Report on palliative sedation medication usage: a survey of palliative care experts in Eight European countries

BACKGROUND

The practice of palliative sedation continues to raise ethical questions among people, which in turn leads to its varied acceptance and practice across regions. As part of the Palliative Sedation European Union (EU) project, the aim of the present study was to determine the perceptions of palliative care experts regarding the practice of palliative sedation in eight European countries (The Netherlands, Belgium, Germany, UK, Italy, Spain, Hungary, and Romania).

METHODS

A specifically designed survey, including questions on the most frequently used medications for palliative sedation, their availability per countries and settings, and the barriers and facilitators to the appropriate practice of palliative sedation was sent to expert clinicians involved and knowledgeable in palliative care in the indicated countries. A purposive sampling strategy was used to select at least 18 participating clinicians per consortium country. Descriptive statistical analysis was conducted on the survey data.

RESULTS

Of the 208 expert clinicians invited to participate, 124 participants completed the survey. Midazolam was perceived to be the most frequently used benzodiazepine in all eight countries. 86% and 89% of expert clinicians in Germany and Italy, respectively, perceived midazolam was used "almost always", while in Hungary and Romania only about 50% or less of the respondents perceived this. Levomepromazine was the neuroleptic most frequently perceived to be used for palliative sedation in the Netherlands, Spain, Germany, and the United Kingdom. Between 38- 86% of all eight countries´ expert clinicians believed that opioid medications were "almost always" used during palliative sedation. The perceived use of IV hydration and artificial nutrition "almost always" was generally low, while the country where both IV hydration and artificial nutrition were considered to be "very often" given by a third of the expert clinicians, was in Hungary, with 36% and 27%, respectively.

CONCLUSIONS

Our study provides insight about the differences in the perceived practice of medication during palliative sedation between eight European countries. In countries where palliative care services have been established longer perceptions regarding medication use during palliative sedation were more in line with the recommended European guidelines than in Central and Eastern European countries like Romania and Hungary.

Quality of Life and Side Effects Management in Cancer Treatment-A Cross Sectional Study

Cancer disease is a world problem which is increasing in its prevalence. Oncology patients have a multitude of symptoms derived from the treatments and from the disease itself that affect their quality of life to a greater or lesser extent. The aim of this study has been to discover the physical and psychological symptoms related to chemotherapy treatment in Spanish cancer patients in order to improve their quality of life. Symptoms from the previous week were taken into account and the Memorial Symptom Assessment Scale was used to measure the frequency, severity and associated distress of 32 symptoms. A total of 246 chemotherapy patients at the University Day Hospital in Salamanca completed the scale once while receiving chemotherapy treatment. A 95% confidence interval was considered. The most prevalent symptoms were a lack of energy (76.4%), anxiety (66.7%) and a dry mouth (60.6%). Lung cancer was the most prevalent cancer in men (26%) and breast cancer was the most prevalent cancer in women (72%). There is no consensus on which is the most prevalent symptom in this population and more studies will need to be carried out to determine the best treatment protocols. Symptom's prevalence knowledge could improve the patients' care to prevent or avoid complications and to improve the cancer patients' quality of life.

Comparison of the prevalence and associated factors of hyperactive delirium in advanced cancer patients between inpatient palliative care and palliative home care

Background

Hyperactive delirium is known to increase family distress and the burden on health care providers. We compared the prevalence and associated factors of agitated delirium in advanced cancer patients between inpatient palliative care and palliative home care on admission and at 3 days before death.

Methods

This was a post hoc exploratory analysis of two multicenter, prospective cohort studies of advanced cancer patients, which were performed at 23 palliative care units (PCUs) between Jan and Dec 2017, and on 45 palliative home care services between July and Dec 2017.

Results

In total, 2998 patients were enrolled and 2829 were analyzed in this study: 1883 patients in PCUs and 947 patients in palliative home care. The prevalence of agitated delirium between PCUs and palliative home care was 5.2% (95% CI: 4.2% ‐ 6.3%) vs. 1.4% (0.7% ‐ 2.3%) on admission (p < 0.001) and 7.6% (6.4% ‐ 8.9%) vs. 5.4% (4.0% ‐ 7.0%) 3 days before death (p < 0.001). However, multivariate logistic regression analysis revealed that the place of care was not significantly associated with the prevalence of agitated delirium at 3 days before death after adjusting for prognostic factors, physical risk factors, and symptoms.

