Quality-of-life assessment during a palliative care programme

Correlation Between Cancer Pain and Quality of Life in Patients With Advanced Cancer Admitted to a Palliative Care Unit

INTRODUCTION

Cancer pain is one of the most prevalent manageable symptoms in patients with advanced cancer, and it has a negative impact on quality of life (QoL).

OBJECTIVE

The aim of this study is to examine the correlation between cancer pain and QoL in patients with advanced cancer who are hospitalized in a palliative care unit.

METHODS

This study is a cross-sectional analysis of patients with advanced cancer who were hospitalized with cancer pain at a specialized palliative care unit between June 2021 and February 2022. Pain intensity and its impact on daily activities were assessed using the Brief Pain Inventory (BPI), while the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 15 PAL (QLQ-C15-PAL) was used to evaluate QoL.

RESULTS

A total of 104 patients with cancer pain were included, with a mean age of 53.6 years (±14.1). Most of the patients were female (65.38%), and the most common primary tumor site was in the gastrointestinal tract (22.11%). The most frequently reported site of cancer pain was the abdomen (32.69%). The mean duration of cancer pain was 52.3 days (±6.2). The domains of QoL most strongly correlated with cancer pain were weakness (coefficient = .52, P < .001), nausea (coefficient = .36, P < .001), and the physical domain (coefficient = -.30, P < .001).

CONCLUSION

Cancer pain is strongly correlated with a deterioration in QoL in patients with advanced cancer, and its management should be pursued as a strategy for optimizing QoL.

Symptoms of advanced cancer in palliative medicine: a longitudinal study

OBJECTIVES

This study aimed to examine the symptomatology of patients with advanced cancer at admittance to palliative care services and to investigate how the symptomatology changed during the first month, and whether these changes were associated with various patient characteristics.

METHODS

In a longitudinal study in Chile, outpatients with advanced cancer completed the questionnaires European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care and the Hospital Anxiety and Depression Scale. Prevalence and severity of symptoms and problems (S/Ps) at baseline were calculated. Differences in S/P scores from baseline to follow-up were calculated overall and according to patient characteristics. Multiple linear regression was used to study the associations between patient characteristics and changes in S/P scores.

RESULTS

At baseline, 201 patients answered the questionnaires and 177 completed the follow-up. Fatigue, pain and sleeping difficulties were the most prevalent S/Ps reported, and also had the highest mean scores at baseline. S/P scores at baseline varied significantly according to sex, age, civil status, residence, children, prior and current antineoplastic treatment. Emotional functioning, pain, sleeping difficulties, constipation and anxiety improved significantly during the first month of palliative care. Residence, cohabitation status, diagnosis and current antineoplastic treatment were associated with changes in S/P scores.

CONCLUSIONS

Patients reported moderate-to-severe levels of S/Ps at admittance to palliative care. Several S/Ps improved the first month. Certain patient characteristics were associated with changes in S/P scores. This information may guide clinicians to more effective interventions that can improve the quality of life of patients receiving palliative care.

Cancer-related Fatigue in Lung Cancer: A Research Agenda: An Official American Thoracic Society Research Statement

Background: Fatigue is the most common symptom among cancer survivors. Cancer-related fatigue (CRF) may occur at any point in the cancer care continuum. Multiple factors contribute to CRF development and severity, including cancer type, treatments, presence of other symptoms, comorbidities, and medication side effects. Clinically, increasing physical activity, enhancing sleep quality, and recognizing sleep disorders are integral to managing CRF. Unfortunately, CRF is infrequently recognized, evaluated, or treated in lung cancer survivors despite more frequent and severe symptoms than in other cancers. Therefore, increased awareness and understanding of CRF are needed to improve health-related quality of life in lung cancer survivors. Objectives: 1) To identify and prioritize knowledge and research gaps and 2) to develop and prioritize research questions to evaluate mechanistic, diagnostic, and therapeutic approaches to CRF among lung cancer survivors. Methods: We convened a multidisciplinary panel to review the available literature on CRF, focusing on the impacts of physical activity, rehabilitation, and sleep disturbances in lung cancer. We used a three-round modified Delphi process to prioritize research questions. Results: This statement identifies knowledge gaps in the 1) detection and diagnostic evaluation of CRF in lung cancer survivors; 2) timing, goals, and implementation of physical activity and rehabilitation; and 3) evaluation and treatment of sleep disturbances and disorders to reduce CRF. Finally, we present the panel's initial 32 research questions and seven final prioritized questions. Conclusions: This statement offers a prioritized research agenda to 1) advance clinical and research efforts and 2) increase awareness of CRF in lung cancer survivors.

Nausea at the start of specialized palliative care and change in nausea after the first weeks of palliative care were associated with cancer site, gender, and type of palliative care service-a nationwide study

PURPOSE

Nausea is a common and distressful symptom among patients in palliative care, but little is known about possible socio-demographic and clinical patient characteristics associated with nausea at the start of palliative care and change after initiation of palliative care. The aim of this study was to investigate whether patient characteristics were associated with nausea at the start of palliative care and with change in nausea during the first weeks of palliative care, respectively.

