Symptom clusters in advanced illness

Symptom trajectories during chemotherapy in patients with non-small cell lung cancer (NSCLC) and the function of prolonging low dose dexamethasone in promoting enhanced recovery after chemotherapy

Background

Lung cancer, mainly non‐small cell lung cancer (NSCLC), is one of the leading causes of death worldwide. Currently, chemotherapy is still the most significant treatment strategy for NSCLC. However, scant attention has been paid in previous studies to those patients who often experience various symptoms and discomfort during chemotherapy treatment cycles.

Methods

This study included 127 NSCLC patients who completed an EORTC QLQ‐C30 questionnaire and specifically designed symptom diary. Chi‐square test, factor analysis, Pearson correlation coefficient and hierarchical cluster analysis were used to perform multivariate analysis.

Results

We identified the top five most‐frequent symptoms within the chemotherapy cycle which included fatigue, insomnia, cough and sputum, appetite loss and hypodipsia. These symptoms were at a moderate level on chemotherapy treatment days 3–7, and were then reduced to a stable and lower level in the following two weeks. A statistically significant difference in adverse events (AEs) was found between 54 patients who received dexamethasone (treatment group) and the control group: fatigue (risk ratio [RR]: 1.48; 95% confidence interval [CI]: 1.120–1.961; p = 0.006), insomnia (RR: 1.34; 95% CI: 1.016–1.778; p = 0.038), cough and sputum (RR: 2.00; 95% CI: 1.484–2.695; p < 0.001), appetite loss (RR: 1.28; 95% CI: 0.959–1.696; p = 0.095). In total, 62 patients completed the EORTC QLQ‐C30 scale. The functioning scales of the treatment group were higher than the control population within positive effect sizes (ES: 0.1–0.8). Apart from diarrhea scales, most symptom scales were lower than the control group within negative effect sizes (ES: 0.1–0.9).

Conclusions

In this study we identified the top five most frequent post‐chemotherapy AEs in a chemotherapy treatment cycle and found that dexamethasone was well tolerated by NSCLC patients who received platinum‐based chemotherapy and substantially alleviated the symptom burden and improved the health‐related quality of life (HRQOL) of patients.

Predicting postoperative fatigue in surgically treated lung cancer patients in Norway: a longitudinal 5-month follow-up study

OBJECTIVES

Despite the negative influence of fatigue on quality of life in patients who undergo lung cancer surgery, little is known about the possible predictors of postoperative fatigue. The aim of this study was to examine demographic and clinical characteristics that might predict postoperative fatigue 5 months after lung cancer surgery.

DESIGN

A prospective longitudinal follow-up study comprising preoperative and postoperative questionnaires, including Lee Fatigue Scale, and sociodemographic and clinical data.

SETTING

Three university hospitals in Norway (eg, Oslo University Hospital, St. Olav University Hospital and Haukeland University Hospital).

PARTICIPANTS

In total, 196 surgically treated patients who answered the questionnaires both preoperatively and at 5-month follow-up with valid fatigue scores.

RESULTS

Bivariate analyses showed that preoperative fatigue was associated with comorbidities and the symptoms of shortness of breath, cough, depression, anxiety, sleep disturbance and pain. Only cough was directly associated with preoperative fatigue in a regression model. Comorbidities and the symptoms of shortness of breath, cough, depression and sleep disturbance were associated with postoperative fatigue in the bivariate analyses, but only shortness of breath was associated with postoperative fatigue in the regression model. We did not find any significant correlations between fatigue and any treatment variable.

CONCLUSION

Clinicians should pay special attention to lung symptoms and be aware that these may lead to long-term postoperative fatigue. Further research should examine whether interventions reducing lung symptoms, such as shortness of breath and coughing, may prevent development of fatigue in patients undergoing lung cancer surgery.

Pain, Opioid Intake, and Delirium Symptoms in Adults Following Joint Replacement Surgery

This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% (n = 36) of participants. Pain was significantly related (p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.

Cluster Analysis of Symptoms of Bangladeshi Women with Breast Cancer

Background:

Breast cancer (BC) patients may experience multiple symptoms due to the disease itself, cancer treatment or combination of both.

Aim:

The aim of the present study was to express multiple symptoms experienced by the patients with BC as clusters.

