Assessing physical functioning: a systematic review of quality of life measures developed for use in palliative care

Physiotherapy applied to palliative care patients: a descriptive practice-based study

BACKGROUND

Over the last few years, the presence of physiotherapists in Palliative Care Units (PCU) has considerably grown based on evidence from studies supporting the use of non-pharmacological measures as part of Palliative Care (PC) treatments. However, more accumulated data are needed to definitively establish its added value. The present study describes the type of patients receiving physiotherapy in a PCU and the benefits obtained in relation to their degree of functional dependence.

METHODS

An observational, prospective, descriptive, practice-based study was undertaken involving patients admitted to the PCU of Fundación Instituto San José (Madrid, Spain), who according to the PCU´s clinical practice, met the criteria for physiotherapy intervention. Daily clinical practice was unchanged for study reasons. Participants were assessed prior to initiating and at the end of the physiotherapy program using the following standard scales: the Barthel Index, the Functional Ambulation Categories scale, the Palliative Performance Scale, and the Braden scale. A descriptive analysis was performed and scale scores prior to and after treatment were compared using the Wilcoxon signed-rank test. Significance was set at 0.05.

RESULTS

A total of 63 patients were included (mean age 71.98 ± 12.72; 61.9% males). Fifty-eight patients (92.1%) were oncological patients; of them, 35 (60.3%) had metastases. Prior to treatment, 28 (44.4%) participants had total dependence according to the Barthel index, and 37 (58.7%) were non-functional ambulator according to the FAC scale. At the end of treatment, the number of patients with total dependence decreased to 15 (23.8%) and those non-functional ambulator to 12 (19.0%).

CONCLUSIONS

Patients who benefited from physical therapy during their admission to our PCU were predominantly males with oncological processes, mainly lung cancer. PC including physiotherapy improved their functionality, independence and skills for activities of daily living in this sample of PCU patients.

Implementing a Standardized Care Pathway Integrating Oncology, Palliative Care and Community Care in a Rural Region of Mid-Norway

INTRODUCTION

To improve quality across levels of care, we developed a standardized care pathway (SCP) integrating palliative and oncology services for hospitalized and home-dwelling palliative cancer patients in a rural region.

METHODS

A multifaceted implementation strategy was directed towards a combination of target groups. The implementation was conducted on a system level, and implementation-related activities were registered prospectively. Adult patients with advanced cancer treated with non-curative intent were included and interviewed. Healthcare leaders (HCLs) and healthcare professionals (HCPs) involved in the development of the SCP or exposed to the implementation strategy were interviewed. In addition, HCLs and HCPs exposed to the implementation strategy answered standardized questionnaires. Hospital admissions were registered prospectively.

RESULTS

To assess the use of the SCP, 129 cancer patients were included. Fifteen patients were interviewed about their experiences with the patient-held record (PHR). Sixty interviews were performed among 1320 HCPs exposed to the implementation strategy. Two hundred and eighty-seven HCPs reported on their training in and use of the SCP. Despite organizational cultural differences, developing an SCP integrating palliative and oncology services across levels of care was feasible. Both HCLs and HCPs reported improved quality of care in the wake of the implementation process. Two and a half years after the implementation was launched, 28% of the HCPs used the SCP and 41% had received training in its use. Patients reported limited use and benefit of the PHR.

CONCLUSION

An SCP may be a usable tool for integrating palliative and oncology services across care levels in a rural region. An extensive implementation process resulted in improvements of process outcomes, yet still limited use of the SCP in clinical practice. HCLs and HCPs reported improved quality of cancer care following the implementation process. Future research should address mandatory elements for usefulness and successful implementation of SCPs for palliative cancer patients.

Physical Activity for Individuals Living with Advanced Cancer: Evidence and Recommendations

OBJECTIVES

To provide health and fitness professionals with screening, triage, prescription, and physical activity recommendations to better serve individuals living with advanced cancer. A call to action regarding next steps to improve research and knowledge translation is also outlined, ensuring the growing number of those with advanced cancers are supported in their efforts to adopt and adhere to active lifestyles.

DATA SOURCES

Sources include published literature, physical activity guidelines, and expert opinion from physical medicine and rehabilitation physicians, exercise physiologists, and health and exercise psychology researchers.

CONCLUSION

Individuals with advanced cancer who engage in regular physical activity report improved function, fatigue management, and quality of life, while objective testing shows improvements in fitness and physical function. Although there are no clear activity guidelines or recommendations for this population, patients must avoid inactivity to gain health benefits and minimize deconditioning. For most patients with advanced cancer, physical activity prescriptions should focus on maintaining fitness and functional independence, and specific modifications based on common comorbidities must be considered.

IMPLICATIONS FOR NURSING PRACTICE

Evidence supports the use of physical activity for the management of symptoms experienced by those with advanced cancers. Understanding the benefits of physical activity for patients with advanced cancer is important because health care providers play a key role in the adoption and adherence of physical activity among patients.

Occupational therapy and physiotherapy interventions in palliative care: a cross-sectional study of patient-reported needs

INTRODUCTION

An interdisciplinary team approach to patients in specialised palliative care is recommended; however, the composition of the professionals tends to vary, and the roles of physiotherapists and occupational therapists may be underestimated. We aimed to investigate patient-reported unmet needs, which potentially could benefit from physiotherapy and occupational therapy interventions in a specialised palliative care team.

METHODS

Adult patients with chronic advanced diseases referred to the Specialised Palliative Care Team at Copenhagen University Hospital, Rigshospitalet were enrolled in the study. The Three-Levels-of-Needs Questionnaire was used as primary outcome to assess symptom/problem intensity, symptom/problem burden and felt needs for 12 commonly reported symptoms/problems for patients referred to a specialised palliative care team. Furthermore, participants' level of distress, fatigue and physical activity, symptoms of anxiety and depression, and barriers towards the rehabilitation programme were registered with other measures.