METHODS

Data was obtained from the nationwide Danish Palliative Care Database. The study included adult cancer patients who were admitted to palliative care and died between June 2016 and December 2020 and reported nausea level at the start of palliative care and possibly 1-4 weeks later. The associations between patient characteristics and nausea at the start of palliative care and change in nausea during palliative care, respectively, were studied using multiple regression analyses.

RESULTS

Nausea level was reported at the start of palliative care by 23,751 patients of whom 8037 also reported 1-4 weeks later. Higher nausea levels were found for women, patients with stomach or ovarian cancer, and inpatients at the start of palliative care. In multivariate analyses, cancer site was the variable most strongly associated with nausea change; the smallest nausea reductions were seen for myelomatosis and no reduction was seen for stomach cancer.

CONCLUSION

This study identified subgroups with the highest initial nausea level and those with the least nausea reduction after 1-4 weeks of palliative care. These latter findings should be considered in the initial treatment plan.

Systematic Review of the Prevalence, Predictors, and Treatment of Insomnia in Palliative Care

Introduction:

The primary function of palliative care is to improve quality of life. The recognition and treatment of symptoms causing suffering is central to the achievement of this goal. Insomnia reduces quality of life of patients under palliative care. Knowledge about prevalence, associated factors, and treatment of insomnia in palliative care is scarce.

Methodology:

Literature review about the prevalence, predictors, and treatment options of insomnia in palliative care patients. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in identified articles and selected reviews. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

Results:

A total of 65 studies were included in the review. Most studies had acceptable /good quality. The prevalence of insomnia in the included studies ranged from 2.1% to 100%, with a median overall prevalence of 49.5%. Sociodemographic factors such as age; clinical characteristics such as functional status, disease stage, pain, and use of specific drugs, including opioids; psychological factors such as anxiety/depression; and spiritual factors such as feelings of well-being were identified as predictors. The treatment options identified were biological (pharmacological and nonpharmacological), psychological (visualization, relaxation), and spiritual (prayer).

Conclusions:

The systematic review showed that the prevalence of insomnia is high, with at least one in 3 patients affected in most studies. Insomnia’s risk factors and treatment in palliative care are both associated to physical, psychological, social, and spiritual factors, reflecting its true holistic nature.

Is there a Relationship between Psychological Well-Being and Patient-Carers Consensus? A Clinical Pilot Study

Does communication with terminal cancer patients about their disease influence their psychological well-being? The degree of patient-carer consensus about the disease was compared to psychological well-being related to acceptance of the disease, emotional state, and hope. These were evaluated and scored from 6 (good) to 0 (poor) through a semi-structured interview of 10 open-ended questions. Nineteen palliative care patients were studied, 18 of whom were suffering from advanced cancer. Overall, 57 interviews were conducted with the patients, staff nurses, and medical doctors. The answers of the carers (staff nurses and doctors) were compared to the patients’ answers to determine the degree of consensus in terms of communication about disease, aim of treatment, and ultimate objective of hospitalization. The consensus between patients and carers was scored from 6 (satisfactory) to 0 (unsatisfactory). A significant positive correlation between the scores of consensus and those of psychological well-being ( r=0.90, p<0.001) was found. These results suggest that good and truthful communication may improve patients’ psychological well-being.

Descriptive Epidemiology of Sweating in a Hospice Population

Sweating can be a distressing and difficult problem to manage in patients with advanced cancer. Despite this, few published data exist on the frequency, nature, and severity of sweating in cancer patients. This prospective survey describes the epidemiology of sweating in patients with advanced cancer on admission to a London hospice. 153 consecutive admissions were assessed. Of these, 100 were suitable for inclusion into the study. A general symptom enquiry was performed on all patients. Age, sex, primary diagnoses, extent of disease, relevant secondary diagnoses, and concurrent medication were also recorded. 16 patients volunteered sweating as a problem. For 12 of these 16 patients, sweating had been severe (drenching sweats requiring change of clothing or bedlinen or both) in nature. This survey highlights sweating as a significant problem in this group of patients.

Integrating Oncology and Palliative Home Care in Italy: The Experience of the “L'Aquila per la Vita” Home Care Unit

Aim

To evaluate the efficacy of a home care program, closely integrated with a medical oncology department.

Patients and methods

The charts, prospectively recorded, of all the patients treated at home by the “L'Aquila per la Vita” Home Care Unit from August 2006 to December 2011, were reviewed. The number of patients, home accesses, length of the home care, hospital admission, emergency calls, and the place of death were recorded. Data were analyzed considering the origin of the patients (medical oncology department or other).

Results

A total of 461 patients was followed at home for a total of 10,503 home accesses (median accesses/patient, 20; range, 1–159). The median length of home care was 76 days (range, 2–643 days). The median was 101 days for patients coming from the medical oncology department and 53 days for patients coming from other origins ( P <0.0005). There were 428 emergency calls (4.1% of all the home accesses). Emergency calls accounted for 253 of 7,364 home accesses (3.4%) among patients coming from the medical oncology department and for 175 of 3,139 home accesses (5.6%) among patients coming from other origins ( P = 0.00005). Eighty of 461 patients (17.3%) required one in-hospital admission and 19/461 patients (4.1%) more than one. Fifty-nine of 259 (17.8%) patients coming from the medical oncology department and 40 of 186 (26.9%) coming from other origins required in-hospital admissions ( P = 0.04). A total of 311 patients died (163 coming from the medical oncology department and 148 from other origins). Twenty-eight of 163 (17.1%) coming from the medical oncology department and 52 of 148 (35.1%) coming from other origins died in the hospital ( P = 0.0002).