Methods:

This was a retrospective study. We examined symptom profiles of 120 patients with BC who attended the Centre for Palliative Care, Bangabandhu Sheikh Mujib Medical University in Dhaka, Bangladesh, from January 2009 to December 2013. We included all case sheets of BC patients, which had documentation of needed information. Following symptoms were analyzed: pain, nausea, loss of appetite, constipation, weakness, cough, breathlessness, sleeplessness, lymphedema, sadness, anxiety, and depression. Hierarchical cluster analysis was used to identify the natural groupings within the set.

Results:

We could identify three clusters, namely (1) “neuropsychiatric,” (2) “gastro-respiratory,” and (3) “miscellaneous” symptom clusters. The symptoms in cluster 2 comprised of cough, breathlessness, nausea, and constipation. Cluster 1 was characterized by pain, depression, anxiety, weakness, sleeplessness, and loss of appetite. Cluster 2 was comprised of cough, breathlessness, nausea, and constipation. Cluster 3 consisted of two symptoms lymphedema and sadness. The results revealed that the multiple symptoms of patients with BC experienced had been clustered together. Neuropsychiatric symptoms and weakness formed a significant strong relationship with each other.

Conclusion:

Knowledge obtained from this study could be beneficial for better understanding, assessment, and management of symptom clusters in women with BC. It may also help patients to plan ahead for them to seek management of concurrent symptoms to improve their quality of life.

Living with Severe Chronic Heart Failure in Palliative Advanced Home Care

BACKGROUND

Living with severe chronic heart failure (CHF) in palliative care has been little studied.

AIM

The aim of this study is to illuminate meaning of living with severe CHF in palliative advanced home care through patients' narratives.

METHODS

Narrative interviews were conducted with 4 patients, tape-recorded and transcribed verbatim. A phenomenological-hermeneutic method was used to interpret the text.

RESULTS

Meaning of living with severe CHF in palliative advanced home care emerged as 'knocking on death's door' although surviving. The course of the illness forces one to live a 'roller coaster life,' with an ongoing oscillation between ups and downs. Making it through the downs breeds a kind of confidence in one's ability to survive and the will to live is strong. Being offered a safety belt in the 'roller coaster' by the palliative advanced home care team evokes feelings of security.

CONCLUSIONS

Meaning of living with severe CHF in palliative advanced home care is on one hand, being aware of one's imminent death, on the other hand, making it through the downs i.e. surviving life-threatening conditions, breed confidence in also surviving the current down. Being constructively dependent on palliative advanced home care facilitates everyday life at home.

Examination of Broad Symptom Improvement Resulting From Mindfulness-Based Stress Reduction in Breast Cancer Survivors: A Randomized Controlled Trial

PURPOSE

The purpose of this randomized trial was to evaluate the efficacy of the Mindfulness-Based Stress Reduction for Breast Cancer (MBSR[BC]) program in improving psychological and physical symptoms and quality of life among breast cancer survivors (BCSs) who completed treatment. Outcomes were assessed immediately after 6 weeks of MBSR(BC) training and 6 weeks later to test efficacy over an extended timeframe.

PATIENTS AND METHODS

A total of 322 BCSs were randomly assigned to either a 6-week MBSR(BC) program (n = 155) or a usual care group (n = 167). Psychological (depression, anxiety, stress, and fear of recurrence) and physical symptoms (fatigue and pain) and quality of life (as related to health) were assessed at baseline and at 6 and 12 weeks. Linear mixed models were used to assess MBSR(BC) effects over time, and participant characteristics at baseline were also tested as moderators of MBSR(BC) effects.

RESULTS

Results demonstrated extended improvement for the MBSR(BC) group compared with usual care in both psychological symptoms of anxiety, fear of recurrence overall, and fear of recurrence problems and physical symptoms of fatigue severity and fatigue interference (P < .01). Overall effect sizes were largest for fear of recurrence problems (d = 0.35) and fatigue severity (d = 0.27). Moderation effects showed BCSs with the highest levels of stress at baseline experienced the greatest benefit from MBSR(BC).

CONCLUSION

The MBSR(BC) program significantly improved a broad range of symptoms among BCSs up to 6 weeks after MBSR(BC) training, with generally small to moderate overall effect sizes.

Pilot Study of Massage to Improve Sleep and Fatigue in Hospitalized Adolescents With Cancer

BACKGROUND

Adolescents with cancer experience many troubling symptoms, including sleep disruptions that can affect mood and quality of life. Massage is a safe and popular intervention that has demonstrated efficacy in pediatric and adult patients with cancer. This study aimed to assess the feasibility of conducting a massage intervention to help with sleep in hospitalized adolescent oncology patients.

