaluated every 7 days for a total of 4 assessments. Physicians evaluated patients' pain on an numeric rating scale (NRS) scale after clinical examination, after which the patients completed NRS, Quality of Life Questionnaire Core 15 Pal (QLQ-C15-PAL), and Edmonton Symptom Assessment System (ESAS) questionnaires. RESULTS On average, physicians minimally underestimated the pain level in patients (3.47 vs. 3.94 on an NRS scale). Pain was overestimated in 28% and underestimated in 46% of the patients. However, half of all underestimation was clinically meaningful, compared with 28% of the overestimation. For patients with an NRS score of ≥7, pain underestimation was both clinically and statistically significant (5.56 vs. 8.17). Pain ratings exhibited a very small correlation to survival (up to r=-0.22), limiting their use as a survival biomarker. DISCUSSION Although physicians can accurately assess mild pain in terminal cancer patients in the hospice setting, the underestimation of pain is still clinically significant in almost a quarter of patients, and especially pronounced in patients with higher levels of pain and in female patients. Hence, validated pain assessment is a necessity in hospice care, with the choice of pain evaluation tool dependent on patient and physician preference.
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Phongtankuel V, Adelman RD, Trevino K, Abramson E, Johnson P, Oromendia C, Henderson CR, Reid MC. Association Between Nursing Visits and Hospital-Related Disenrollment in the Home Hospice Population. Am J Hosp Palliat Care 2018; 35:316-323. [PMID: 28285542 PMCID: PMC5494025 DOI: 10.1177/1049909117697933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Over 10% of hospice patients experience a transition out of hospice care during the last months of life. Hospice transitions from home to hospital (ie, hospital-related hospice disenrollment) result in fragmented care, which can be burdensome for patients and caregivers. Nurses play a major role in delivering home hospice care, yet little is known about the association between nursing visits and disenrollment. OBJECTIVES The study's purpose is to examine the association between the average number of nursing visits per week and hospital-related disenrollment in the home hospice population. We hypothesize that more nursing visits per week will be associated with reduced odds for disenrollment. DESIGN A retrospective cohort study using Medicare data. PARTICIPANTS Medicare hospice beneficiaries who were ≥18 years old in 2012. OUTCOME MEASURED Hospitalization within 2 days of hospice disenrollment. RESULTS The sample included 115 103 home hospice patients, 6450 (5.6%) of whom experienced a hospital-related disenrollment. The median number of nursing visits per week was 2 (interquartile range 1.3-3.2), with a mean of 2.5 (standard deviation ±1.6). There was a decreased likelihood of a hospital-related disenrollment when comparing enrollments that had <3 nursing visits per week on average to 3 to <4 visits (odds ratio [OR] 0.39; P value <.001), 4 to <5 visits (OR 0.29; P value <.001), and 5+ visits (OR 0.21; P value <.001). CONCLUSIONS More nursing visits per week was associated with a decreased likelihood of a hospital-related hospice disenrollment. Further research is needed to understand what components of nursing care influence care transitions in the home hospice setting.
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Affiliation(s)
- Veerawat Phongtankuel
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
- New York-Presbyterian Hospital, New York, NY, USA
| | - Ronald D. Adelman
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
- New York-Presbyterian Hospital, New York, NY, USA
| | - Kelly Trevino
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
- New York-Presbyterian Hospital, New York, NY, USA
| | - Erika Abramson
- New York-Presbyterian Hospital, New York, NY, USA
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Phyllis Johnson
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, USA
| | - Clara Oromendia
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, USA
| | | | - M. Carrington Reid
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
- New York-Presbyterian Hospital, New York, NY, USA
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Kogure E, Hara T, Ishii T, Maeda M. Changes in fatigue and physical function with age for patients with gastrointestinal cancer in the perioperative period: a comparison between older and young patients. J Phys Ther Sci 2017; 29:2004-2008. [PMID: 29200645 PMCID: PMC5702835 DOI: 10.1589/jpts.29.2004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 08/23/2017] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The purpose of this study was to examine changes in fatigue and physical
function with age for groups of patients with gastrointestinal cancer in the perioperative
period. [Subjects and Methods] The study involved 52 patients with gastrointestinal cancer
(28 males and 24 females, aged 62.4 ± 12.0 years). The subjects were divided into two
groups: those 65 or over (the so-called elderly group,) and those 64 or under (the
so-called young group). The six minute walk distance (6MWD), Cancer Fatigue Scale (CFS),
and serum albumin (ALB) were evaluated on three occasions: before surgery, after surgery
and after discharge. This study considered change in physical function and fatigue,
differences between the two groups and correlations between age and each evaluation on the
three occasions. [Results] The 6MWD was the main difference between the elderly and young
groups, with the former having significantly reduced 6MWD values as compared to the latter
after surgery. Age was positively correlated with 6MWD and ALB after surgery and after
discharge. Moreover, age was negatively correlated with CFS after surgery and after
discharge. [Conclusion] It is suggested that elderly patients are more likely to
experience a decline in exercise tolerance and an increase in fatigue.