Conclusions

A multidisciplinary and expert team, closely integrated with the hospital, can guarantee a long length of home care, avoiding hospitalization and closing the gap between the patients' preferences and the services offered regarding the place of death.

Cancer-Related Fatigue in Cancer Survivorship

Cancer-related fatigue (CRF) significantly interferes with usual functioning because of the distressing sense of physical, emotional, and cognitive exhaustion. Assessment of CRF is important and should be performed during the initial cancer diagnosis, throughout cancer treatment, and after treatment using a fatigue scoring scale (mild-severe). The general approach to CRF management applies to cancer survivors at all fatigue levels and includes education, counseling, and other strategies. Nonpharmacologic interventions include psychosocial interventions, exercise, yoga, physically based therapy, dietary management, and sleep therapy. Pharmacologic interventions include psychostimulants. Antidepressants may also benefit when CRF is accompanied by depression.

Cancer-Related Fatigue, Version 2.2015

Cancer-related fatigue is defined as a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. It is one of the most common side effects in patients with cancer. Fatigue has been shown to be a consequence of active treatment, but it may also persist into posttreatment periods. Furthermore, difficulties in end-of-life care can be compounded by fatigue. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer-Related Fatigue provide guidance on screening for fatigue and recommendations for interventions based on the stage of treatment. Interventions may include education and counseling, general strategies for the management of fatigue, and specific nonpharmacologic and pharmacologic interventions. Fatigue is a frequently underreported complication in patients with cancer and, when reported, is responsible for reduced quality of life. Therefore, routine screening to identify fatigue is an important component in improving the quality of life for patients living with cancer.

Cancer related fatigue: A ubiquitous problem yet so under reported, under recognized and under treated

Background:

Cancer related fatigue (CRF) is a problem that is highly under reported, under recognized and thus, under treated. About 80% of patients receiving chemotherapy/radiotherapy experience CRF, making it the most common side effect of cancer treatment. Functional assessment of chronic illness therapy fatigue (FACIT-F) version-4 is a 13 item questionnaire that has been used to measure the level of fatigue of cancer patients during their daily activities over the past 7 days.

Materials and Methods:

92 patients of age 18 years and above attending the oncology Out Patient Department (OPD) of a regional cancer center were recruited in this study and were given FACIT-F questionnaire. The relevant sociodemographic parameters were obtained from the medical records of the patients. The internal consistency of the 13 items was measured using the Cronbach's alpha.

Results:

The Cronbach alpha coefficient for FACIT-F scale in our study was found to be 0.74. Kendall's coefficient of concordance was estimated to be 0.080. The correlation between Eastern Cooperative Oncology Group (ECOG) performance status and mean score of FACIT-F was studied, Pearson correlation coefficient was estimated to be 0.271 (P = 0.009).

Conclusions:

FACIT-F is a brief, simple, easy to administer and patient friendly tool to measure the fatigue in last 7 days. CRF should be given adequate attention from the beginning of the treatment to improve the quality of life of cancer patients.

Determination of morphine, codeine, and paclitaxel in human serum and plasma by micellar electrokinetic chromatography

A micellar electrokinetic chromatography method is proposed for the determination of morphine, codeine, and paclitaxel at clinical relevant levels in human serum and plasma, which are employed in the treatment of patients with cancer. Optimal conditions for the separation were investigated. A background electrolyte solutions consisting of 20 mM borate buffer adjusted to pH 8.5, sodium dodecyl sulphate 60 mM and 15% methanol, hydrodynamic injection, and 25 kV as separation voltage were used. Detection wavelength was 212 nm for morphine and codeine and 200 nm for paclitaxel. Aspects such as stability of the solutions, linearity, accuracy, precision, and robust and ruggedness were examined in order to validate the proposed method. Detection limits obtained for all the studied compounds ranged between 26 and 52 ng/mL. Before micellar electrokinetic chromatography determination, the samples were purified and enriched by means of an extraction-preconcentration step with a preconditioned C(18) cartridge. This method was applied to the analysis of serum and plasma samples from different cancer patients undergoing treatment with paclitaxel or/and codeine.

Treating nausea and vomiting in palliative care: a review

Nausea and vomiting are portrayed in the specialist palliative care literature as common and distressing symptoms affecting the majority of patients with advanced cancer and other life-limiting illnesses. However, recent surveys indicate that these symptoms may be less common and bothersome than has previously been reported. The standard palliative care approach to the assessment and treatment of nausea and vomiting is based on determining the cause and then relating this back to the "emetic pathway" before prescribing drugs such as dopamine antagonists, antihistamines, and anticholinergic agents which block neurotransmitters at different sites along the pathway. However, the evidence base for the effectiveness of this approach is meager, and may be in part because relevance of the neuropharmacology of the emetic pathway to palliative care patients is limited. Many palliative care patients are over the age of 65 years, making these agents difficult to use. Greater awareness of drug interactions and QT(c) prolongation are emerging concerns for all age groups. The selective serotonin receptor antagonists are the safest antiemetics, but are not used first-line in many countries because there is very little scientific rationale or clinical evidence to support their use outside the licensed indications. Cannabinoids may have an increasing role. Advances in interventional gastroenterology are increasing the options for nonpharmacological management. Despite these emerging issues, the approach to nausea and vomiting developed within palliative medicine over the past 40 years remains relevant. It advocates careful clinical evaluation of the symptom and the person suffering it, and an understanding of the clinical pharmacology of medicines that are available for palliating them.