RESULTS

In total, 43 of 67 (64%) patients participated. The majority of participants reported severe symptoms/problems concerning fatigue (81%), impaired physical activities (77%), carrying out work and daily activities (77%), pain (72%), and worries (58%). Furthermore, need for help was expressed concerning physical activities (79%), work and daily activities (77%), fatigue (70%), pain (65%), concentration (58%) and worries (51%). On average the patients characterised 6 (out of 12) symptoms/problems as severe.

CONCLUSION

Patients referred to a specialised palliative care team reported extensive unmet needs concerning physical activities, work and daily activities, fatigue, pain, concentration and worries. Unmet needs that potentially could be alleviated by physiotherapists or occupational therapists implemented in the interdisciplinary team.

Activity and advanced cancer: A grounded theory

BACKGROUND

Cancer-related fatigue and loss of physical functioning are distressing symptoms which negatively impact the quality of life of people with advanced cancer. Physical activity has been shown to have positive effects on these symptoms in early-stage cancer, but previous research demonstrated an incongruence between people with advanced cancer's expressed interest and actual participation in a physical activity intervention.

AIM

To gain an in-depth understanding of the experience of activity and quality of life in people with advanced cancer, using a classic grounded theory approach.

DESIGN

Through the post-positivist lens of subtle realism, and informed by classic grounded theory methods, a two-phase, cross-sectional, qualitative study was conducted. For 7 days duration, participants wore an activPAL™ activity monitor and completed a daily record sheet, which were then used as qualitative probes for face-to-face, semi-structured interviews.

SETTING/PARTICIPANTS

A total of 15 people with advanced cancer, aged 18 years or older, and with a median survival of 100 days from time of study consent, were recruited from an outpatient department of a tertiary cancer centre in Alberta, Canada.

FINDINGS

Maintaining their responsibilities, no matter how small, was the prime motive for participants' behaviour. For people with advanced cancer, the minimum level of responsibility was dynamic and unique. It was achieved through a multifaceted interaction between the perceived benefits, prevailing conditions and mechanisms.

CONCLUSION

This grounded theory enables understanding of activity as a mechanism through which responsibility is managed and may inform future behavioural interventions in people with advanced cancer.

Measuring health-related quality of life in patients with advanced cancer: a systematic review of self-administered measurement instruments

PURPOSE

Patient-reported outcome measures (PROMs) are becoming increasingly important in clinical practice. The implementation of PROMS in routine practice is challenging because information regarding psychometric quality of measurement instruments is fragmented and standardization is lacking. The aim of this study is to evaluate the quality of self-administered HRQoL measurement instruments for use in patients with advanced cancer in clinical practice.

METHODS

A systematic literature search was performed in PubMed, Embase, PsycINFO, and CINAHL to identify studies concerning self-administered HRQoL measurement instruments in patients with advanced cancer between January 1990 and September 2016. Quality of the measurement instruments was assessed by predefined criteria derived from the COSMIN checklist.

RESULTS

Sixty-nine articles relating to 39 measurement instruments met the inclusion criteria. Information regarding important measurement properties was often incomplete. None of the instruments performed sufficient on all measurement properties. Considering available information, the EORTC QLQ-C15-PAL appeared to have adequate psychometric properties, together with the EORTC QLQ-BM22.

CONCLUSIONS

Many of the existing HRQoL measurement instruments have not yet been evaluated in an adequate manner. Validation of self-administered HRQoL measurement instruments is an ongoing development and should be prioritized. This review contributes to improved clarity regarding the availability and quality of HRQoL measurement instruments for patients with advanced cancer and supports health care professionals in an adequate selection of suitable PROMs in clinical practice.

The Spanish Adaptation of the Palliative Performance Scale (Version 2) Among Cancer Patients at the End of Life: Psychometric Properties

BACKGROUND

Palliative Performance Scale (PPS) is a reliable tool to assess performance status in cancer patients receiving palliative care (PC). Spanish validated and culturally adapted tools are needed.

OBJECTIVES

The objectives are to develop PPS translation and cross-cultural adaptation into Spanish and to assess its psychometric properties.

DESIGN

Translation process with cross-cultural adaptation to produce Spanish Palliative Performance Scale (PPS-SPANISH).

SETTINGS

PC Team at one University hospital in Spain.

PARTICIPANTS

Fifteen advanced cancer patients (60 assessments) were included for PPS translation and validation and 250 patients for cross-sectional analysis. All participants were recruited at oncology ward, emergency area, and outpatient clinic by PC team professionals. Informed consent was given. Average age was 66.4 ± 13 years (60% men).

METHODS

The process is designed in three steps. In Step 1, PPS translation and reverse translation into Spanish (three bilingual speakers) and linguistic complexity measurement were performed. In Step 2, readability and intelligibility assessment was carried out. In Step 3, a pilot study was conducted to assess test-retest reliability followed by a cross-sectional study to measure internal consistency. Inclusion criteria were the same for two samples. Demographic data were also analyzed by descriptive statistics.

RESULTS

Following cultural, linguistic, and grammatical adaptation, PPS-SPANISH was readable and reliable. The analysis of the test-retest reliability after 48 hours showed intraclass correlations >0.60. Cronbach's alpha coefficient was 0.99 (0.988-0.992). There was high agreement with other functional assessment tools (Barthel Index and Karnofsky Performance Status Index).

CONCLUSIONS

PPS-SPANISH showed reliability and validity, and it is suitable to assess performance status in cancer patients receiving PC.

The Dutch-Flemish PROMIS Physical Function item bank exhibited strong psychometric properties in patients with chronic pain

OBJECTIVE

The objective of this study was to assess the psychometric properties of the Dutch-Flemish Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function item bank in Dutch patients with chronic pain.

STUDY DESIGN AND SETTING

A bank of 121 items was administered to 1,247 Dutch patients with chronic pain. Unidimensionality was assessed by fitting a one-factor confirmatory factor analysis and evaluating resulting fit statistics. Items were calibrated with the graded response model and its fit was evaluated. Cross-cultural validity was assessed by testing items for differential item functioning (DIF) based on language (Dutch vs. English). Construct validity was evaluated by calculation correlations between scores on the Dutch-Flemish PROMIS Physical Function measure and scores on generic and disease-specific measures.