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Affiliation(s)
- Eisuke Kogure
- Department of Rehabilitation, International University of Health and Welfare Graduate School: 1-3-3 Minami Aoyama, Minato-ku, Tokyo 107-0062, Japan.,Division of Rehabilitation, International University of Health and Welfare Mita Hospital, Japan
| | - Tsuyoshi Hara
- Department of Physical Therapy, Faculty of Health Science, International University of Health and Welfare, Japan
| | - Takaya Ishii
- Division of Rehabilitation, International University of Health and Welfare Mita Hospital, Japan
| | - Masaharu Maeda
- Department of Rehabilitation, International University of Health and Welfare Graduate School: 1-3-3 Minami Aoyama, Minato-ku, Tokyo 107-0062, Japan
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Haywood A, Duc J, Good P, Khan S, Rickett K, Vayne-Bossert P, Hardy JR. Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. Hippokratia 2017. [DOI: 10.1002/14651858.cd012704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University; Gold Coast Australia
- Mater Research Institute - The University of Queensland; Brisbane Australia
| | - Jacqueline Duc
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
- Faculty of Medicine; University of Brisbane Brisbane Australia
- Children's Health Queensland; Paediatric Palliative Care Service; Brisbane Australia
| | - Phillip Good
- Mater Research Institute - The University of Queensland; Brisbane Australia
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
- St Vincent's Private Hospital; Department of Palliative Care; 411 Main Street Kangaroo Point Brisbane Queensland Australia 4169
| | - Sohil Khan
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University; Gold Coast Australia
- Mater Research Institute - The University of Queensland; Brisbane Australia
| | - Kirsty Rickett
- UQ/Mater McAuley Library; The University of Queensland Library; Raymond Terrace Brisbane Queensland Australia 4101
| | - Petra Vayne-Bossert
- University Hospitals of Geneva; Department of Readaptation and Palliative Medicine; 11 chemin de la Savonnière Collonge-Bellerive Geneva Switzerland 1245
| | - Janet R Hardy
- Mater Research Institute - The University of Queensland; Brisbane Australia
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
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Phongtankuel V, Paustian S, Reid MC, Finley A, Martin A, Delfs J, Baughn R, Adelman RD. Events Leading to Hospital-Related Disenrollment of Home Hospice Patients: A Study of Primary Caregivers' Perspectives. J Palliat Med 2016; 20:260-265. [PMID: 27893951 DOI: 10.1089/jpm.2015.0550] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Approximately 25% of hospice disenrollments in the United States occur as the result of hospitalization, which can lead to burdensome transitions and undesired care. Informal caregivers (e.g., spouses, children) play a critical role in caring for patients on home hospice. Research examining hospital-related disenrollment among these patients is limited. OBJECTIVE To understand the events surrounding the hospitalization of patients discharged from home hospice through the perspective of their informal caregivers. DESIGN Thirty-eight semistructured phone interviews with caregivers were conducted, and data regarding the events leading to hospitalization and hospice disenrollment were collected. Study data were analyzed by using qualitative methods. SETTING/SUBJECTS Subjects included caregivers of 38 patients who received services from one not-for-profit home hospice organization in New York City. Participants were English speaking only. MEASUREMENTS Caregiver recordings were transcribed and analyzed by using content analysis. RESULTS Content analysis revealed four major themes contributing to hospitalization: (1) distressing/difficult-to-witness signs and symptoms, (2) needing palliative interventions not deliverable in the home setting, (3) preference to be cared for by nonhospice physicians or at a local hospital, and (4) caregivers not comfortable with the death of their care recipient at home. Over half of all caregivers called 911 before calling hospice. CONCLUSIONS Our study provides insight into the events leading to hospitalization of home hospice patients from the caregivers' perspective. Further research is needed to quantify the drivers of hospitalization and to develop interventions that reduce utilization, while improving care for home hospice patients and their caregivers.
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Affiliation(s)
- Veerawat Phongtankuel
- 1 Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College , New York, New York
| | - Shawn Paustian
- 1 Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College , New York, New York
| | - Manney Carrington Reid
- 1 Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College , New York, New York
| | - Amanda Finley
- 2 The Visiting Nurse Service of New York , New York, New York
| | - Angela Martin
- 2 The Visiting Nurse Service of New York , New York, New York
| | - John Delfs
- 2 The Visiting Nurse Service of New York , New York, New York
| | - Rosemary Baughn
- 2 The Visiting Nurse Service of New York , New York, New York
| | - Ronald D Adelman
- 1 Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College , New York, New York
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Johnson DC, Kassner CT, Kutner JS. Current use of guidelines, protocols, and care pathways for symptom management in hospice. Am J Hosp Palliat Care 2016; 21:51-7. [PMID: 14748524 DOI: 10.1177/104990910402100112] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Evidence-based guidelines or care pathways for symptom management could provide a means to reduce symptom distress in dying patients. We surveyed directors of nursing from hospices affiliated with the Population-based Palliative Care Research Network (PoPCRN) regarding their hospices’ current use of and attitudes toward written symptom management materials. A majority (53/78, 68 percent) of participating hospices reported use of written materials, such as guidelines, protocols, or care pathways, for one or more symptoms. Materials were based on multiple sources and varied from simple medication orders to more comprehensive, multicategory symptom management resources. Regardless of the composition, these materials were perceived as helpful. Given this favorable view, variations in the use and content of written materials may signify an opportunity to decrease symptom distress in hospice through the implementation of evidence-based symptom management resources.