Conclusions

There was no significant difference in the prevalence of agitated delirium at 3 days before death between inpatient palliative care and palliative home care after adjusting for the patient background, prognostic factors, symptoms, and treatment.

Dignity in Dying: A Preliminary Study of Patients in the Last Three Days of Life

The final three days of life of 50 consecutive patients on a busy integrated palliative care service is described, with regard to final cause of death, symptom control, drug prescription, retention of personal function, and other measures possibly relevant to dignity in dying. Good symptom relief was maintained without rapid or high escalation of doses of morphine or sedatives. Personal function was maintained in at least a moderate degree in the majority of patients. This study also illustrates some of the difficulties in describing and evaluating the concept of “dying with dignity”.

The nature of nausea: prevalence, etiology, and treatment in patients with advanced cancer not receiving antineoplastic treatment

BACKGROUND

The prevalence of nausea/vomiting in patients with advanced cancer has a wide range. Due to a very low level of evidence regarding antiemetic treatment, current guidelines recommend an etiology-based approach. The evidence for this approach is also slim and research is urgently needed.

OBJECTIVES

(Part One) to elucidate the prevalence of nausea and the possible associations with sociodemographic and clinical variables and (Part Two) to investigate possible etiologies of nausea and antiemetic treatments initiated in patients with nausea.

METHODS

Patients with advanced cancer and no recent antineoplastic treatment were included in a prospective two-part study. In Part One, patients completed an extended version of the EORTC QLQ-C15-PAL. Nauseated patients could then be included in Part Two in which possible etiologies and antiemetic treatment were recorded and a follow-up questionnaire was completed.

RESULTS

Eight hundred twenty-one patients were included and 46% reported any degree of nausea. Younger age and female sex were associated with a higher degree of nausea. Common etiologies included constipation, opioid use, and "other," and treatments associated with a statistically significant decrease in nausea/vomiting were olanzapine, laxatives, corticosteroids, domperidone, and metoclopramide.

CONCLUSION

Nausea was a common symptom in this patient population and many different etiologies were suggested. Most patients reported a lower degree of nausea at follow-up. More research in treatment approaches and specific antiemetics is strongly needed.

Quality of Life and Symptom Burden in Cancer Patients Admitted to An Acute Palliative Care Unit

This paper describes the quality of life and symptom burden of 211 cancer patients admitted to an acute palliative care unit (PCU) in a comprehensive cancer centre. Participants completed the McGill Quality of Life Questionnaire (MQOL), Edmonton Symptom Assessment Scale (ESAS), Short Orientation-Memory-Concentration Test, and Palliative Performance Scale within 24 hours of admission to the PCU. The mean MQOL total was 6.1±1.4, and the mean single-item scale score was 4.9±2.4. The mean total ESAS score was 36.3±15.8, with a median of six reported symptoms. Women and younger patients reported a lower quality of life (QoL) and a higher symptom burden. Regression and correlational analyses highlighted the importance of the existential and psychological domains to overall QoL. These findings emphasize the need for interdisciplinary, collaborative approaches to managing the complex physical, psychosocial, and existential needs of cancer patients admitted to acute PCUs.

Nausea in advanced cancer: relationships between intensity, burden, and the need for help

PURPOSE

This study aimed at expanding the knowledge of nausea in patients with advanced cancer by elucidating (a) the prevalences of patients having nausea, experiencing nausea as a problem, and having a need for help with their nausea, respectively, (b) determining variables associated with nausea, and (c) investigating the relation between nausea and the need for help regarding nausea.

METHODS

In 2004-2006, the EORTC QLQ-C30 and the Three-Levels-of-Needs Questionnaire (3LNQ) were mailed to 2364 patients with advanced cancer who had been in contact with one of the 54 hospital departments within the past year. Further information was collected from medical records.