RESULTS

Results supported the Dutch-Flemish PROMIS Physical Function item bank's unidimensionality (Comparative Fit Index = 0.976, Tucker Lewis Index = 0.976) and model fit. Item thresholds targeted a wide range of physical function construct (threshold-parameters range: -4.2 to 5.6). Cross-cultural validity was good as four items only showed DIF for language and their impact on item scores was minimal. Physical Function scores were strongly associated with scores on all other measures (all correlations ≤ -0.60 as expected).

CONCLUSION

The Dutch-Flemish PROMIS Physical Function item bank exhibited good psychometric properties. Development of a computer adaptive test based on the large bank is warranted.

Concordance of Barthel Index, ECOG-PS, and Palliative Performance Scale in the assessment of functional status in patients with advanced medical diseases

OBJECTIVE

Analysing most relevant clinical features and concordance between different functional scales in patients with advanced medical diseases (PAMD).

METHODS

Cross-sectional multicentre study that included PAMD (heart, lung, kidney, liver, and neurological diseases) in hospital settings from February 2009 to October 2010. We analysed clinical, biological and functional features in performing activities of daily living (ADL) by medians of Barthel Index (BI); additionally we assessed their performance status by medians of Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) and Palliative Performance Scale (PPS) scores. We evaluated the concordance of these instruments in assessing functional impairment by κ and intraclass correlation coefficient tests.

RESULTS

1847 patients were included (average age 79 years, 50.1% men). Most common symptoms were dyspnoea (62.31%), asthenia (23%) and delirium (20.14%). Functional assessment showed a high prevalence of severe or total impairment in performing basic ADL by medians of used instruments (BI median=35 (IQR=70), and 52.1% of patients with severe-total impairment; ECOG-PS median=2 (IQR 30), and 44% of patients with severe-total impairment; and PPS median=50 (IQR 30), and 32% of patients with severe-total impairment). Concordance among these instruments was acceptably good (κ indexes ranging from 0.653 to 0.745 (p<0.0001)).

CONCLUSIONS

PAMD represent a population with severe functional impairment, which requires a multidisciplinary approach for proper management. Assessment of functional ability in this population by BI, ECOG-PS, and PPS showed good concordance.

The importance of measuring customer satisfaction in palliative care

In the last decades, palliative care has been more and more focused on the evaluation of patients' and families' satisfaction with care. However, the evaluation of customer satisfaction in palliative care presents a number of issues such as the presence of both patients and their families, the frail condition of the patients and the complexity of their needs, and the lack of standard quality indicators and appropriate measurement tools. In this manuscript, we critically review existing evidence and literature on the evaluation of satisfaction in the palliative care context. Moreover, we provide - as a practical example - the preliminary results of our experience in this setting with the development of a dedicated tool for the measurement of satisfaction.

Systematic Literature Review on ICF From 2001 to 2013 in the Nordic Countries Focusing on Clinical and Rehabilitation Context

We present a systematic review on International Classification of Functioning, Disability and Health (ICF) used in the Nordic countries from 2001 through 2013, describing and quantifying the development in utilization of ICF, and describe the extent to which the different components of the ICF have been used. A search was conducted in EMBASE, MEDLINE and PsycInfo. Papers from Nordic countries were included if ICF was mentioned in title or abstract. Papers were assigned to one of eight categories covering the wide rehabilitation area; furthermore, area of focus was assigned. Use of ICF components and intervention were coded in papers categorized as "clinical and/or rehabilitation contexts" or "non-clinical contexts". One hundred seventy papers were included, of these 99 papers were from the categories "clinical and/or rehabilitation contexts" or "non-clinical contexts". Forty-two percent of the 170 included papers were published in the period 2011 - 2013. There was an increase in ICF-relevant papers from 2001 to 2013, especially in the categories "clinical and/or rehabilitation contexts" and "non-clinical contexts". The most represented focus areas were neurology, musculoskeletal, and work-related areas. All five or at least four ICF components were mentioned in the results or discussions in most papers, and activity was most frequently mentioned.

REHABILITATION IN PALLIATIVE CARE

ABSTRACT: The objective of this study was to describe the activities and effects of functional rehabilitation in patients receiving palliative care. It is an integrative review, in which LILACS, BDENF, Coleciona SUS (Brazil) and PUBMED were used, 20 articles were selected, subsequently characterized as having designs of medium and low impact, more than half ranked with evidence levels II, III and IV and with samples not always consistent with the research designs. However, the results revealed the potential of rehabilitation to improve the functional status, quality of life and symptoms like pain and anxiety in this population, through interventions that are many times undervalued in palliative care. The conclusion is that rehabilitation is a feasible strategy to combat functional decline and improve the quality of life of patients in palliative care.

Is exercise ignored in palliative cancer patients?

Exercise and rehabilitation approaches in palliative care programs for cancer patients affect patients’ symptoms, physical functioning, muscle strength, emotional wellbeing, psychological symptoms, functional capacities, quality of life, mortality and morbidity positively. Based on scientific data, palliative cancer patients should be recommended to participate in exercise programs. There is no standard approach to recipe an exercise regimen for a palliative cancer survivor. Studies for demonstrating the positive effects of exercising in palliative care patients are increasing in number day by day. At this point, increasing awareness about exercising in the entire team monitoring the patient and our efforts in this matter seems to be very important.

Suffering assessment: a review of available instruments for use in palliative care

BACKGROUND

The prevention and relief of suffering in palliative care are critical to the well-being and quality of life of patients and families facing life-threatening diseases. Many tools to assess different issues in health care are available, but few are specifically designed to evaluate suffering, which is essential for its prevention, early management, and treatment.

OBJECTIVE

The purpose of this review was to identify and describe existing instruments developed to assess suffering in palliative care, as well as to comment on their psychometric properties.

METHODS

A review of articles indexed in MEDLINE, PsycINFO, and SciELO up to June 2011 was conducted. All articles reporting the development, description, or psychometric properties of instruments that assess suffering were included. An assessment of their psychometric quality was performed following a structured checklist.