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Affiliation(s)
- Daniel C Johnson
- Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, Colorado, USA
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Cadwalader A, Orellano S, Tanguay C, Roshan R. The Effects of a Single Session of Music Therapy on the Agitated Behaviors of Patients Receiving Hospice Care. J Palliat Med 2016; 19:870-3. [PMID: 27115462 DOI: 10.1089/jpm.2015.0503] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Research suggests that agitation is a common symptom for hospice patients, but while studies have examined the outcomes of music therapy on the agitated behaviors of patients in other settings, none have addressed this symptom in patients with terminal illnesses. OBJECTIVE The study objective was to determine whether a single session of music therapy provided by a board certified music therapist and using the entrainment principle would decrease agitation in hospice patients. DESIGN This pilot study was a single-blind, pretest/posttest design. Music therapists used the principle of entrainment with live music during the treatment session. SETTING/SUBJECTS Subjects included in the study were 77 patients at a large hospice in south Florida with documented agitation. MEASUREMENTS Agitation was measured using the Overt Agitation Severity Scale (OASS) for 5 minutes prior to and 5 minutes following a 20 minute music therapy intervention. RESULTS Results from 73 participants were analyzed with a mean difference of -5.77 points from pretest to posttest. Results indicating a decrease in agitation were statistically significant (p < 0.001) for the entire sample. Age, gender, location, and diagnosis were found to have no significant effects on the results. CONCLUSIONS Results indicate that a single session of music therapy using the entrainment principle may be an effective treatment for hospice patients experiencing agitation.
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Affiliation(s)
- Alyssa Cadwalader
- 1 Trust Bridge Health, Hospice of Palm Beach County , West Palm Beach, Florida
| | | | - Carla Tanguay
- 4 Mount Desert Island Hospital Organization , Bar Harbor, Maine
| | - Ramesh Roshan
- 3 TrustBridge Health Medical Education , West Palm Beach, Florida
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Shah N, Homel P, Breznay J. Use of Medical Devices in Hospice for Symptom Management. Am J Hosp Palliat Care 2015; 33:929-934. [PMID: 26275782 DOI: 10.1177/1049909115600856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Home health services in the United States(US) have been on a rise. Hospice patients cope with diverse physical and pain symptoms; medical devices are used for symptom management to improve their quality-of-care at end-of-life. OBJECTIVE Using the National Home and Hospice Care Survey (NHHCS), the study summarizes medical device use for symptom management and tracks various demographic variables for home hospice patients. METHODS A cross-sectional analysis of data using the 2007 NHHCS was conducted. There were 4733 hospice discharges which corresponded to 2,505,011 individuals in US with sampling weights. The data was analyzed using chi square tests and confounding factors adjusted with logistic regression. RESULTS Eighty-nine percent of hospice discharges were evaluated for pain at first assessment. The regression model for pain at first assessment was significantly associated with use of patient controlled analgesia (OR = 1.82, 95% CI = 1.28, 2.59) and urinary catheters (OR = 1.16, 95% CI = 1.02, 1.33). Patient with dyspnea were associated with significant use of oxygen (OR = 3.00, 95% CI = 2.64, 3.40) and metered dose inhaler (OR = 2.43, 95% CI = 1.92, 3.07). There was negligible use of total parenteral nutrition (TPN) noted in the study. CONCLUSION In conclusion, the study highlights medical device use in home hospice care for end-of-life symptom management. It noted the significant use of IV infusion pumps and patient controlled analgesia. Conversely, there is little use of TPN or CPAP in patients with anorexia or dyspnea. While missing data on critical symptom evaluations regrettably raises questions about the validity of the study, the NHHCS serves as an important reservoir of data on the growing population of home hospice patients.
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Affiliation(s)
- Nidhi Shah
- Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Peter Homel
- Maimonides Medical Center, Brooklyn, NY, USA
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Romem A, Tom SE, Beauchene M, Babington L, Scharf SM, Romem A. Pain management at the end of life: A comparative study of cancer, dementia, and chronic obstructive pulmonary disease patients. Palliat Med 2015; 29:464-9. [PMID: 25680377 DOI: 10.1177/0269216315570411] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Limited data exist concerning the unique pain characteristics of patients with non-cancer terminal diseases referred for inpatient hospice care. AIMS To define the unique pain characteristics of patients admitted to an acute inpatient hospice setting with end-stage dementia or chronic obstructive lung disease (or chronic obstructive pulmonary disease) and to compare them to patients with end-stage cancer. DESIGN Retrospective patient chart review. Demographic, physiological, pain parameters, and medication utilization data were extracted. Associations between pain characteristics, medication utilization, and admission diagnoses were assessed. Analyses included descriptive statistics. SETTING/PARTICIPANTS In total, 146 patients admitted to an acute inpatient hospice between 1 April 2011 and 31 March 2012 with an underlying primary diagnosis of chronic obstructive pulmonary disease (n = 51), dementia (n = 48), or cancer (n = 47). RESULTS Pain was highly prevalent in all diagnostic groups, with cancer patients experiencing more severe pain on admission. Cancer patients received a significantly higher cumulative opioid dose compared with dementia and chronic obstructive pulmonary disease patients. Pain control within 24 h of pain onset was achieved in less than half of all patient groups with chronic obstructive pulmonary disease patients the least likely to achieve pain control. CONCLUSIONS Despite the fact that pain is the most common complaint at the end of life, pain management may be suboptimal for some primary diagnoses. Admission diagnosis is the strongest predictor of pain control. Patient with cancer achieve the best pain control, and chronic obstructive pulmonary disease patients are the least likely to have their pain adequately treated.