RESULTS

Patient-response rate was 61%. Twenty-two percent reported having had some degree of nausea within the past week, with a mean nausea score of 10.4 and a two-item combined nausea and vomiting score of 7.5 (0-100, 100 = "very much"). Factors associated with nausea on the multivariate level were contact type (inpatient/outpatient) and treatment status (receiving ongoing oncologic treatment yes/no). "Nausea intensity" and "nausea problem burden" showed acceptable abilities to distinguish between patients having or not having an unmet need for help regarding nausea with areas under the curve (AUCs) of 0.81 and 0.82, respectively.

CONCLUSIONS

Around one in four patients with advanced cancer reported nausea within the past week, highest in patients who were inpatients or undergoing active oncologic treatment. Almost all patients reporting nausea on the EORTC QLQ-C30 experienced this to be a problem, and the 3LNQ can therefore be restricted to cases where additional details are needed.

The Rotterdam Elderly Pain Observation Scale (REPOS) is reliable and valid for non-communicative end-of-life patients

BACKGROUND

In palliative care, administration of opioids is often indispensable for pain treatment. Pain assessment may help recognize pain and guide treatment in non-communicative patients. In the Netherlands the Rotterdam Elderly Pain Observation Scale (REPOS) is recommended to this aim, but not yet validated. Therefore the objective of this study was to validate the REPOS in non-communicative or unconscious end-of-life patients.

METHODS

In this observational study, the primary researcher applied the REPOS, while both the researcher and a nurse applied the Numeric Rating Scale (NRS). If possible, the patient in question applied the NRS as well. The NRS scores were compared with the REPOS scores to determine concurrent validity. REPOS scores obtained before and after a pain-reducing intervention were analysed to establish the scale's sensitivity to change.

RESULTS

A total of 183 REPOS observations in 100 patients were analysed. Almost 90% of patients had an advanced malignancy; observations were done a median of 3 days (IQR 1 to 13) before death. Internal consistency of the REPOS was 0.73. The Pearson product moment correlation coefficient ranged from 0.64 to 0.80 between REPOS and NRS scores. REPOS scores declined with median 2 points (IQR 1 to 4) after a pain-reducing intervention (p < 0.001). Optimal sensitivity (0.81) and specificity (0.62) were found at cut-off score 3.

CONCLUSIONS

This study demonstrates that the REPOS has promising psychometric properties for pain assessment in non-communicative end-of-life patients. Its application may be of additional value to relieve suffering, including pain, in palliative care.

Urinary Retention and Medication Utilization on a Palliative Care Unit: A Retrospective Observational Study

Urinary retention is a common problem at end-of-life that may be a result of medications used to control other symptoms. To determine whether use of retention-causing drugs was associated with catheterization for urinary retention among palliative care unit (PCU) patients, the authors reviewed charts of 91 consecutively admitted patients to a hospital-based PCU. Utilization of eight classes of retention-causing medications (opioids, antidopaminergics, benzodiazepines, anticholinergics, antidepressants, calcium channel antagonists, nonsteroidal anti-inflammatory drugs [NSAIDs], and H1 histamine antagonists) was compared between those catheterized for urinary retention (n = 34) and those never catheterized (n = 31). All patients used medication from more than one class of retention-causing medication. A statistically significant association with urinary retention occurred for antidopaminergic medications, but not other drug classes. The total number of classes of retention-causing medications was not associated with catheterization. These findings question whether urinary retention need hinder medication use for symptom management at end-of-life. Tapering of antidopaminergic medications, compared with other drug classes studied, may be more likely to resolve retention.