RESULTS

Ten instruments that assess suffering were identified. Their main features and psychometric properties are described in order to facilitate the selection of the appropriate one given each patient's context.

CONCLUSION

By taking into consideration all features of the assessment instruments under review, the evaluation of suffering can be made easier. A wide and ever expanding range of approaches is now available, which facilitates the selection of the suffering-assessment instrument that is best suited to the needs of the specific patient. One of the challenges ahead will be to further analyze the psychometric properties of some existing instruments.

Does quality of life assessment in palliative care look like a complex screening program?

BACKGROUND

Palliative Care (PC) is an approach that improves the Quality of Life (QoL). A number of QoL assessment tools have been developed and validated in PC. It is not clear how QoL should be measured in PC practice. A procedure of QoL assessment in clinical practice can be defined as a clinical intervention focused on QoL assessment. This is a typical complex intervention that should be appropriately developed and described in all its components and assessed for its effectiveness. The aim of this study is to define a framework to help researchers to develop and evaluate clinical interventions focused on QoL assessment in PC.

METHODS

A study group of experts in PC and in research methodology was set up to define a framework that would describe the principles of clinical interventions focused on QoL assessment in PC. The study group discussed the WHO Population Screening Principles as a possible useful framework. The new principles had to be developed taking into account the following criteria: 1) specific to PC practice; 2) address a single underlying characteristic; 3) anchored to relevant literature; 4) consistent with the WHO PC definition.With regard to contents and the format of the principles, discussions occurred among the study group members through a cognitive process.

RESULTS

We reviewed each of the WHO Population Screening Principles and adapted them to QoL assessment, taking into account the defined criteria. As a result, a new framework, the QoL Assessment Principles in Palliative Care was developed. It consisted of 4 sections, for a total of 11 principles.

CONCLUSIONS

The WHO Screening Principles framework was used to outline the eleven essential principles to be considered in developing and/or evaluating clinical interventions focused on QoL assessment in PC. The QoL Assessment Principles in Palliative Care identified could represent a methodological and ethical standard to be considered when developing and evaluating a clinical intervention focused on QoL assessment in PC.

Development of a set of process and structure indicators for palliative care: the Europall project

Background

By measuring the quality of the organisation of palliative care with process and structure quality indicators (QIs), patients, caregivers and policy makers are able to monitor to what extent recommendations are met, like those of the council of the WHO on palliative care and guidelines. This will support the implementation of public programmes, and will enable comparisons between organisations or countries.

Methods

As no European set of indicators for the organisation of palliative care existed, such a set of QIs was developed. An update of a previous systematic review was made and extended with more databases and grey literature. In two project meetings with practitioners and experts in palliative care the development process of a QI set was finalised and the QIs were categorized in a framework, covering the recommendations of the Council of Europe.

Results

The searches resulted in 151 structure and process indicators, which were discussed in steering group meetings. Of those QIs, 110 were eligible for the final framework.

Conclusions

We developed the first set of QIs for the organisation of palliative care. This article is the first step in a multi step project to identify, validate and pilot QIs.

Reporting of "quality of life": a systematic review and quantitative analysis of research publications in palliative care journals

CONTEXT

Palliative care clinical practice depends upon an evidence-based decision-making process which in turn is based upon current research evidence. One of the most important goals in clinical palliative care is to improve patients' quality of life (QoL).

AIM

This study aimed to perform a quantitative analysis of research publications in palliative care journals for reporting characteristics of articles on QoL.

SETTINGS AND DESIGN

This was a systematic review of palliative care journals.

MATERIALS AND METHODS

Twelve palliative care journals were searched for articles with "QoL" in the title of the articles published from 2006 to 2010. The reporting rates of all journals were compared. The selected articles were categorized into assessment and treatment, and subsequently grouped into original and review articles. The original articles were subgrouped into qualitative and quantitative studies, and the review articles were grouped into narrative and systematic reviews. Each subgroup of original article category was further classified according to study designs.

STATISTICAL ANALYSIS USED

Descriptive analysis using frequencies and percentiles was done using SPSS for Windows, version 11.5.

RESULTS

The overall reporting rate among all journals was 1.95% (71/3634), and Indian Journal of Palliative Care (IJPC) had the highest reporting rate of 5.08% (3/59), followed by Palliative Medicine (PM) with 3.71% (20/538), and Palliative and Supportive Care (PSC) with 3.64% (9/247) reporting.

CONCLUSIONS

The overall reporting rate for QoL articles in palliative care journals was 1.95% and there were very few randomized clinical trials and systematic reviews found. The study findings indicate further high-quality research to establish an adequate evidence base for QoL.

Health-related quality of life in cancer patients at the end of life, translation, validation, and longitudinal analysis of specific tools: study protocol for a randomized controlled trial

Background

The end of life for cancer patients is the ultimate stage of the disease, and care in this setting is important as it can improve the wellbeing not only of patients, but also the patients' family and close friends. As it is a matter of profoundly personal concerns, patients' perception of this phase of the disease is difficult to assess and has thus been insufficiently studied. Nonetheless, caregivers are required to provide specific care to help patients and to treat them in order to improve their wellbeing during this period.

While tools to assess health-related quality of life (QoL) in cancer patients at the end of life exist in English, to our knowledge, no validated tools are available in French.

Methods/design

This randomized multicenter cohort study will be carried out to cross-culturally adapt and validate a French version of the English QUAL-E and the Missoula Vitas Quality Of Life Index (MVQOLI) questionnaires for advanced cancer patients in a palliative setting. A randomized clinical trial component in addition to a cohort study is implemented in order to test psychometric hypotheses: order effect and improvement of sensibility to change.

The validation procedure will ensure that the psychometric properties are maintained.

The main criterion to assess the reliability of the questionnaires will be reproducibility (test-retest method) using intraclass correlation coefficients. It will be necessary to include 372 patients. The sensitivity to change, discriminant capability as well as convergent validity will be also investigated.