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Affiliation(s)
- Anat Romem
- School of Nursing Sciences, The Academic College of Tel-Aviv, Yaffo, Israel
| | - Sarah E Tom
- Pharmaceutical Health Services Research Department, University of Maryland, Baltimore, MD, USA
| | - Michelle Beauchene
- School of Nursing, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Lynn Babington
- School of Nursing, Fairfield University, Fairfield, CT, USA
| | - Steven M Scharf
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ayal Romem
- Pulmonary Institute, Shaare Zedek Medical Center, Jerusalem, Israel
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Aktas A, Walsh D, Kirkova J. The psychometric properties of cancer multisymptom assessment instruments: a clinical review. Support Care Cancer 2015; 23:2189-202. [PMID: 25894883 DOI: 10.1007/s00520-015-2732-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 03/29/2015] [Indexed: 01/29/2023]
Abstract
PURPOSE Various instruments are used to assess both individual and multiple cancer symptoms. We evaluated the psychometric properties of cancer multisymptom assessment instruments. METHODS An Ovid MEDLINE search was done. All searches were limited to adults and in English. All instruments published from 2005 to 2014 (and with at least one validity test) were included. We excluded those who only reported content validity. Instruments were categorized by the three major types of symptom measurement scales employed as follows: visual analogue (VAS), verbal rating (VRS), and numerical rating (NRS) scales. They were then examined in two areas: (1) psychometric thoroughness (number of tests) and (2) psychometric strength of evidence (validity, reliability, generalizability). We also assigned an empirical global psychometric quality score (which combined the concepts of thoroughness and strength of evidence) to rank the instruments. RESULTS We analyzed 57 instruments (17 original, 40 modifications). They varied in types of scales used, symptom dimensions measured, and time frames evaluated. Of the 57, 10 used VAS, 28 VRS, and 19 NRS. The Edmonton Symptom Assessment System (ESAS), ESAS-Spanish, Hospital Anxiety and Depression Scale (HADS), Profile of Mood States (POMS), Symptom Distress Scale (SDS), M.D. Anderson Symptom Inventory (MDASI)-Russian, and MDASI-Taiwanese were the most comprehensively tested for validity and reliability. The ESAS, ESAS-Spanish, ASDS-2, Memorial Symptom Assessment Scale (MSAS)-SF, POMS, SDS, MDASI (and some translations), and MDASI-Heart Failure all showed good validity and reliability. CONCLUSIONS The MDASI appeared to be the best overall from a psychometric perspective. This was followed by the ESAS, ESAS-Spanish, POMS, SDS, and some MDASI translations. VRS-based instruments were most common. There was a wide range of psychometric rigor in validation. Consequently, meta-analysis was not possible. Most cancer multisymptom assessment instruments need further extensive validation to establish the excellent reliability and validity required for clinical utility and meaningful research.
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Affiliation(s)
- Aynur Aktas
- Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
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Janberidze E, Pereira SM, Hjermstad MJ, Knudsen AK, Kaasa S, van der Heide A, Onwuteaka-Philipsen B. Depressive symptoms in the last days of life of patients with cancer: a nationwide retrospective mortality study. BMJ Support Palliat Care 2015; 6:201-9. [PMID: 25669202 DOI: 10.1136/bmjspcare-2014-000722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 12/19/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Depressive symptoms are common in patients with cancer and tend to increase as death approaches. The study aims were to examine the prevalence of depressive symptoms in patients with cancer in their final 24 h, and their association with other symptoms, sociodemographic and care characteristics. METHODS A stratified sample of deaths was drawn by Statistics Netherlands. Questionnaires on patient and care characteristics were sent to the physicians (N=6860) who signed the death certificates (response rate 77.8%). Adult patients with cancer with non-sudden death were included (n=1363). Symptoms during the final 24 h of life were assessed on a 1-5 scale and categorised as 1=no, 2-3=mild/moderate and 4-5=severe/very severe. RESULTS Depressive symptoms were registered in 37.6% of the patients. Patients aged 80 years or more had a reduced risk of having mild/moderate depressive symptoms compared with those aged 17-65 years (OR 0.70; 95% CI 0.50 to 0.99). Elderly care physicians were more likely to assess patients with severe/very severe depressive symptoms than patients with no depressive symptoms (OR 4.18; 95% CI 1.48 to 11.76). Involvement of pain specialists/palliative care consultants and psychiatrists/psychologists was associated with more ratings of severe/very severe depressive symptoms. Fatigue and confusion were significantly associated with mild/moderate depressive symptoms and anxiety with severe/very severe symptoms. CONCLUSIONS More than one-third of the patients were categorised with depressive symptoms during the last 24 h of life. We recommend greater awareness of depression earlier in the disease trajectory to improve care.