Corticosteroids for adult patients with advanced cancer who have nausea and vomiting (not related to chemotherapy, radiotherapy, or surgery)

BACKGROUND

Nausea is a common symptom in advanced cancer, with a prevalence of up to 70%. While nausea and vomiting can be related to cancer treatments, such as chemotherapy, radiotherapy, or surgery, a significant number of people with advanced cancer also suffer from nausea unrelated to such therapies. Nausea and vomiting may also cause psychological distress, and have a negative impact on the quality of life of cancer patients; similarly to pain, nausea is often under-treated. The exact mechanism of action of corticosteroids on nausea is unclear, however, they are used to manage a number of cancer-specific complications, including spinal cord compression, raised intracranial pressure, and lymphangitis carcinomatosis. They are also commonly used in palliative care for a wide variety of non-specific indications, such as pain, nausea, anorexia, fatigue, and low mood. However, there is little objective evidence of their efficacy in symptom control, and corticosteroids have a wide range of adverse effects that are dose and time dependent. In view of their widespread use, it is important to seek evidence of their effects on nausea and vomiting not related to cancer treatment.

OBJECTIVES

To assess the effects of corticosteroids on nausea and vomiting not related to chemotherapy, radiotherapy, or surgery in adult cancer patients.

SEARCH METHODS

We searched CENTRAL, MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, Science Citation Index Web of Science, Latin America and Caribbean Health Sciences (LILACS), Conference Proceedings Citation Index - Science Web of Science, and clinical trial registries, from inception to 23rd August 2016.

SELECTION CRITERIA

Any double-blind randomised or prospective controlled trial that included adults aged 18 years and over with advanced cancer with nausea and vomiting not related to chemotherapy, radiotherapy, or surgery were eligible for the review, when using corticosteroids as antiemetic treatment.

DATA COLLECTION AND ANALYSIS

All review authors independently assessed trial quality and extracted data. We used arithmetic means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). We assessed the quality of the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

Three studies met the inclusion criteria, enrolling 451 participants. The trial size varied from 51 to 280 participants. Two studies compared dexamethasone to placebo, and the third study compared a number of additional interventions in various combinations, including metoclopramide, chlorpromazine, tropisetron, and dexamethasone. The duration of the studies ranged from seven to 14 days. We included two studies (127 participants) with data at eight days in the meta-analysis for nausea intensity; no data were available that incorporated the same outcome measures for the third study. Corticosteroid therapy with dexamethasone resulted in less nausea (measured on a scale of 0 to 10, with a lower score indicating less nausea) compared to placebo at eight days (MD 0.48 lower nausea, 95% CI 1.53 lower to 0.57 higher; very low-quality evidence), although this result was not statistically significant (P = 0.37). Frequency of adverse events was not significantly different between groups, and the interventions were well tolerated. Factors limiting statistical analysis included the lack of standardised measurements of nausea, and the use of different agents, dosages, and comparisons. Subgroup analysis according to type of cancer was not possible due to insufficient data. The quality of this evidence was downgraded by three levels, from high to very low due to imprecision, likely selection bias, attrition bias, and the small number of participants in the included studies.

AUTHORS' CONCLUSIONS

There are few studies assessing the effects of corticosteroids on nausea and vomiting not related to chemotherapy, radiotherapy, or surgery in adult cancer patients. This review found very low-quality evidence which neither supported nor refuted corticosteroid use in this setting. Further high quality studies are needed to determine if corticosteroids are efficacious in this setting.

A palliative medicine program in a community setting: 12 points from the first 12 months

This paper reports the first year’s experience of a consultative, interdisciplinary, integrated palliative medicine program in a community hospital system. Prospective data collection was performed on 308 consecutive consultations. A computer database was developed and used to analyze demographics, reason for consultation, complexity of medical problems, current medications and allergies, physical suffering, spiritual concerns, personal and family concerns, consult recommendations, and mortality. In addition, data were collected on patient rating of the severity of physical symptoms, pain, spiritual suffering, and personal and family suffering; this data also was analyzed using the database.

Cancer was the most frequent diagnosis (34 percent) and pain the most common reason for consultation (43 percent). Population medians were identified as follows: five (range, 1 to 10) acute medical problems; three (range, 1 to 10) chronic medical problems; and one (range, 0 to 10) medication allergy/intolerance. Patients were taking a median of 10 (range, 0 to 29) medications, including a median of two analgesics. Eighty percent could communicate concerning physical symptoms and had a median of two (range, 0 to 7) bothersome symptoms, with pain the most frequent. Fifty percent or fewer could rate physical suffering, pain, hope, spiritual suffering, or personal/family suffering using a 0 to 10 scale at consultation. Individual patient ratings provided over time for physical suffering, pain, hope, spiritual suffering, and personal/family suffering were available for less than 25 percent. A median of eight recommendations was made for each consultation, with medication changes suggested for 84 percent. For those known to have died, the median survival from time of consultation to death was 11 days.