Discussion

If the cross-cultural validation of the MVQOLI and QUAL-E questionnaires for advanced cancer patients in a palliative setting have satisfactory psychometric properties, it will allow us to assess the specific dimensions of QoL at the end of life.

Trial registration

Current Controlled Trials NCT01545921.

Utilization of brief pain inventory as an assessment tool for pain in patients with cancer: a focused review

The Pain Research Group of the world health organization (WHO) Collaborating Centre for Symptom Evaluation in Cancer Care had developed the Brief Pain Inventory (BPI), a pain assessment tool for use with cancer patients. The BPI measures both the intensity of pain (sensory dimension) and interference of pain in the patient's life (reactive dimension). The objective of this review paper was to provide a detailed update of existing evidence on applicability of BPI in evaluation of patients with cancer pain. The BPI demonstrated good construct and concurrent validity. It was translated and validated into many languages - Brazilian, Chinese, Greek, Hindi, Italian, Japanese, Korean, Malay, Norwegian, Polish, Russian, Spanish, Taiwanese and Thai. The BPI was validated in patient populations such as bone metastases, breast cancer and postoperative cancer patients. The BPI can be used both as a quantitative or a qualitative measure for statistical analysis. The BPI was a powerful tool and, having demonstrated both reliability and validity across cultures and languages, was being adopted in many countries for clinical pain assessment, epidemiological studies, and in studies on the effectiveness of pain treatment. Future studies are warranted on its responsiveness and cross-cultural adaptation into other cancer pain syndromes and into other Indian languages.

Symptom burden and quality of life in patients with malignant fungating wounds

AIM

This study describes the relationship between symptoms and quality of life in patients with malignant fungating wounds.

BACKGROUND

Malignant fungating wounds are complex wounds that can bleed, become malodorous due to infection and are painful causing physical and psychological distress. However, there is a lack of literature on the impact that such wounds can have on quality of life.

METHODS

This was a descriptive, cross-sectional multi-centre study of patients with malignant fungating wounds. Participants were recruited from the palliative care, hospice, outpatient clinic and oncology units of three medical centres in Taiwan. Data were collected from February 2008 to August 2009. A structured questionnaire obtained socio-demographic information, medical details, wound assessment information and the Taiwanese version of the McGill quality of life questionnaire was administered by interview.

RESULTS

  McGill quality of life scores indicated that the participants had the lowest quality of life. The participant's age, dressing change frequency, pain, wound dressing comfort, wound symptom, bleeding and malodour had statistically significant negative correlations with quality of life. Multiple regression analysis showed that age, malodour, pain issues and psychological issues explained 87% of the total variance in quality of life.

CONCLUSION

  This study contributes to our understanding of the impact of malignant fungating wounds and how correct assessment and management is necessary to improve quality of life. Educational intervention research is needed for patients and caregivers in countries where this has not yet been performed. Further research should also identify whether nursing competence has a direct impact on quality of life.

Rehabilitation of the hospice and palliative care patient

Disability is a common problem among hospice and palliative care patients. It leads to depression, poor quality of life, increased caregiver needs, health care resource utilization, and need for institutionalization. There is a growing body of evidence that rehabilitation interventions improve functional status, quality of life, and symptoms such as pain and anxiety in this population. Having adequate knowledge about rehabilitation is essential for the provision of comprehensive end-of-life care. The goals of this article are to review the role and benefits of rehabilitation in hospice and palliative care; to discuss the elements of patient assessment for rehabilitation including the use of functional assessment tools; and to review the roles of physical, occupational, and speech therapy in hospice and palliative care patients.

Physical exercise for cancer patients with advanced disease: a randomized controlled trial

BACKGROUND

Physical exercise can improve cancer patients' functioning and reduce their symptom levels. A randomized, controlled trial was launched to test the hypothesis that physical exercise reduces fatigue and improves physical performance in cancer patients with advanced and incurable disease.

METHODS

Cancer patients (n = 231) with a life expectancy ≤2 years were randomized to a physical exercise group (PEG, n = 121) or a control usual care group (UCG, n = 110). The PEG exercised under supervision 60 minutes twice a week for 8 weeks. Assessments were performed before and after the intervention. The primary outcome was physical fatigue (PF) measured by the Fatigue Questionnaire. Physical performance was a secondary outcome measured by the Shuttle Walk Test (SWT) and hand grip strength (HGS) test. Analyses were performed after multiple imputations for missing data. The trial is registered with ClinicalTrials.gov (identifier, NCT00397774).

FINDINGS

Thirty-six percent of the PEG were lost to follow-up compared with 23% of the UCG, primarily as a result of disease progression. Seventy-eight PEG and 85 UCG patients completed the intervention. Analyses showed no significant between-group effects in PF. However, clinically and statistically significant between-group effects were found for the SWT and HGS test.

INTERPRETATION

Fatigue was not reduced but physical performance (SWT and HGS test) was significantly improved after 8 weeks of physical exercise. Physical exercise might therefore be a suitable approach for maintaining physical capacity in cancer patients with incurable and advanced disease.

Linking health and health-related information to the ICF: a systematic review of the literature from 2001 to 2008

INTRODUCTION

In 1976, the World Health Organization (WHO) estimated worldwide disability prevalence at 10%; recent evidence suggests the prevalence is even higher. Given the extent of disability around the world, it is essential for researchers and policy makers to have a uniform language for describing and discussing disability. The International Classification of Functioning, Disability and Health (ICF) is WHO's attempt to provide that standard language. Linking rules were published in 2002 and 2005 suggesting a method for standardising the process of connecting outcome measures to the ICF classification. The objective of this study is to study the extent to which the linking rules have been used by researchers to link health and health-related information to the ICF and collect the feedback about the current practices, applications and areas to improve the linking method.

METHOD

Using a systematic review of health-based literature between 2001 and February 2008, we (1) determined research areas where the linking method is applied, (2) examined the characteristics of studies that linked information to the ICF and (3) described current practices and issues related to the process of linking health and health-related information to the ICF both quantitatively and qualitatively.