PROCEDURE

Adolescents ages 12-21 with cancer who were expected to be hospitalized for at least four consecutive nights were recruited from the inpatient unit at Children's National Health System and randomized to either massage intervention or a waitlist control. Patients in the intervention group received one massage per night, for two or three nights. Sleep was measured with actigraphy and patient and proxy reported instruments were used to measure fatigue, mood, and anxiety.

RESULTS

The majority (78%) of patients approached for the study consented, and almost all patients in the intervention group (94%) received at least one massage, 69% received two, and rates of completion of instruments among adolescents were high demonstrating feasibility. There were trends toward increased night time and overall sleep in the intervention group compared with standard of care, but no differences between groups in the patient reported outcome measures. Participant and parent feedback on the intervention was positive and was the impetus for starting a clinical massage service at the hospital.

CONCLUSIONS

Massage for hospitalized adolescents with cancer is feasible, well received, and can potentially improve patients' sleep. A randomized multicenter efficacy study is warranted.

Should we cluster patients or symptoms? The myth of symptom clusters based on 'depression, insomnia, pain' and 'depression, fatigue, pain'

CONTEXT

'Depression, fatigue, pain' (DFP) and 'depression, insomnia, pain' (DIP) symptom clusters (SCs) have been proposed in cancer. These symptoms are common and co-occur, that is, they constitute clusters of patients rather than symptoms.

OBJECTIVES

The following research questions were addressed: (1) What is the frequency of co-occurrence of two symptom groups (DFP and DIP) in advanced cancer? (2) What is the degree of symptom item association within each symptom group? (3) Were either of these symptom trios associated with prognosis?

METHODS

We reanalysed a symptom data set of 1000 patients with advanced cancer. We identified the frequency of co-occurrence of two symptom groups: DFP and DIP, using both prevalence and severity data. The symptom associations were tested by χ(2) and Spearman correlations. We also determined whether either of these symptom trios were associated with a major biological outcome, that is, survival by time-to-event analyses.

RESULTS

(1) Although DFP and DIP co-occured in about a quarter of the population, they were not SCs, but rather patient clusters. (2) Many persons had only one symptom from any symptom pair, and correlation coefficients were low for all symptom pairs. (3) Neither DFP nor DIP were associated with survival.

CONCLUSIONS

Neither DFP nor DIP symptom item combinations constituted a specific cancer SC contrary to prior reports. DFP co-occurred in 27% and DIP in only 20%. Additionally, these symptom combinations were not associated with a biological outcome, that is, poor prognosis. Patient subgroups identified by shared symptom experiences alone do not identify SCs.

Palliative Care Consultation Trajectories

Background:

Palliative care consultations teams (PCCTs) promote comprehensive health but only if the PCCT can influence actual care. The purpose of this study is to document the types of recommendations made by a PCCT, determine the rates at which recommendations are implemented, and identify the factors related to implementation.

Results:

The mean number of recommendations per patient was 1.44 (standard deviation = 1.81), and 57% of the recommendations were implemented. Discharge and goals of care recommendations were significantly more likely to be implemented than recommendations for pain, symptom management, and consultation of other services.

Conclusions:

Although PCCTs may have suggestions about how to guide care, many of those recommendations are not implemented. Future research is needed to understand how to maximize the impact of PCCTs.

Supportive care in lung cancer: clinical update

OBJECTIVES

To present a clinical update regarding common distressing lung cancer symptoms and provide an update on management interventions.

DATA SOURCES

Journal articles, systematic reviews.

CONCLUSION

Goals of treatment of the patient with lung cancer must include management of the high symptom burden that often accompanies the disease.

IMPLICATIONS FOR NURSING PRACTICE

Early assessment and management of symptoms improves quality of life. Nurses play a key role in implementing and monitoring these interventions.

Subgroups of advanced cancer patients clustered by their symptom profiles: quality-of-life outcomes

BACKGROUND

Symptom cluster analysis is a new frontier of research in symptom management. This study clustered patients by their symptom profiles to identify subgroups that may be at higher risk for poor quality of life (QOL) and that may, therefore, benefit most from targeted interventions.

METHODS

Longitudinal study of metastatic cancer patients using the Edmonton Symptom Assessment Scale (ESAS). We generated two-, three-, and four-cluster subgroups and examined the relationship of cluster membership with patient outcomes. To address the problem of missing longitudinal data, we developed a novel outcome variable (QualTime) that measures both QOL and time in study.