Terminal restlessness as perceived by hospice professionals

Any hospice professional can identify the syndrome known as terminal restlessness, and all would agree that it is extremely distressing to patients as well as their families and care-givers. Often, caregivers cannot ameliorate the anguish many patients experience at life’s end. Many clinicians assert that the causes are physical resulting from medication toxicity, organ shutdown and the associated metabolic changes, pain, urinary or fecal retention, dyspnea and related hypoxia, and sepsis. Yet, many also credit psychosocial and spiritual distress as precipitating factors.

The purposes of this study were twofold: to compare the perceptions of practicing hospice clinicians with the literature related to terminal restlessness, and to determine if their experience with terminal restlessness agreed with the components of the one established scale for terminal restlessness found in the literature.

In general, the study findings corresponded to the literature in regards to frequency, definition, causes, and behavioral manifestations of terminal restlessness. The clinicians in the study supported the impact of psychosocial and spiritual causes of terminal restlessness and defined the phenomenon in terms of time period; emotional, physical, and spiritual distress; changes in consciousness; and increased activity. However, the study did not support the inclusion of impaired consciousness and withdrawal as comprised in the terminal restlessness scale.

How far along the disease trajectory? An examination of the time-related patient characteristics in the palliative oncology literature

PURPOSE

Adequate reporting of time-related patient characteristics is needed for research findings to be properly interpreted, applied, and reproduced. Our objective was to characterize the time-related patient characteristics in palliative oncology studies and to examine the differences in time-related patient characteristics by various study characteristics.

METHODS

We extracted time-related patient characteristics including actual survival, performance status, cancer stage, disease trajectory, study setting, and eligibility criteria (life expectancy and performance status) from an established cohort of original palliative oncology articles published in 2004 and 2009.

RESULTS

Among 742 original articles, 409 (55 %) were case series. Only 247 (33 %) articles reported actual survival, 157 (21 %) reported actual performance status, 362 (49 %) cancer stage, and 392 (53 %) reported study setting. Based on all the available time-related characteristics, we were able to classify the studies into specific time-related categories in 378 (51 %) studies. Among these, only 47 (13 %) focused on patients in the last month of life. Compared to studies involving patients earlier in the disease trajectory, these studies were more likely to be case series (81 vs. 56 %, P = 0.005), retrospective (64 vs. 49 %, P = 0.03), and had a smaller sample size (median 20 vs. 61, P = 0.06).

CONCLUSIONS

A majority of studies did not adequately report time-related patient characteristics. We also identified a gap in both the quantity and quality of studies involving patients in the last month of life. Our study has implications for study reporting and future directions for palliative oncology research.

The effect of a care bundle on nursing staff when caring for the dying

BACKGROUND

Most Australians die in acute hospital settings. Despite this, hospitals remain ill-equipped to care for dying patients with hospital deaths not uncommonly perceived as distressing by both patients and their families. As a quality improvement project, a care bundle for the dying was developed and piloted on two medical wards. The aim of this study was to examine whether or not the quality initiative had any effect on the ward nurse's attitudes and self-assessed competency to care for dying patients.

METHODS

A pre- and post-survey using self-administered questionnaires were given to nursing staff who voluntarily completed these before and after implementation of the caring for the dying bundle.

RESULTS

Over the 6 months the bundle was piloted, 74.5% of people who died did so with the bundle in place. While this was seen as clinically useful by nearly half the nurses who responded, there was not a significant change in the staff's attitudes or self-assessed competency to care for dying patients. There was a minor change in the Thanatophobia Scale (pre 18.2: SD±9.0 versus post 16.8: SD 7.8; P=0.53), the Self-efficacy in Palliative Care Scale for communication (pre 47.4: SD ±17.4 versus post 54.7:SD±17.9; P=0.11) and patient management respectively (pre 54.3: SD ±12.9 versus 59.1: SD ±12.6; P=0.15).