RESULTS

The systematic review yielded 109 articles from 58 journals that linked health information to the ICF and 58 of the articles employed published linking rules. The majority of articles were descriptive in nature, used linking for connecting content of health instruments to the ICF and linked English health content. Quality controls such as reliability checks, multiple raters and iterative linking processes were found frequently among users of the linking rules. Qualitative analysis created themes about: preparing units of information, who links to the ICF, reliability, matching or translating concepts from text to ICF categories, information unable or difficult to capture, quantitative reporting standards and overall linking process.

DISCUSSION

This review also shows that the linking process is a useful way to apply the ICF classification in research. With over 100 articles published in 58 peer-reviewed journals across 50 focus areas, linking health and health-related information to the ICF has been shown to be a useful tool for describing, comparing and contrasting information from outcome measures used to collect quantitative data, qualitative research results and clinical patient reports across diagnoses, settings, languages and countries.

Physical activity and palliative cancer care

Palliative care is an interdisciplinary and holistic approach aimed at alleviating suffering from physical, psychosocial, and spiritual issues in progressive, advanced disease. Progressive fatigue and anorexia-cachexia syndrome can contribute to loss of physical function in the palliative cancer patient, to the detriment of overall quality of life. Physical activity is one potential intervention, which may address these needs in the palliative cancer patient. There is preliminary evidence that at least some palliative cancer patients are willing and able to tolerate physical activity interventions, with some patients demonstrating improvement in select supportive care outcomes postintervention. Methodologically rigorous studies and consensus on common definitions are required to advance this area of research.

Systematic literature review on ICF from 2001 to 2009: its use, implementation and operationalisation

PURPOSE

To present a systematic literature review on the state of the art of the utilisation of the International Classification of Functioning, Disability and Health (ICF) since its release in 2001.

METHOD

The search was conducted through EMBASE, MEDLINE and PsychInfo covering the period between 2001 and December 2009. Papers were included if ICF was mentioned in title or abstract. Papers focussing on the ICF-CY and clinical research on children and youth only were excluded. Papers were assigned to six different groups covering the wide scenario of ICF application.

RESULTS

A total of 672 papers, coming from 34 countries and 211 different journals, were included in the analysis. The majority of publications (30.8%) were conceptual papers or papers reporting clinical and rehabilitation studies (25.9%). One-third of the papers were published in 2008 and 2009.

CONCLUSIONS

The ICF contributed to the development of research on functioning and on disability in clinical, rehabilitation as well as in several other contexts, such as disability eligibility and employment. Diffusion of ICF research and use in a great variety of fields and scientific journals is a proof that a cultural change and a new conceptualisation of functioning and disability is happening.

Content and spiritual items of quality-of-life instruments appropriate for use in palliative care: a review

Despite the importance of palliative care and quality of life (QoL) as an outcome measure, little research evaluated the QoL instruments that are used in end-of-life situations. We evaluated the content of and domains measured by QoL instruments that are suitable for use in palliative care and how the domain of spirituality was operationalized in these instruments. We conducted two literature reviews. One identified the domains that are most important for the QoL of incurably ill patients and resulted in a framework of QoL domains. The other review identified 29 instruments measuring (at least one domain of) QoL that are appropriate for use in palliative care. Most of the instruments covered only one or two QoL domains, and none of the instruments covered all QoL domains included in the framework. Among the 29 instruments, 15 included items on spirituality. We also categorized the spirituality items contained in the instruments into the spirituality aspects in the framework. Most spirituality items concerned the meaning or purpose of life. This study provides information about the domains included in QoL instruments that are suitable for use in palliative care and provides insights into the differences in content, which can be helpful when choosing an instrument for use in palliative care.

[Reliability of different criteria in identifying end-of-life trajectory of patients with chronic medical diseases. PALIAR Project]

INTRODUCTION

It is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations.

OBJECTIVES

To evaluate the sensitivity (Se), specificity (Sp), positive predictive values (PPV) and negative (NPV), and validity index (IV) of NHO criteria for terminal medical conditions, PPI and ECOG in patients with advanced heart, lung, liver, kidney and/or neurological diseases, and to build and validate an accurate index to determine this border-line.

METHODS

A multicentre prospective cohort study, with inclusion of patients with the predefined advanced medical diseases. Demographic, clinical, care, stratification and staging of disease(s), functional, analytical, NHO criteria, ECOG, PPS and PPI data collection; The end-point (death) will be assessed 180 days after inclusion. Analysis of Se, Sp, PPV, NPV, and IV of the NHO criteria, ECOG scale and PPI at 30, 60, 90, 120, 150 and 180 days. Derivation of PALIAR Index, after multivariate analysis and appropriate weighting of risk factors (beta of risk factor/lowest beta of the model), and validation in the validation cohort, and in the historical PROFUND cohort.

RESULTS

The project is still ongoing, with 50 investigators from 33 hospitals throughout Spain, who have already included 1138 patients (92.5% during hospital admissions, 51.4% of them are male, with a mean age of 78.5 years). Mean inclusion chronic diseases were 1.4 per patient (44.5% of patients suffered chronic neurological diseases, 38.6% with heart failure, 34.2% with lung diseases, 12% with liver diseases, and 6.5% with renal diseases). Around 69% fulfilled the criteria of polypathological patients (mean Charlson index 3.4), and were prescribed around 8 drugs chronically. Mean Barthel index was 40 points, and 77% of them were dependent on a caregiver. Around 46% were ECOG-PS stage III or IV, and mean PPS score was 45 points.

CONCLUSION

The availability of an accurate and powerful tool that could enable us to identify the end-of-life trajectory of these patients could allow us to establish specific intervention strategies for these populations. Therefore, and with these preliminary data, we believe that the PALIAR PROJECT will answer with rigour the questions and objectives of the study.