RESULTS

Two hundred and twenty-one patients with a mean Palliative Performance Scale (PPS) of 59.1 were enrolled. The three-cluster model was chosen for further analysis. The low-burden subgroup had all low severity symptom scores. The intermediate subgroup separates from the low-burden group on the "debility" profile of fatigue, drowsiness, appetite, and well-being. The high-burden group separates from the intermediate-burden group on pain, depression, and anxiety. At baseline, PPS (p=0.0003) and cluster membership (p<0.0001) contributed significantly to global QOL. In univariate analysis, cluster membership was related to the longitudinal outcome, QualTime. In a multivariate model, the relationship of PPS to QualTime was still significant (p=0.0002), but subgroup membership was no longer significant (p=0.1009).

CONCLUSION

PPS is a stronger predictor of the longitudinal variable than cluster subgroups; however, cluster subgroups provide a target for clinical interventions that may improve QOL.

Assessment and management of gastrointestinal symptoms in advanced illness

Primary care clinicians increasingly encounter patients with advanced illness, many suffering from symptoms other than pain. Key principles that guide palliative care must be incorporated into a plan of care for each patient and family. Although medical management continues to be the mainstay of treatment, the generalist in palliative care needs to be familiar with the patient's preferences and goals of care. This article provides an overview of gastrointestinal symptoms including anorexia, cachexia, nausea, vomiting, and constipation. Advanced progressive illnesses are defined here as incurable conditions that have significant morbidity in the later stages of illness.

Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms and symptom clusters

To investigate prevalence and severity of symptoms and symptom clustering in breast cancer survivors who attended MBSR(BC). Women were randomly assigned into MBSR(BC) or Usual Care (UC). Eligible women were ≥ 21 years, had been diagnosed with breast cancer and completed treatment within 18 months of enrollment. Symptoms and interference with daily living were measured pre- and post-MBSR(BC) using the M.D. Anderson Symptom Inventory. Symptoms were reported as highly prevalent but severity was low. Fatigue was the most frequently reported and severe symptom among groups. Symptoms clustered into 3 groups and improved in both groups. At baseline, both MBSR(BC) and the control groups showed similar mean symptom severity and interference; however, after the 6-week post-intervention, the MBSR(BC) group showed statistically-significant reduction for fatigue and disturbed sleep (P < 0.01) and improved symptom interference items, compared to the control group. For the between-group comparisons, 11 of 13 symptoms and 5 of 6 interference items had lower means in the MBSR(BC) condition than the control condition. These results suggest that MBSR(BC) modestly decreases fatigue and sleep disturbances, but has a greater effect on the degree to which symptoms interfere with many facets of life. Although these results are preliminary, MBSR intervention post-treatment may effectively reduce fatigue and related interference in QOL of breast cancer survivors.

Advanced cancer: a mind-body-spirit approach to life and living

OBJECTIVES

To present the nursing theory of Modeling and Role Modeling as a holistic theoretical basis for identifying needs, planning and implementing care and services, and measuring and enhancing outcomes of programs and interventions to meet the needs of people living with advanced cancer.

DATA SOURCES

Published books and journal articles, web resources, newspapers and current events magazines, and trade publications.

CONCLUSION

The growing number of people living with advanced cancer has numerous unique, multi-dimensional, and interrelated needs that are underexplored, generally unmet, and require a holistic approach to be adequately addressed.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses in clinical practice and research settings must be informed, aware of and prepared to assess and intervene to address the needs of the rapidly emerging subpopulation of cancer survivors. Using a holistic nursing theory promotes our understanding of human responses to illness and provides a way to holistically approach health, wellness, and healing among people living with advanced cancer.

Symptom clusters: myth or reality?

Clinical experience suggests that many symptoms occur together. In this paper, we examine the rationale and evidence base for symptom clusters in different medical fields, particularly the cluster phenomenon in cancer. Cancer symptom clusters are a reality. Various symptoms that cluster clinically have also been verified statistically. Specific clusters such as nausea-vomiting, anxiety-depression, and cough-dyspnea are evident on both clinical observation and in research investigation. Fatigue-pain and fatigue-insomnia-pain have also been demonstrated statistically as clusters. Another proposed cluster 'depression-fatigue-pain' seems relevant to clinical practice. Other clusters may serve only as theoretical models that illustrate possible common biological etiologies in cancer; they need to be validated in future research. Analysis of the literature is complicated by considerable inconsistencies across studies. Discrepancies between clinically defined and statistically obtained clusters raise important questions. We must consider the analytical techniques used, and how methodology might influence cluster occurrence and composition. Further research is warranted to establish universally accepted statistical methods and assessment tools for symptom cluster research.