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Affiliation(s)
- Elene Janberidze
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Sandra Martins Pereira
- Department of Public and Occupational Health, VU University Medical Center, and EMGO+ Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, Amsterdam, Netherlands
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Regional Centre for Excellence in Palliative Care, South Eastern Norway, Oslo University Hospital, Oslo, Norway
| | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Agnes van der Heide
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bregje Onwuteaka-Philipsen
- Department of Public and Occupational Health, VU University Medical Center, and EMGO+ Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, Amsterdam, Netherlands
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Hirai K, Kanda K, Takagai J, Hosokawa M. Development of the Hirai Cancer Fatigue Scale: Testing its reliability and validity. Eur J Oncol Nurs 2015; 19:427-32. [PMID: 25656217 DOI: 10.1016/j.ejon.2014.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 11/25/2014] [Accepted: 12/15/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this study was to develop the Hirai Cancer Fatigue Scale (HCFS) to assess the fatigue experienced by cancer patients, and to verify its reliability and validity. METHODS Based on qualitative research about the perception of fatigue by Japanese cancer patients, we developed a questionnaire. The content validity was confirmed by 5 expert oncology nurses and 5 oncologists. 281 Japanese cancer patients participated in this study. Construct validity was analyzed using factor analysis, and internal consistency was analyzed using Cronbach's α coefficient. RESULTS A 15-item scale with 3 dimensions, "physical/mental sensation", "activity-related sensation" and "cognitive sensation," was developed by factor analysis. This scale had an overall Cronbach's α coefficient of .943 and a test-retest reliability coefficient of r = .820 (p < 0.01), confirming the high reliability of the scale. The correlation coefficient was r = .759 (p < 0.01) between HCFS and abridged Profile of Mood States-Fatigue (POMS-F), and r = .763 (p < 0.01) between HCFS and Cancer Fatigue Scale (CFS), both showing high correlations and confirming criterion-related validity. CONCLUSION HCFS enables reliable and valid evaluation of Japanese cancer patients' fatigue. Use of the HCFS would assist in convenient self-evaluation of fatigue, and would allow information to be effectively provided to healthcare professionals. It could also be used for outcome evaluation in an intervention study.
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Affiliation(s)
- Kazue Hirai
- Faculty of Medicine, School of Nursing, Tokyo Medical University, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan.
| | - Kiyoko Kanda
- Department of Nursing, Gunma University Graduate School of Health Science, 3-29-21 Showa-machi, Maebashi, Gunma, 371-8514, Japan.
| | - Junko Takagai
- Faculty of Medicine, School of Health Science, Akita University, 1-1-1 Hondou, Akita, Akita, 010-8543, Japan.
| | - Mai Hosokawa
- The Jikei University School of Nursing, 8-3-1, Kokuryocho, Chofu, Tokyo, 182-8570, Japan.
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Lok CW. Management of Breathlessness in Patients With Advanced Cancer: A Narrative Review. Am J Hosp Palliat Care 2014; 33:286-90. [PMID: 25318928 DOI: 10.1177/1049909114554796] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Breathlessness is defined as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity." It is a common and distressing symptom reported by patients with advanced malignancy. It occurs in up to 70% of patients with advanced cancer, and the symptom is aggravated with disease progression. This article reviews the etiology, assessment, and measurement of dyspnea in patients with advanced cancer. Because of its complex biopsychological etiology and manifestations, multidisciplinary approach with combination of both pharmacological and nonpharmacological interventions provides the best treatment plan for patients with dyspnea.
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Affiliation(s)
- Chan Wing Lok
- Department of Clinical Oncology, Queen Mary Hospital, Hong Kong
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Moens K, Higginson IJ, Harding R. Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions? A systematic review. J Pain Symptom Manage 2014; 48:660-77. [PMID: 24801658 DOI: 10.1016/j.jpainsymman.2013.11.009] [Citation(s) in RCA: 273] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 11/18/2013] [Accepted: 11/21/2013] [Indexed: 12/20/2022]
Abstract
CONTEXT If access to effective palliative care is to extend beyond cancer patients, an understanding of the comparative prevalence of palliative care problems among cancer and non-cancer patients is necessary. OBJECTIVES This systematic review aimed to describe and compare the prevalence of seventeen palliative care-related problems across the four palliative care domains among adults with advanced cancer, acquired immune deficiency syndrome, chronic heart failure, end-stage renal disease (ESRD), chronic obstructive pulmonary disease, multiple sclerosis, motor neuron disease, Parkinson's disease, and dementia. METHODS Three databases were searched using three groups of keywords. The results of the extraction of the prevalence figures were summarized. RESULTS The electronic searches yielded 4697 hits after the removal of 1784 duplicates. Of these hits, 143 met the review criteria. The greatest number of studies were found for advanced cancer (n=57) and ESRD patients (n=47), and 75 of the 143 studies used validated scales. Few data were available for people living with multiple sclerosis (n=2) and motor neuron disease (n=3). The problems with a prevalence of 50% or more found across most of the nine studied diagnostic groups were: pain, fatigue, anorexia, dyspnea, and worry. CONCLUSION There are commonalities in the prevalence of problems across cancer and non-cancer patients, highlighting the need for palliative care to be provided irrespective of diagnosis. The methodological heterogeneity across the studies and the lack of non-cancer studies need to be addressed in future research.
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Affiliation(s)
- Katrien Moens
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, United Kingdom.
| | - Irene J Higginson
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, United Kingdom
| | - Richard Harding
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, United Kingdom
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Cherny N. ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 2014; 25 Suppl 3:iii143-52. [DOI: 10.1093/annonc/mdu238] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Albright DL, Kruse RL, Oliver DP, Washington K, Cagle J, Demiris G. Testing the factorial validity of scores from the caregiver pain medicine questionnaire. J Pain Symptom Manage 2014; 48:99-109. [PMID: 24246789 PMCID: PMC4022713 DOI: 10.1016/j.jpainsymman.2013.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 08/06/2013] [Accepted: 08/13/2013] [Indexed: 11/28/2022]
Abstract
CONTEXT The Caregiver Pain Medicine Questionnaire is designed to measure caregiver agreement with statements regarding pain management. However, little testing has been done to determine its reliability and validity. OBJECTIVES The objective of the study was to test the factorial validity of scores from the Caregiver Pain Medicine Questionnaire as hypothesized by the original study authors. METHODS Confirmatory factor analysis was conducted to assess whether the subscales postulated by the instrument authors could be replicated in external data. RESULTS Fit statistics reveal an unsatisfactory fit between the hypothesized model and the observed data. CONCLUSION The theoretical model hypothesized by the original study authors was not confirmed. Results lead us to conclude that the instrument is poor and should not be used. Further research is needed to define content domains and validate the items developed to assess them.