Time course and characteristics of symptom distress and quality of life at the end of life

This study sought to describe the characteristics and correlates of symptom distress and quality of life (QOL) among persons receiving hospice/palliative care. English-speaking adults (n=86), their nurses (n=86), and family caregivers (n=49) from 11 hospice/palliative care organizations completed the Memorial Symptom Assessment Scale (MSAS) and McGill Quality of Life Questionnaire (MQOL) at hospice/palliative care enrollment, at one week, two weeks, then monthly until death or discharge. Mixed effects modeling using proxy reports to impute missing patient-reported data were used to describe predictors of symptom distress and QOL. Given study population attrition due to death, analyses are limited to the first 17 days following hospice/palliative care admission. While lack of energy and pain were the most prevalent and distressing symptoms (prevalence 92% and 82%, respectively; mean MSAS scores 3.27 and 2.71, respectively), pain was identified as the most distressing symptom based on its contribution to MSAS summary scores and responses to a single-item "most distressing symptom" question. Pain, nonpain symptom distress, and MQOL scores remained fairly stable throughout the study period. Distress from all other physical symptoms was significantly associated with distress due to pain. There were no significant associations between patient characteristics and distress due to pain. While greater psychological symptom distress had a negative association with QOL, neither pain nor other physical symptom distress was associated with QOL. The persistence of significant symptom distress, particularly due to pain, argues for the need for enhanced evidence to guide care provided in the last days and weeks of life.

A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease

Little attention has been paid to the symptom management needs of patients with life-threatening diseases other than cancer. In this study, we aimed to determine to what extent patients with progressive chronic diseases have similar symptom profiles. A systematic search of medical databases (MEDLINE, EMBASE, and PsycINFO) and textbooks identified 64 original studies reporting the prevalence of 11 common symptoms among end-stage patients with cancer, acquired immunodeficiency syndrome (AIDS), heart disease, chronic obstructive pulmonary disease, or renal disease. Analyzing the data in a comparative table (a grid), we found that the prevalence of the 11 symptoms was often widely but homogeneously spread across the five diseases. Three symptoms-pain, breathlessness, and fatigue-were found among more than 50% of patients, for all five diseases. There appears to be a common pathway toward death for malignant and nonmalignant diseases. The designs of symptom prevalence studies need to be improved because of methodological disparities in symptom assessment and designs.

The Needs Assessment for Advanced Cancer Patients (NA-ACP): a measure of the perceived needs of patients with advanced, incurable cancer. a study of validity, reliability and acceptability

AIMS

To describe the psychometric evaluation of a measure designed to assess the perceived needs of patients with advanced, incurable cancer.

METHOD

A questionnaire known as the Needs Assessment for Advanced Cancer Patients (NA-ACP) was developed based on a review of available literature and professional opinion. A sample of 246 patients (consent rate = 59%) completed the NA-ACP, 28 patients completed the acceptability questions, while 41 completed a retest copy of the NA-ACP. The construct validity of the questionnaire was examined via principal components analysis, while reliability was evaluated in terms of the internal consistency of domains and test-retest scores.

RESULTS

The principal components analysis revealed seven domains assessing patients' psychological/emotional, medical information/communication, social, symptom, daily living, spiritual and financial needs. The test-retest reliability estimates were within accepted levels, as were all but one of the internal consistency scores. The NA-ACP was highly acceptable for this patient group.

CONCLUSION

The NA-ACP is one of the first multi-dimensional instruments specifically designed to assess the needs of patients with advanced, incurable cancer. The present study provides evidence of the NA-ACP's validity, reliability, and acceptability. The NA-ACP has potential applications both as a research tool and within clinical settings.

Palliative care in hospitals

Hospital-based palliative care teams have evolved as a natural outgrowth of the modern hospice movement. This article examines why these hospital-based palliative care programs have proliferated, how they typically function, and what data exist as to their effectiveness. Crucial steps necessary for the design and implementation of a successful hospital-based palliative care service also are reviewed.

Fatigue and aging

Fatigue is the most common chronic symptom of cancer and the symptom most likely to disrupt the patient's activity and to cause disability.Fatigue affects older cancer patients to the same order of magnitude as younger ones and appears to be related to different factors such as anemia, depression, and reduced neuromuscular energy production. Interestingly, some studies have suggested that the duration of fatigue may be age-related. In the elderly, fatigue may cause functional dependence; functional dependence may lead to interruption of treatment, decline in quality of life and expensive home care. Available interventions include reduction of centrally acting drugs, management of anemia and metabolic abnormalities, and management of depression, treatment of sleep disorders, correction of endocrine abnormalities and realistic exercise programmes.