Significance of symptom clustering in palliative care of advanced cancer patients

Patients with advanced cancer often experience multiple concurrent symptoms. To explore this symptom clustering and its associated parameters, we prospectively surveyed 427 consecutive patients on admission to the Palliative Care Unit. There were 222 males (52.0%) and 205 females (48.0%), with a median age of 66 years (range: 27-93 years). The main tumor sites were lung (19.9%), liver (18.0%), and colorectum (11.0%). The median survival was 13 days (1-418 days). Symptoms were assessed using a face-valid Symptom Reporting Form. We identified five symptom clusters by exploratory factor analysis. Clusters were named "loss of energy," "poor intake," "autonomic dysfunction," "aerodigestive impairment," and "pain complex." We used nonhierarchical cluster analysis to divide the 394 patients with complete data into six groups. Each group was characterized by a particular pattern that was composed of different symptom clusters. Survival, functional performance, bone metastasis, and fluid accumulation were significantly associated with symptom clustering in six groups of patients. The severity of psychological distress also related to their physical deterioration. These data suggest that different underlying mechanisms associate with symptom clustering. Further elucidation of these processes may assist in symptom management.

Cancer Symptom Clusters: Old Concept But New Data

Individuals with cancer have multiple symptoms, which frequently co-occur. A nonrandom distribution of symptoms suggests a common mechanism. Symptom clusters (SCs) were considered part of various syndromes in the early years of medicine. The SC concept in clinical medicine is old. Symptom clusters were commonly described in the psychology/psychiatry and neurology literature. Symptom cluster may be defined either clinically or statistically. Statistically derived clusters can differ from clinically defined clusters. The clinical importance of statistically derived clusters is unclear. Pain-insomnia-fatigue and pain-depression-fatigue are commonly recognized clinical clusters. Nausea-vomiting and anxiety-depression are also statistically observed clusters. The longitudinal stability of clusters is unknown. Certain SCs, appear to have a greater adverse influence on outcomes (such as performance status and survival) than others. Comorbidities probably influence symptoms at different levels, but their effect on cancer clusters is unknown. Comprehensive symptom assessment is crucial to cluster identification. The potential use of the cluster concept to abbreviate symptom assessment tools needs validation. Symptom cluster can be disease and/or treatment related and may change as individuals undergo antitumor therapies. Polypharmacy in symptom management is frequent but could be minimized if 1 drug could be used to treat cluster symptoms. Symptom cluster appears to vary with the assessment tool, disease stage, symptom domain used to cluster, cluster methodology, and number of symptoms assessed. The validity and reliability of SCs need universally accepted statistical methods, assessment tools, and symptom domains. For now, nausea-vomiting is recognized as a consistent cluster across multiple studies. Pain-depression-fatigue and pain-insomnia-fatigue are also well recognized. Symptom clusters may help in cancer diagnosis, symptom management, and prognostication. However, the cluster method, reliability, and validity need to be established before assessment or treatment guidelines are established. Symptom clusters require further research before becoming part of routine medical symptom assessment and management.

Multivariate methods to identify cancer-related symptom clusters

Multivariate methods are required to assess the interrelationships among multiple, concurrent symptoms. We examined the conceptual and contextual appropriateness of commonly used multivariate methods for cancer symptom cluster identification. From 178 publications identified in an online database search of Medline, CINAHL, and PsycINFO, limited to articles published in English, 10 years prior to March 2007, 13 cross-sectional studies met the inclusion criteria. Conceptually, common factor analysis (FA) and hierarchical cluster analysis (HCA) are appropriate for symptom cluster identification, not principal component analysis. As a basis for new directions in symptom management, FA methods are more appropriate than HCA. Principal axis factoring or maximum likelihood factoring, the scree plot, oblique rotation, and clinical interpretation are recommended approaches to symptom cluster identification.

Aging and delirium: too much or too little pain medication?

Review of the literature revealed an association of pain and delirium in hip fracture patients. The literature was sparse addressing other types of patients. The purpose of the present study was therefore to examine the association of pain and delirium in medical and surgical patients. A retrospective record review was conducted using records of 100 patients who developed delirium while hospitalized. Data included: age, comorbidities, hospital day when delirium developed, presence of major risk factors for delirium on admission, and amount of medication received in the 24 h before onset of delirium. Descriptive statistics, correlations, and univariate analysis of variance were used to determine association between the variables. The mean age was 76.71 years. The mean number of comorbidities was 2.22. The mean number of risk factors for delirium on admission was 2.26 (range 0 to 5). The mean percentage of total amount of medication ordered that was received was 27.67%. Those individuals admitted with a risk factor of hearing loss received significantly less amount of pain medication than those with other risk factors (p = .023). Nurses should carefully assess pain management in their older patients. If using a PCA pump, the older patient's ability to manage the pump should be reassessed often. If a patient is admitted with risk factors for development of delirium, unmanaged pain might be the additional factor that precipitates delirium.