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Affiliation(s)
- David L Albright
- School of Social Work, University of Missouri, Columbia, Missouri, USA.
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Debra Parker Oliver
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Karla Washington
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - John Cagle
- School of Social Work, University of Maryland, Baltimore, Maryland, USA
| | - George Demiris
- School of Nursing & School of Medicine, University of Washington, Seattle, Washington, USA
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Oliver DP, Wittenberg-Lyles E, Washington K, Kruse RL, Albright DL, Baldwin PK, Boxer A, Demiris G. Hospice caregivers' experiences with pain management: "I'm not a doctor, and I don't know if I helped her go faster or slower". J Pain Symptom Manage 2013; 46:846-58. [PMID: 23731855 PMCID: PMC3795892 DOI: 10.1016/j.jpainsymman.2013.02.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 02/13/2013] [Accepted: 02/18/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Those caring for their loved ones in hospice experience tremendous stress, being faced with numerous decisions as they work to manage the pain experienced by their loved one. Although hospice care teams create pain management strategies, it is the role of the caregiver to implement these plans. OBJECTIVES The purpose of this study was to further understand the hospice caregiver experience relating to pain management. METHODS Semistructured interviews with 146 caregivers provided data for the study. Responses to seven questions asking for a ranking of end-of-life pain management indicated a less than ideal experience. Available narratives from 38 caregivers were analyzed for themes related to further understanding of the concerns. RESULTS Five themes were identified in the data including difficulty with administration of pain medicines, concerns about side effects of medications, insecurity with pain assessment, frustrations with communication among health care team members, and memories of unrelieved pain. CONCLUSION These findings should raise concern among hospice professionals, whose commitment is to the management of pain, including emotional pain, with a focus on both the patient and the family as a unit of care. These data clearly suggest that hospice providers have an opportunity to be sensitive to perceptions held by caregivers regarding pain management. Effective planning for pain control must incorporate the values and beliefs not only of each patient but also of the family caregiver.
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Affiliation(s)
- Debra Parker Oliver
- Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA.
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Ornstein K, Wajnberg A, Kaye-Kauderer H, Winkel G, DeCherrie L, Zhang M, Soriano T. Reduction in symptoms for homebound patients receiving home-based primary and palliative care. J Palliat Med 2013; 16:1048-54. [PMID: 23746230 DOI: 10.1089/jpm.2012.0546] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Increasing numbers of patients are living with multiple, chronic medical conditions and functional impairments that leave them homebound. Home-based primary and palliative care (HBPC) programs provide access to health care services for this vulnerable population. Homebound patients have high symptom burden upon program enrollment. Yet little is known as to how individual symptoms are managed at home, especially over longer time periods. OBJECTIVES The purpose of this study was to determine whether high symptom burden decreases following HBPC enrollment. METHODS All patients newly enrolled in an HBPC program who reported at least one symptom on the Edmonton Symptom Assessment Scale (ESAS) were eligible for telephone ESAS follow-up. Patients received a comprehensive initial home visit and assessment by a physician with subsequent follow-up care, interdisciplinary care management including social work, and urgent in-home care as necessary. Multivariate linear mixed models with repeated measures were used to assess the impact of HBPC on pain, depression, anxiety, tiredness, and loss of appetite among patients with moderate to severe symptom levels at baseline. RESULTS One hundred forty patients were followed. Patient pain, anxiety, depression, and tiredness significantly decreased following intervention with symptom reductions seen at 3 weeks and maintained at 12 weeks. (p<0.01) Loss of appetite trended toward an overall significant decrease and showed significant reductions at 12 week follow-up. CONCLUSION In a chronically ill population of urban homebound, patient symptoms can be successfully managed in the home. Future work should continue to explore symptom assessment and management over time for the chronically ill homebound.
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Affiliation(s)
- Katherine Ornstein
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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Advancing the science of hospice care: Coalition of Hospices Organized to Investigate Comparative Effectiveness. Curr Opin Support Palliat Care 2013; 6:459-64. [PMID: 23108341 DOI: 10.1097/spc.0b013e32835a66b7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is very little high-quality evidence to guide clinical practice in hospice care. In the areas of medical therapy, patient-centered and family-centered outcomes, and patient safety, there are numerous high-impact questions for which answers are needed. Although randomized controlled trials are the gold standard for research, such trials are difficult, time consuming, and expensive to conduct in a hospice population. Moreover, they cannot examine the implementation of therapies in real-world settings. Therefore, there is a need for novel, complementary approaches to research in this unique population. RECENT FINDINGS This article describes the initial experience of the Coalition of Hospices Organized to Investigate Comparative Effectiveness (CHOICE). CHOICE is a national network of hospices that use electronic health record-based data collection procedures to answer key questions relevant to clinical care and policy. By using a rich source of existing data to conduct observational studies, CHOICE is able to overcome many of the most significant challenges of randomized controlled trials in hospice. However, this approach also created unique challenges related to governance and privacy concerns. SUMMARY CHOICE is a growing research network that has the potential to make a contribution to the science of palliative care in a hospice population.