Health-related quality of life in female long-term colorectal cancer survivors

Although the number of women who survive treatment for colorectal cancer is growing, little is known about the quality of life of long-term survivors. The purpose of analyses presented in this paper is to describe the overall health-related quality of life of female long-term colorectal cancer survivors and the factors that may modify their levels of quality of life. A population-based sample of 726 Wisconsin women diagnosed with colorectal cancer from 1990-1991 was recontacted. Of the 443 women alive in 1999, 307 (69%) completed a follow-up questionnaire including the Medical Outcomes Study Short-Form 36 Health Status Survey, which is comprised of 36 items that generate nine domain scale scores and two summary scores: the Physical Component Summary score and the Mental Component Summary score. The mean follow-up was 9 years (range 7-11), and the mean age at follow-up was 72 years (range 43-85). The mean Physical Component Summary score was lower for participants with greater ages, greater numbers of comorbidities, and greater body masses at the time of follow-up. The mean Mental Component Summary score also was lower for participants with greater numbers of comorbidities. Differences associated with degree of comorbidity were observed for all eight domain scales. Female long-term survivors of colorectal cancer appear to report health-related quality of life comparable with that of similarly aged women in the general population. These data suggest that, over the long term, factors attributable to aging, body weight, and chronic medical conditions play more dominant roles in determining physical and mental health than factors related to the initial colorectal cancer diagnosis.

Multicenter study of pain and its management in patients with advanced cancer in Korea

The aim of this study was to evaluate the prevalence, severity, and management of pain in Korean patients with advanced cancer, and to identify the predictors of inadequate management of cancer pain in Korea. From 8 university hospitals, 655 patients with advanced cancer were surveyed. Information concerning analgesics prescribed was acquired from the medical records by the investigator. Physicians, nurses and caregivers were asked to estimate patients' pain. The Korean Brief Pain Inventory and the Barrier Questionnaire were completed by the patients. The Pain Management Index was estimated. Among all patients, 70.8% (464 of 655) reported pain. Among those who had pain, 63.6% (295 of 464) reported pain rated 5 or higher on a 0-10 scale. Thirty-nine percent of the patients had not received any analgesics and 53.2% were not receiving optimal pain management. Although there was a correlation between patients' pain ratings and those of doctors, nurses, and caregivers, there was no significant correlation between patients' ratings and health care providers' ratings at pain levels above moderate intensity. Cancer pain was more poorly managed in advanced cancer than terminal cancer patients (OR:3.20, 95%C.I, 1.83-5.60), in patients with better performance(OR:3.17, 95%C.I, 1.64-6.11), and in those patients whose pain was underestimated by the doctor (OR:2.58, 95%C.I. 1.42-4.69). Despite the high prevalence and severity of pain in cancer patients, the assessment and management of cancer pain were found to be inadequate in Korea.

Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers?

Palliative care provision varies widely, and the effectiveness of palliative and hospice care teams (PCHCT) is unproven. To determine the effect of PCHCT, 10 electronic databases (to 2000), 4 relevant journals, associated reference lists, and the grey literature were searched. All PCHCT evaluations were included. Anecdotal and case reports were excluded. Forty-four studies evaluated PCHCT provision. Teams were home care (22), hospital-based (9), combined home/hospital care (4), inpatient units (3), and integrated teams (6). Studies were mostly Grade II or III quality. Funnel plots indicated slight publication bias. Meta-regression (26 studies) found slight positive effect, of approximately 0.1, of PCHCTs on patient outcomes, independent of team make-up, patient diagnosis, country, or study design. Meta-analysis (19 studies) demonstrated small benefit on patients' pain (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.23-0.64), other symptoms (OR: 0.51, CI: 0.30-0.88), and a non-significant trend towards benefits for satisfaction, and therapeutic interventions. Data regarding home deaths were equivocal. Meta-synthesis (all studies) found wide variations in the type of service delivered by each team; there was no discernible difference in outcomes between city, urban, and rural areas. Evidence of benefit was strongest for home care. Only one study provided full economic cost-benefit evaluation. This is the first study to quantitatively demonstrate benefit from PCHCTs. Such comparisons were limited by the quality of the research.

A measure of the quality of dying and death. Initial validation using after-death interviews with family members

A reliable and valid measure of the quality of the dying experience would help clinicians and researchers improve care for dying patients. To describe the validity of an instrument assessing the quality of dying and death using the perspective of family members after death and to identify clinical correlates of a high quality death, a retrospective cohort study evaluated the 31-item Quality of Dying and Death (QODD) questionnaire. The questionnaire was administered to family members of patients who died in Missoula county Montana in 1996 and 1997. The interview included questions assessing symptoms, patient preferences, and satisfaction with care. Measurement validity was examined for item and total scores and reliability analyses for the QODD total score were assessed. Construct validity was assessed using measures of concepts hypothesized to be associated with the quality of dying and death. There were 935 deaths, of which 252 (27.0%) family interviews were represented. Non-enrolled decedents were not significantly different from enrolled decedents on age, sex, cause of death, or location of death. We excluded sudden deaths (n = 45) and decedents under age 18 (n = 2), leaving 205 after-death interviews. A total QODD score, on a scale from 0 to 100 with higher scores indicating better quality, ranged from 26.0 to 99.6, with a mean of 67.4 and Cronbach's alpha of 0.89. The total QODD score was not associated with patient age, sex, education, marital status, or income. As hypothesized, higher QODD scores were significantly associated with death at home (P < 0.01), death in the location the patient desired (P < 0.01), lower symptom burden (P < 0.001), and better ratings of symptom treatment (P< 0.01). Although the total score was not associated with the presence of an advance directive, higher scores were associated with communication about treatment preferences (P < 0.01), compliance with treatment preferences (P < 0.001), and family satisfaction regarding communication with the health care team (P < 0.01). Availability of a health care team member at night or on weekends was also associated with a higher QODD score (P < 0.001). The QODD total score demonstrated good cross-sectional validity. Clinicians caring for dying patients should focus on improving communication with the patient and family and improving symptom assessment and treatment. Health care teams should focus on continuity of care, including having a team member familiar with the patient available for calls at nights and on weekends. Future work will assess the potential role of the QODD in improving the quality of the dying experience.