Functioning and health in patients with cancer on home-parenteral nutrition: a qualitative study

Background

Malnutrition is a common problem in patients with cancer. One possible strategy to prevent malnutrition and further deterioration is to administer home-parenteral nutrition (HPN). While the effect on survival is still not clear, HPN presumably improves functioning and quality of life. Thus, patients' experiences concerning functioning and quality of life need to be considered when deciding on the provision of HPN. Currently used quality of life measures hardly reflect patients' perspectives and experiences. The objective of our study was to investigate the perspectives of patients with cancer on their experience of functioning and health in relation to HPN in order to get an item pool to develop a comprehensive measure to assess the impact of HPN in this population.

Methods

We conducted a series of qualitative semi-structured interviews. The interviews were analysed to identify categories of the International Classification of Functioning, Disability and Health (ICF) addressed by patients' statements. Patients were consecutively included in the study until an additional patient did not yield any new information.

Results

We extracted 94 different ICF-categories from 16 interviews representing patient-relevant aspects of functioning and health (32 categories from the ICF component 'Body Functions', 10 from 'Body Structures', 32 from 'Activities & Participation', 18 from 'Environmental Factors'). About 8% of the concepts derived from the interviews could not be linked to specific ICF categories because they were either too general, disease-specific or pertained to 'Personal Factors'. Patients referred to 22 different aspects of functioning improving due to HPN; mainly activities of daily living, mobility, sleep and emotional functions.

Conclusions

The ICF proved to be a satisfactory framework to standardize the response of patients with cancer on HPN. For most aspects reported by the patients, a matching concept and ICF category could be found. The development of categories of the component 'Personal Factors' should be promoted to close the existing gap when analyzing interviews using the ICF. The identification and standardization of concepts derived from individual interviews was the first step towards creating new measures based on patients' preferences and experiences which both catch the most relevant aspects of functioning and are sensitive enough to monitor change associated to an intervention such as HPN in a vulnerable population with cancer.

Conducting Outcomes Research in Pediatric Palliative Care

Around the globe, health care costs continue to rise resulting in the emphasis on allocating scarce resources toward interventions that have been found to be cost- and clinically effective. Palliative care is no exception, yet the science of outcomes measurement in palliative care, and especially in pediatric palliative care, lags behind other disciplines. National and international experts and organizations have recognized the importance of outcomes measurement and have included this as a research priority. This article outlines some of the complexities of measuring outcomes in pediatric palliative care. It is recommended that national and international collaborations include representatives of the pediatric palliative care community.

Evaluation of quality-of-life measures for use in palliative care: a systematic review

PURPOSE

In this literature review we evaluated the feasibility and clinimetric quality of quality-of-life (QoL) measurement instruments suitable for use in palliative care.

METHODS

We conducted a systematic literature review to identify instruments measuring (at least one domain of) QoL. We selected articles that present data on patients receiving palliative care and at least one measurement property. A checklist was used to describe the characteristics of the instruments, and a widely accepted rating list was used to evaluate the clinimetric aspects.

RESULTS

29 instruments were identified and evaluated, most of which were targeted at palliative patients in general. None of the instruments demonstrated satisfactory results for all measurement properties. Fourteen instruments received positive ratings for construct validity. Thirteen instruments were tested for reliability, but only two were tested adequately and had positive results (ICC>0.70). Responsiveness was not tested adequately for any of the instruments. Very few of the studies provided information on the interpretation of the scores. Overall, the MQOL, followed by the QUAL-E and the QODD, received the best ratings for their measurement properties.

CONCLUSIONS

Many measurement instruments were identified, but most had not yet been adequately evaluated. The evaluation of existing instruments with good content validity should have priority over the development of new instruments.

Associations between physical activity and quality of life in cancer patients receiving palliative care: a pilot survey

The primary aim of this study was to examine the association between physical activity and quality of life (QoL) in cancer patients receiving palliative care. Fifty advanced cancer patients aged 18 years or older with clinician-estimated life expectancy of 3-12 months and Palliative Performance Status Scale scores greater than 30% were recruited from an outpatient palliative care clinic and palliative home care. Participants completed a cross-sectional survey by means of face-to-face interview assessing self-reported QoL (McGill Quality of Life Questionnaire [MQOL]), self-reported physical function (Late-Life Function and Disability Instrument), symptoms (Edmonton Symptom Assessment System), and physical activity behavior. Seventy-six percent (38 of 50) of the participants were deceased at the time of data analysis, with a median survival of 104 days from time of survey to time of death. Walking was the most common reported physical activity. Analyses of variance indicated that participants who reported walking more than 30 minutes per day also reported higher existential subscores (+/-0.8 [95% CI, 0.0-1.5]; P=0.045), support subscores (+/-0.7 [95% CI, 0.1-1.4]; P=0.027), and total scores (+/-0.5 [95% CI, 0.0-0.9]; P=0.046) on the MQOL. There were no significant differences for self-reported physical function or symptoms. Our findings show a significant positive association between physical activity and QoL scores in this sample of patients with advanced cancer. A pilot intervention trial testing the causal effects of physical activity on QoL in cancer patients receiving palliative care is warranted.

Effects of exercise intervention on persons with metastatic cancer: a systematic review

PURPOSE

To systematically review and synthesize results of studies that examined the effects of exercise on persons with metastatic cancer.

METHODS

Databases searched were MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials. Search terms used were "metastatic or advanced or palliative AND cancer or neoplasms AND exercise or physical activity or exercise therapy or physical fitness." The search identified 8 studies published in 10 articles between 2000 and 2007. Two quality-assessment tools were used, and levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine (CEBM) guidelines.

RESULTS

Of the eight studies, three were randomized controlled trials (RCTs) and five were case series. Because three of the RCTs were based on the same sample, only one was included in the results and discussion sections. CEBM levels of evidence ranged from 2b to 4. Two overall recommendations were made, one grade A and one grade C. Exercise interventions ranged from aerobic exercise and strength training to multidimensional programmes with exercise as one component. All studies used physical and/or quality-of-life outcome measures.

CONCLUSIONS

Review findings suggest that exercise may be beneficial for persons with metastatic cancer. Future research should clarify optimal exercise dose parameters.