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Challenge of assessing symptoms in seriously ill intensive care unit patients: can proxy reporters help? Crit Care Med 2012; 40:2760-7. [PMID: 22890258 DOI: 10.1097/ccm.0b013e31825b94d8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Determine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients' symptoms and compare levels of mean intensity (i.e., the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters. DESIGN Prospective study of proxy reporters of symptoms in seriously ill patients. SETTINGS Two intensive care units in a tertiary medical center in the Western United States. PATIENTS Two hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS On the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients' and family members' ratings met this criterion (≥.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ≥.36 between patients' and physicians' ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ≥.28 between patients' and nurses' ratings. Two symptoms had symptom-distress correlation coefficients between patients' and physicians' ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively. CONCLUSIONS Patient-family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients' symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians' and patients' symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients' symptoms. Proxy overestimation of patients' symptom scores warrants further study because this may influence decisions about treating patients' symptoms.
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Malhotra C, Chan A, Do YK, Malhotra R, Goh C. Good end-of-life care: perspectives of middle-aged and older Singaporeans. J Pain Symptom Manage 2012; 44:252-63. [PMID: 22658472 DOI: 10.1016/j.jpainsymman.2011.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 09/01/2011] [Accepted: 09/09/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT Understanding preferences for end-of-life care is important for planning and improving services that provide such care. However, little is known about the perspective of Singaporeans regarding good end-of-life care. OBJECTIVES To identify the key components of good end-of-life care as perceived by middle-aged and older Singaporeans (≥50 years). METHODS Nine focus groups were conducted with a total of 63 participants. Preferences regarding end-of-life care were discussed. Thematic analysis was conducted on the transcribed results of the focus groups. RESULTS Eight components of good end-of-life care were identified: 1) have physical comfort at the end of life, 2) avoid inappropriate prolongation of the dying process, 3) maintain sensitivity toward religious and spiritual beliefs, 4) avoid burden on the family, 5) avoid expensive care, 6) be cared for by a trustworthy doctor, 7) maintain control over care decisions, and 8) achieve a sense of completion. CONCLUSION Eight components of good end-of-life care involving the person, family, and health services were identified among middle-aged and older Singaporeans. A focus on better management of pain, training of caregivers and doctors, shared decision making, and availability of affordable care may improve care at the end of life.
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Affiliation(s)
- Chetna Malhotra
- Program in Health Services and Systems Research, Duke-National University of Singapore Graduate Medical School, Singapore.
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Kamal AH, Miriovsky BJ, Currow DC, Abernethy AP. Improving the management of dyspnea in the community using rapid learning approaches. Chron Respir Dis 2012; 9:51-61. [PMID: 22308555 DOI: 10.1177/1479972311433576] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patients with chronic pulmonary disease often suffer from breathlessness or dyspnea. Traditional evidence generation techniques to expand upon current treatment paradigms are limited by the significant delay between study initiation and clinical implementation of findings. Rapid learning health care is a novel approach to health care delivery that relies on intelligent and continuous integration of clinical and research data sets to deliver personalized medicine using the most current evidence available. Results of important studies in the management of chronic respiratory disease are presented in brief; however, the focus of this review is on evidence supporting the implementation of a rapid learning model for symptom management. Recent findings suggest that a rapid learning system is feasible and acceptable to patients with advanced illness, helps monitor symptoms overtime, facilitates study of the impact of novel interventions, and can identify unrecognized needs and concerns. A rapid learning model improves comprehensive assessment, timeliness of intervention, and accrual of contemporaneous data to support best practice that tailors care specific to the needs of patients as their disease and lifestyle change overtime. Using the rapid learning health care model, data collected in the process of routine care can simultaneously function both as clinical information and as a resource for research on patient-centered experiences and outcomes.
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Affiliation(s)
- Arif H Kamal
- Division of Medical Oncology, Department of Medicine, Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center, NC 27710, USA
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Kamal AH, Maguire JM, Wheeler JL, Currow DC, Abernethy AP. Dyspnea review for the palliative care professional: assessment, burdens, and etiologies. J Palliat Med 2011; 14:1167-72. [PMID: 21895451 PMCID: PMC3189385 DOI: 10.1089/jpm.2011.0109] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2011] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Dyspnea is a common symptom experienced by many patients with chronic, life-threatening, and/or life-limiting illnesses. Although it can be defined and measured in several ways, dyspnea is best described directly by patients through regular assessment, as its burdens exert a strong influence on the patient's experience throughout the trajectory of serious illness. Its significance is amplified due to its impact on family and caregivers. DISCUSSION Anatomic and physiologic changes associated with dyspnea, and cognitive perceptions related to patients and the underlying disease, provide insights into how to shape interventions targeting this oppressive symptom. Additionally, as described in the concept of "total dyspnea," the complex etiology and manifestation of this symptom require multidisciplinary treatment plans that focus on psychological, social, and spiritual distress as well as physical components. Several validated assessment tools are available for clinical and research use, and choice of method should be tailored to the individual patient, disease, and care setting in the context of patient-centered care. CONCLUSION This article, the first in a two-part series, reviews the identification and assessment of dyspnea, the burden it entails, and the underlying respiratory and nonrespiratory etiologies that may cause or exacerbate it.