Fever and sweats in the patient with advanced cancer

Fever and sweats are common complications of cancer and its treatment. This article reviews potential causes and pathophysiologic mechanisms of fever and sweat. Management recommendations, consisting of primary interventions directed at contributing causes and pathophysiologic mechanisms, and non-specific palliative measures are discussed. Optimal management is contingent on the physician's integration of medical expertise with patient-derived goals of care.

Appropriate time frames for data collection in quality of life research among cancer patients at the end of life

Longitudinal research has been recommended as the most appropriate research design to ensure the validity of quality of life assessments. However, high attrition and non-random missing data in quality of life studies for terminal cancer patients raise questions about generalizability of the study, and at worst they may jeopardize interpretation of the results. Appropriate time frames for eliciting information directly from terminal cancer patients can ensure the internal and external validity of quality of life research in end-of-life care, allow health care professionals to detect sensitively the effects of end-of-life care within the shortest intervention period, and make comparisons across studies possible. From a review of the literature, it is recommended that the appropriate time frame for interviewing terminal cancer patients about their quality of life be a weekly assessment schedule based on the following factors: (a) the median survival of terminal cancer patients enrolling in a hospice/palliative care program is approximately 30 days and there are substantial number of patients who die in each week; (b) at the final weeks of life, quality of life and symptoms of some terminal cancer patients change dramatically; and (c) the shortest intervention period that is likely to give a clinically significant effect of end-of-life care management is 1 week after the enrollment in end-of-life care.

Do hospital-based palliative teams improve care for patients or families at the end of life?

To determine whether hospital-based palliative care teams improve the process or outcomes of care for patients and families at the end of life, a systematic literature review was performed employing a qualitative meta-synthesis and quantitative meta-analysis. Ten databases were searched. This was augmented by hand searching specific journals, contacting authors, and examining the reference lists of all papers retrieved. Studies were included if they evaluated palliative care teams working in hospitals. Data were extracted by two independent reviewers. Studies were graded using two independent hierarchies of evidence. A Signal score was used to assess the relevance of publications. Two analyses were conducted. In a qualitative meta-synthesis data were extracted into standardized tables to compare relevant features and findings. In quantitative meta-analysis we calculated the effect size of each outcome (dividing the estimated mean difference or difference in proportions by the sample's standard deviation). Nine studies specifically examined the intervention of a hospital-based palliative care team or studies. A further four studies considered interventions that included a component of a hospital or support team, although the total intervention was broader. The nature of the interventions varied. The studies were usually in large teaching hospitals, in cities, and mainly in the United Kingdom. Outcomes considered symptoms, quality of life, time in hospital, total length of time in palliative care, or professional changes, such as prescribing practices. Only one of the studies was a randomized controlled trial and this considered a hospital team as part of other services. Most method scores indicated limited research quality. Comparison groups were subject to bias and the analyses were not adjusted for confounding variables. In addition, there were problems of attrition and small sample sizes. Nevertheless, all studies indicated a small positive effect of the hospital team, except for one study in Italy, which documented deterioration in patient symptoms. The Signal scores indicated that the studies were relevant. No study compared different models of hospital team. This review suggests that hospital-based palliative care teams offer some benefits, although this finding should be interpreted with caution. The study designs need to be improved and different models of providing support at the end of life in hospital need comparison. Standardized outcome measures should be used in such research and in practice.

The management of pain in the oncology patient

The treatment of cancer pain is improving, but pain remains a significant problem. Although better analgesics with greater efficacy and fewer side effects are needed, the most significant problem regarding the appropriate management of cancer pain remains a lack of knowledge among physicians treating cancer patients. Cancer management should be undertaken within a palliative care model, in which autonomy and respect for individuals and their families guides all aspects of care.

Xerostomia in patients with advanced cancer

The aim of the study was to investigate the features of xerostomia in patients with advanced cancer. The protocol involved completion of the Memorial Symptom Assessment Scale, and measurement of the unstimulated whole salivary flow rate (UWSFR) and the stimulated whole salivary flow rate (SWSFR). One hundred twenty patients participated in the study. Xerostomia was the fourth most common symptom (78% of patients). It was associated with a poor performance status (P = 0.01). The usual cause of xerostomia was drug treatment. There was an association with the total number of drugs prescribed (P = 0.009): the median number of xerostomic drugs prescribed was 4. Xerostomia was ranked the third most distressing symptom. Its severity was correlated with the severity of oral discomfort, dysgeusia, dysmasesia, dysphagia, dysphonia, and anorexia. The UWSFR was a relatively sensitive, but nonspecific, investigation. In contrast, the SWSFR was a relatively specific, but insensitive, investigation.