Symptom clusters and relationships to symptom interference with daily life in Taiwanese lung cancer patients

The number one cause of cancer death in Taiwan is lung cancer. Of the few studies describing the experience of patients living with lung cancer, most use bivariate analyses to test associations between individual symptoms. Few have systematically investigated multiple symptoms. This prospective study was undertaken to explore the phenomenon of symptom distress, to investigate the presence of symptom clusters, and to examine the relationship of symptom clusters to symptom interference with daily life in Taiwanese lung cancer patients. A sample of 108 lung cancer patients was recruited using the Taiwanese version of the M. D. Anderson Symptom Inventory. Data were analyzed by hierarchical cluster analysis, factor analysis, Pearson correlation, t-test, and regression analysis. The top five most-severe symptoms were fatigue, sleep disturbance, lack of appetite, shortness of breath, and general distress. Factor analysis generated a two-factor solution (general and gastrointestinal symptoms) for symptom severity items. Consistent with the result from factor analysis, cluster analysis also indicated the same two cluster groups (general and gastrointestinal symptoms). Both clusters were significantly correlated with symptom interference items; however, the general symptom cluster presented higher correlation coefficients than did the gastrointestinal symptom cluster. These results provide an important basis for developing novel strategies to manage multiple symptoms in lung cancer patients and thereby improve their well-being.

Conceptual issues in symptom clusters research and their implications for quality-of-life assessment in patients with cancer

The majority of the research on the various aspects of symptom management has focused on individual symptoms. However, patients with cancer often experience multiple symptoms simultaneously as a result of their disease and treatment. In 2001, symptom management researchers began to study the impact of symptom clusters on patient outcomes. Over the past 6 years, a number of conceptual reviews as well as several research studies have been published on symptom clusters in oncology patients. This paper summarizes the conceptual basis for symptom cluster research, describes two conceptual approaches to symptom cluster research, and discusses the implications of symptom clusters for quality-of-life research. The paper concludes with an enumeration of the critical considerations that need to be addressed if this area of scientific inquiry is to move forward.

Clinical Dilemma: Dyspnea

OBJECTIVES

To review the current state of evidence for the nursing treatment of cancer-related dyspnea.

DATA SOURCES

Nursing and medical literature, published guidelines, and Cochrane Systematic reviews.

CONCLUSION

Limited evidence exists for the current strategies used to treat dyspnea among persons with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be cognizant of the level of evidence or the lack of scientific evidence supporting treatment strategies used. Keeping abreast of the developments in the area of dyspnea management is imperative as research adds to the current body of evidence. Nurses are uniquely positioned to add to the body of evidence through collaboration with nurse researchers.

Is there a biological basis for the clustering of symptoms?

OBJECTIVES

To examine symptom clusters in oncology patients; to determine if these symptom clusters might share a common biologic mechanism; and to describe potential biologic mechanisms that warrant investigation.

DATA SOURCES

Synthesis of the theoretical and research papers on symptom clusters.

CONCLUSION

Definitive conclusions about whether there is a biologic basis for the clustering of symptoms cannot be determined at this time. The animal model of sickness behavior holds promise as a potential biologic mechanism for clustering symptoms.

IMPLICATIONS FOR NURSING PRACTICE

Until more definitive studies of symptom clusters are performed, clinicians need to monitor patients for the co-occurrence of multiple symptoms and develop appropriate management plans.

Clinical Management of Symptom Clusters

OBJECTIVES

To discuss the current evidence for the management of symptoms in clusters and future directions in symptom cluster management research.

DATA SOURCES

Research and review articles.

CONCLUSION

Currently no research has been reported on management of formally identified symptom clusters in oncology. Several researchers have described psychoeducational and exercise interventions that have decreased multiple concurrent symptoms. Understanding common biological mechanisms that underlie symptom clusters, such as inflammatory pathways, may suggest more effective treatments for symptom clusters.

IMPLICATIONS FOR NURSING PRACTICE

Clinicians and researchers need to collaborate to better understand symptom clusters and develop effective interventions.