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Affiliation(s)
- Arif H. Kamal
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jennifer M. Maguire
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Jane L. Wheeler
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - David C. Currow
- Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Amy P. Abernethy
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia
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Nadimi F, Currow DC. As death approaches: a retrospective survey of the care of adults dying in Alice Springs Hospital. Aust J Rural Health 2011; 19:4-8. [PMID: 21265918 DOI: 10.1111/j.1440-1584.2010.01169.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Australians are more likely to die in a hospital than anywhere else, and most of these deaths are 'expected'. The aims of this survey were to identify if specific end-of-life issues were documented in clinical records of a regional hospital serving remote Australia. DESIGN A retrospective consecutive case-note audit covering 18 months from 1 January 2006. SETTING Alice Springs Hospital. PARTICIPANTS Adult deaths in Alice Springs Hospital. During this period there were 128 deaths. OUTCOME MEASURES Demographic, process (diagnosis of dying documented, 'not for resuscitation' documentation, intensive care unit (ICU) admission, social worker referral and specialised palliative care service referral) and outcome data ('comfort at end of life') were surveyed. RESULTS Of the 128 admissions, 55 cases were excluded: 10 were children under 18, 33 died in < 48 hours, nine were coroner's cases and three files could no't be found. Of the 73 deaths surveyed (33 men), 47 (64%) were Aboriginal. A diagnosis of dying was made in 84%, 88% had an 'not for resuscitation' order, 48% were admitted to ICU during their last admission, 66% were referred to social workers, 68% were referred to palliative care and 85% of people were documented to be 'comfortable' during the dying process with no differential outcomes for Aboriginal and non-Aboriginal decedents except age (P < 0.0001). CONCLUSION This survey highlights the continuing need to diagnose dying, understand optimal use of intensive care and improve comfort care at the end of life.
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Affiliation(s)
- Fariba Nadimi
- Southern Adelaide Palliative Services, Repatriation General Hospital, Daw Park, South Australia, Australia.
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Black B, Herr K, Fine P, Sanders S, Tang X, Bergen-Jackson K, Titler M, Forcucci C. The relationships among pain, nonpain symptoms, and quality of life measures in older adults with cancer receiving hospice care. PAIN MEDICINE (MALDEN, MASS.) 2011; 12:880-9. [PMID: 21539700 PMCID: PMC3117028 DOI: 10.1111/j.1526-4637.2011.01113.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Gathering firsthand or reported information about patients in the final stages of terminal cancer is difficult due to patient frailty, cognitive impairment, excessive fatigue, and severity of illness, as well as gatekeeping by hospice providers and caregivers, and highly variable documentation practices. We sought to further understand and elucidate end-of-life experiences in older cancer patients through the application of validated tools employed in the hospice setting. This article summarizes data collected about pain, non-pain symptoms, and other aspects of quality of life (QOL) as reported by older hospice patients or by their caregivers during the 2 weeks of hospice care. DESIGN Data was collected from an ongoing Institutional Human Subjects Review Board-approved research project with 94 older adults with cancer or their caregivers receiving service in a home setting from 14 Midwestern hospices. Participants completed one or two telephone interviews. Instruments used to gather information include the Brief Pain Inventory and the Brief Hospice Inventory. RESULTS Data analysis showed mean "worst pain" ratings significantly decreased from Interview 1 to Interview 2, and pain reports were significantly correlated with fatigue, anxiety, appetite, comfort, symptom control, and overall QOL. CONCLUSIONS Our findings reinforce previously held views that older patients with cancer experience pain and non-pain symptoms. And both pain and non-pain symptoms can impact and confound the treatment of other symptoms and interfere with the patient's overall QOL. The results of this study support the assertion that hospice care can have a positive impact on pain severity and related suffering, as well as patient QOL as death approaches.
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Affiliation(s)
- Brianne Black
- College of Nursing, University of Iowa, Iowa City, Iowa 52242, USA
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Meeussen K, Van den Block L, Bossuyt N, Echteld M, Bilsen J, Deliens L. Dealing with requests for euthanasia: interview study among general practitioners in Belgium. J Pain Symptom Manage 2011; 41:1060-72. [PMID: 21402463 DOI: 10.1016/j.jpainsymman.2010.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 09/09/2010] [Accepted: 09/15/2010] [Indexed: 11/23/2022]
Abstract
CONTEXT In many countries, physicians are confronted with requests for euthanasia. Notwithstanding that euthanasia is legally permitted in Belgium, it remains the subject of intense debate. OBJECTIVES To gather in-depth empirical data on how general practitioners (GPs) deal with these requests in Belgium. METHODS Mortality follow-back study in 2005-2006 via the nationwide Sentinel Network of General Practitioners. Standardized face-to-face interviews were conducted with GPs for all the reported patients who did not die suddenly or totally unexpectedly at home, as judged by the GP. RESULTS We conducted 205 interviews. Of these, 27 patients had at some point expressed a wish to receive a drug administered by a physician with the explicit intention to end life, that is, euthanasia. Thirteen of these formulated their requests explicitly and repeatedly, according to their GP. Compared with patients who expressed a wish but not an explicit/repeated request for euthanasia, those patients' requests were more often documented (8 of 13 vs. 2 of 14; P=0.01), and reiterated until their final days of life (6 of 13 vs. 0 of 14; P=0.02). Five patients received euthanasia. For the other 22 patients, GPs gave different reasons for not acceding to the request, often related to criteria stipulated in the Belgian law on euthanasia, and sometimes related to personal reasons. CONCLUSION It is not uncommon for patients to ask their GP for euthanasia, although explicit requests remain relatively rare. Requests tend to vary widely in form and content, and far more are expressed than complied with. For many GPs, the Belgian law on euthanasia serves as a guiding principle in this decision-making process, although in a minority of the cases, a GP's personal opinion toward euthanasia seems to be decisive.
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Affiliation(s)
- Koen Meeussen
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.
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