Evaluating the quality of dying and death

We propose a model for evaluating the quality of dying and death based on concepts elicited from literature review, qualitative interviews with persons with and without chronic and terminal conditions, and consideration of desirable measurement properties. We define quality of dying and death as the degree to which a person's preferences for dying and the moment of death agree with observations of how the person actually died, as reported by others. Expected level of agreement is modified by circumstances surrounding death that may prevent following patient's prior preferences. Qualitative data analysis yielded six conceptual domains: symptoms and personal care, preparation for death, moment of death, family, treatment preferences, and whole person concerns. These domains encompass 31 aspects that can be rated by patients and others as to their importance prior to death and assessed by significant others or clinicians after death to assess the quality of the dying experience. The proposed model uses personal preferences about the dying experience to inform evaluation of this experience by others after death. This operational definition will guide validation of after-death reports of the quality of dying experience and evaluation of interventions to improve quality of end-of-life care.

Oral care for patients with cancer: a review of the literature

Mouth care is an integral part of nursing practice. However, it has become a ritualistic and banal activity, a topic of conflicting advice and subjective conclusions from sporadic research. Rarely do experts teach it, and it frequently is delegated to the most junior members of the nursing staff. Many cancer treatments result in unavoidable oral toxicity, and the significant prevalence of oral complications in oncology makes mouth care a particular priority for cancer nurses. The confusion and conflict that surrounds best nursing practice in relation to delivering appropriate mouth care should be redressed. This review article details pertinent research to date regarding oral care, with an aim to clarify intervention options, and to identify and promote best nursing practice.

Quality of life assessment and outcome of palliative care

Quality of life (QoL) assessment is crucial for the evaluation of palliative care outcome. In this paper, our methodological approach was based on the creation of summary measures. Fifty-eight Palliative Care Units (PCUs) in Italy participated in the study. Each PCU randomly selected patients to be 'evaluated' among the consecutively 'registered' patients. At baseline (first visit) and each week the patient was asked to fill in a QoL questionnaire, the Therapy Impact Questionnaire (TIQ). Short-survivors (<7 days) were not included in the QoL study. The random sample of patients (n = 601) was highly representative of the general patient population cared for by the PCUs in Italy. The median survival was 37.9 days. We collected 3546 TIQ, 71.4 % completed by the patients. A Summary Measure Outcome score was calculated for 409 patients (81% of the patients included in the QoL study). The results of this national study showed that cooperative clinical research in palliative care is possible and QoL measures can be used to assess the outcome.

Living with cancer: "good" days and "bad" days--what produces them? Can the McGill quality of life questionnaire distinguish between them?

BACKGROUND

To determine the impact of care on quality of life (QOL), or to detect a change in QOL over time, measures of QOL must remain stable when QOL is stable (test-retest reliability) and change when QOL changes (responsiveness). This study addresses these issues for the McGill Quality of Life Questionnaire (MQOL). Unlike other studies that use disease status to indicate whether QOL has remained stable or changed, in this study the patient determines QOL stability or change. The authors also sought to clarify the determinants of "good" and "bad" days for oncology patients.

METHODS

Patients attending an oncology outpatient clinic or who were being treated by a palliative care service were asked to complete MQOL 4 times: on days they judged to be "good," "average," and "bad" and 2 days after the first completion. They also were asked to directly rate the change in their QOL during the intervals between MQOL completion and to report the most important determinants of their good and bad days.

RESULTS

The test-retest reliability of MQOL as measured by an intraclass correlation coefficient ranged from 0.69 to 0.78. All MQOL scores were significantly different on good, average, and bad days, except for the support subscale, in both clinical settings. Five domains were determinants of QOL: physical symptoms, physical functioning, psychologic well-being, existential well-being, and relationships.

CONCLUSIONS

MQOL's reliability and responsiveness suggest it can be used to determine changes in the QOL of groups. The results allow interpretation of changes in MQOL scores with respect to meaning of the change to oncology patients. This in turn is helpful to determine the sample size required in future studies. Some of the domains important to the QOL of oncology patients are not included in widely used measures of QOL.

The course of symptom frequency and intensity in advanced cancer patients followed at home

Four hundred consecutive patients who were referred to a home palliative care program were prospectively surveyed to estimate the prevalence and severity of common symptoms according to the changes in the performance status. Patients were admitted for the presence of different symptoms and psychosocial support. Common symptoms included in a standard form were rated for severity (absent 0, mild 1, moderate 2, severe 3) for each visit. Pain intensity was rated on a numerical scale (0-10). For each level of Karnofsky performance score (K), the frequency and the worse symptom intensity were recorded until patient's death. Data from 370 patients were analyzed. Pain was effectively controlled. In the final stage, it was also less frequently observed, despite the use of lower analgesic doses in the last days of life. The peak of opioid consumption and symptom frequency and severity was found at K40. This was also the most frequent K level at admission. Some symptoms, such as nausea and vomiting, dry mouth, gastric pyrosis, and diarrhea reached a peak in frequency and severity, then decreased with the advanced stage of the disease. Other symptoms, such as dyspnea, drowsiness, weakness, and confusion tended to further increase and to have a peak at the lowest levels of K. Dysphagia and constipation progressively increased in frequency and intensity, but decreased at the end. These findings clarify the actual frequency and intensity of symptoms in a non-selected home care population with advanced cancer.