A first step in the development of an international self-report instrument for physical functioning in palliative cancer care: a systematic literature review and an expert opinion evaluation study

Decline in physical functioning (PF) in progressive cancer increases risk of psychological problems, dependence, and distress, and it considerably affects quality of life. Despite this, assessment of PF has received little attention. Standardized, internationally endorsed assessment tools are needed that assess activities of relevance to palliative cancer patients from very low to high levels of PF. This study was done in cooperation with the European Association for Palliative Care Research Network. It was initiated to develop a computer-based symptom-assessment tool and aimed to 1) identify relevant existing PF-assessment instruments, 2) extract relevant items and classify them into meaningful subdimensions, and 3) construct unidimensional scales of selected PF domains. A systematic literature review was performed to detect relevant PF items from existing instruments. The International Classification of Functioning and Health was used to decide relevant subdimensions of PF, and expert panels within palliative cancer care were consulted to make decisions on activities to be included. One hundred and thirty-five instruments containing 743 items were included from the literature review. Two relevant PF subdimensions were revealed: Mobility (386 items representing 65 different activities) and Self-Care (143 items representing 30 different activities). The final PF tool consisted of two unidimensional scales: 24 hierarchically ranked Mobility items ranging from turning in bed to running, and 16 non-hierarchically ranked Self-Care items. Further testing of the instrument in a palliative cancer population is needed to develop the final PF instrument.

Symptom Assessment in Palliative Care: A Need for International Collaboration

This article describes the research strategy for the development of a computerized assessment tool as part of a European Union (EU)–funded project, the European Palliative Care Research Collaborative (EPCRC). The EPCRC is funded through the Sixth Framework Program of the EU with major objectives to develop a computer-based assessment and classification tool for pain, depression, and cachexia. A systematic approach will be applied for the tool development with emphasis on multicultural and multilanguage challenges across Europe. The EPCRC is based on a long lasting collaboration within the European Association for Palliative Care Research Network. The ongoing change in society towards greatly increased use of communication as well as information transfer via digital systems will rapidly change the health care system. Therefore, patient-centered outcome assessment tools applicable for both clinic and research should be developed. Report of symptoms via digital media provides a start for face-to-face communication, treatment decisions, and assessment of treatment effects. The increased use of electronic media for exchange of information may facilitate the development and use of electronic assessment tools and decision-making systems in oncology. In the future, patients may find that a combination of a face-to-face interview plus a transfer of information of subjective symptoms by electronic means will optimize treatment.

A reliability and validity study of the Palliative Performance Scale

Background

The Palliative Performance Scale (PPS) was first introduced in1996 as a new tool for measurement of performance status in palliative care. PPS has been used in many countries and has been translated into other languages.

Methods

This study evaluated the reliability and validity of PPS. A web-based, case scenarios study with a test-retest format was used to determine reliability. Fifty-three participants were recruited and randomly divided into two groups, each evaluating 11 cases at two time points. The validity study was based on the content validation of 15 palliative care experts conducted over telephone interviews, with discussion on five themes: PPS as clinical assessment tool, the usefulness of PPS, PPS scores affecting decision making, the problems in using PPS, and the adequacy of PPS instruction.

Results

The intraclass correlation coefficients for absolute agreement were 0.959 and 0.964 for Group 1, at Time-1 and Time-2; 0.951 and 0.931 for Group 2, at Time-1 and Time-2 respectively. Results showed that the participants were consistent in their scoring over the two times, with a mean Cohen's kappa of 0.67 for Group 1 and 0.71 for Group 2. In the validity study, all experts agreed that PPS is a valuable clinical assessment tool in palliative care. Many of them have already incorporated PPS as part of their practice standard.

Conclusion

The results of the reliability study demonstrated that PPS is a reliable tool. The validity study found that most experts did not feel a need to further modify PPS and, only two experts requested that some performance status measures be defined more clearly. Areas of PPS use include prognostication, disease monitoring, care planning, hospital resource allocation, clinical teaching and research. PPS is also a good communication tool between palliative care workers.

Diagnostic criteria of cachexia and their assessment: decreased muscle strength and fatigue

PURPOSE OF REVIEW

The classification of cachexia or wasting disease is currently being revised to improve clinical trial design and clinical care. Decreased muscle strength and fatigue are proposed as diagnostic criteria for cachexia or wasting disease including, but not limited to, cancer. This review discusses their expected value in cancer cachexia.

RECENT FINDINGS

Fatigue is frequent and multifactorial in cancer patients with limited value to predict cachexia, however, most cachectic patients have fatigue. Its assessment requires multimodal subjective instruments, for outcome monitoring many other fatigue cofactors need to be controlled. Cachexia seems a dominant cause for decreased muscle strength. Most cachectic patients lose muscle strength, usually together with reduced muscle mass. High-individual variability of muscle strength limits its use to longitudinal monitoring. Physical activity monitoring, applying also body-worn sensors, offers additional monitoring tools.

SUMMARY

To diagnose and monitor cachexia, muscle strength should be measured directly, whereas fatigue is seen as a global outcome.

Health-related quality of life during the last three months of life in patients with advanced cancer

GOALS OF WORK

The aim of the study was to explore the development of functioning impairments and symptom occurrence during the last months of life of advanced cancer patients.

MATERIALS AND METHODS

Self-reported data from 116 patients who all completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) at 3, 2 and 1 month before death were analysed.

MAIN RESULTS

All functioning aspects deteriorated. For physical, cognitive and social function, the most marked changes occurred between 2 and 1 month before death. The proportion reporting serious difficulties with self-care activities increased from 14% to 43%. The most seriously affected activity could not be distinguished from the EORTC QLQ-C30 scores. Levels of fatigue, dyspnoea and appetite loss increased significantly. More than 50% of the patients had severe pain at all assessments, and only a minor number (8%) reported any improvement.

CONCLUSIONS

The findings have implications for the planning of care and indicate that further research is required to improve assessment, treatment and follow-up procedures. Adequate pain treatment seems still to be a challenge. Anorexia, fatigue as well as dyspnoea are all symptoms that need further focus.