Subjective scales for the evaluation of therapeutic effects and their use in complementary medicine

Using existing systems for appraising the efficacy of various therapies, regardless of their typology, the authors considered approximately 10 methods commonly used to evaluate quality of life. They provide guidelines on how to build another index for judging quality of life, taking into account the patient's conditions of life. These indexes share similar problems in finding objective measures for assessing personal situations without regard to patients' or observers' subjective impressions. Nevertheless, the authors demonstrate that for randomized controlled clinical trials and for meta-analyses this deficiency is also a problem, at least qualitatively, for scientific methods that are considered quite objective. Therefore, according to the methodological manifesto of the World Health Organization, the authors conclude by suggesting the simultaneous adoption, for complementary medicine studies, of some methods already known for their use in conventional medicine, despite general limited validity.

Palliative care and end-of-life issues

As stated, the goal of palliative care is the achievement of the best quality of life for patients and their families. It incorporates many aspects of care: providing physical comfort, psychosocial and spiritual support, and providing various services in order to achieve this goal. The skills described should be a priority in the practice of all types of medicine because the goal of palliative care is among the central tenets of the medical profession.

Contributing factors to physical symptoms in terminally-ill cancer patients

Prediction of future suffering could improve palliative care. To identify the factors contributing to physical symptoms, a prospective study was performed on two series of hospice inpatients with cancer (n = 150 and n = 200, respectively). Physical symptoms, patients' characteristics, and tumor locations were recorded using a structured protocol on admission and throughout the clinical course. Common symptoms on admission and during the patient's course were pain (65%, 88%), general malaise (58%, 77%), anorexia (57%, 94%), constipation (33%, 71%), dyspnea (33%, 66%), nausea/vomiting (29%, 48%), cough/sputum (29%, 48%), edema (27%, 65%), fever (26%, 70%), abdominal swelling (26%, 42%), and dry mouth (25%, 61%), respectively. The mean number of symptoms was 5.7 +/- 3.0 on admission and 9.6 +/- 3.1 during the course. Factors that contributed to the symptoms were young age (pain, abdominal swelling, dry mouth), performance status (anorexia, general malaise, edema, dyspnea), brain tumor (paralysis), neoplasms of lung/pleura (dyspnea, cough/sputum, death rattle), bone metastasis (pain, paralysis), gastric/pancreas cancer (abdominal swelling), peritoneal metastasis (general malaise, edema, nausea/vomiting, abdominal swelling, dry mouth), opioids (constipation, dry mouth, myoclonus), anticholinergics (dry mouth), and antidopaminergics (myoclonus). Opioid requirement was positively correlated with the presence of bone metastasis, and negatively correlated with age and brain involvement. Additional opioids were frequently used in the final 48 hours in cases with lung/pleura neoplasms. These data suggest that terminal symptoms in cancer patients are determined by local and/or general factors. Clinicians can predict the probability of future symptoms from patients' characteristics, general condition, tumor locations, and medications.

Management of cancer pain

Patients with cancer have diverse symptoms, impairments in physical and psychological functioning, and other difficulties that can undermine their quality of life. If inadequately controlled, pain can have a profoundly adverse impact on the patient and his or her family. The critical importance of pain management as part of routine cancer care has been forcefully advanced by WHO, international and national professional organisations, and governmental agencies. The prevalence of chronic pain is about 30-50% among patients with cancer who are undergoing active treatment for a solid tumour and 70-90% among those with advanced disease. Prospective surveys indicate that as many as 90% of patients could attain adequate relief with simple drug therapies, but this success rate is not achieved in routine practice. Inadequate management of pain is the result of various issues that include: undertreatment by clinicians with insufficient knowledge of pain assessment and therapy; inappropriate concerns about opioid side-effects and addiction; a tendency to give lower priority to symptom control than to disease management; patients under-reporting of pain and non-compliance with therapy; and impediments to optimum analgesic therapy in the healthcare system. To improve the management of cancer pain, every practitioner involved in the care of these patients must ensure that his or her medical information is current and that patients receive appropriate education.

Trends in Cancer Pain Management

BACKGROUND: Pain is a prevalent symptom in cancer patients, affecting up to 50% of patients undergoing active cancer treatment and up to 90% of those with advanced disease. Although adequate relief can be achieved in the majority of cancer patients, pain is often treated inadequately in traditional settings. METHODS: The authors use their experience and that of others to review the evaluation and diagnosis of pain syndromes and the principles of management. RESULTS: The World Health Organization and other governmental agencies have recognized the importance of pain management as part of routine cancer care. Conducting a comprehensive assessment, competently providing analgesic drugs, and communicating with the patient and family allow effective management of pain in the cancer patient. CONCLUSIONS: Several approaches can promote adequate management of cancer pain, such as enhancing clinician knowledge of pain syndromes, improving pain assessment, and updating medical information related to pain and symptom control.