DISCUSSION

This work highlighted that at least in the short term, that a quality initiative had only a modest impact on nursing attitudes to caring for dying patients. However, as a collection of clinical tools grouped as a care bundle, a proportion of nursing staff acknowledged this initiative as useful.

CONCLUSION

Further research is required to understand if such an initiative approach may, in the long term, positively impacts attitude. This is highly relevant given the increasing numbers of people likely to die in acute care.

Walking the line. Palliative sedation for existential distress: still a controversial issue?

Adequate symptom relief is a central aspect of medical care of all patients especially in those with an incurable disease. However, as an illness progresses and the end of life approaches, physical or psychoexistential symptoms may remain uncontrollable requiring palliative sedation. Although palliative sedation has become an increasingly implemented practice in the care of terminally ill patients, sedation in the management of refractory psychological symptoms and existential distress is still a controversial issue and much debated. This case report presents a patient who received palliative sedation for the treatment of existential distress and discusses considerations that may arise from such a therapeutic approach.

Attitudes Regarding Palliative Sedation and Death Hastening Among Swiss Physicians: A Contextually Sensitive Approach

In Switzerland, where assisted suicide but not euthanasia is permitted, the authors sought to understand how physicians integrate palliative sedation in their practice and how they reflect on existential suffering and death hastening. They interviewed 31 physicians from different care settings. Five major attitudes emerged. Among specialized palliative care physicians, convinced, cautious and doubtful attitudes were evident. Within unspecialized settings, palliative sedation was more likely to be considered as death hastening: clinicians either avoid it with an inexperienced attitude or practice it with an ambiguous attitude, raising the issue of unskilled and abusive uses of sedatives at the end of life.

Evidence for the use of Levomepromazine for symptom control in the palliative care setting: a systematic review

BACKGROUND

Levomepromazine is an antipsychotic drug that is used clinically for a variety of distressing symptoms in palliative and end-of-life care. We undertook a systematic review based on the question "What is the published evidence for the use of levomepromazine in palliative symptom control?".

METHODS

To determine the level of evidence for the use of levomepromazine in palliative symptom control, and to discover gaps in evidence, relevant studies were identified using a detailed, multi-step search strategy. Emerging data was then scrutinized using appropriate assessment tools, and the strength of evidence systematically graded in accordance with the Oxford Centre for Evidence-Based Medicine's 'levels of evidence' tool. The electronic databases Medline, Embase, Cochrane, PsychInfo and Ovid Nursing, together with hand-searching and cross-referencing provided the full research platform on which the review is based.

RESULTS

33 articles including 9 systematic reviews met the inclusion criteria: 15 on palliative sedation, 8 regarding nausea and three on delirium and restlessness, one on pain and six with other foci. The studies varied greatly in both design and sample size. Levels of evidence ranged from level 2b to level 5, with the majority being level 3 (non-randomized, non-consecutive or cohort studies n = 22), with the quality of reporting for the included studies being only low to medium.

CONCLUSION

Levomepromazine is widely used in palliative care as antipsychotic, anxiolytic, antiemetic and sedative drug. However, the supporting evidence is limited to open series and case reports. Thus prospective randomized trials are needed to support evidence-based guidelines.

The use of massage therapy for reducing pain, anxiety, and depression in oncological palliative care patients: a narrative review of the literature

A considerable number of cancer patients use complementary medicine therapies in order to alleviate different symptoms such as pain, anxiety, and depression, occurring in connection with cancer. This paper explores the question to what extent massage therapies are able to reduce the amount of pain, anxiety, and depression. For this purpose, a systematic literature analysis was carried out in the electronic databases and specialist journals. There is already evidence that massage therapies can influence the symptoms of pain, anxiety, and depression in a positive way.

Opioid Use amongst Cancer Patients at the End of Life

Introduction: Concerns about the life shortening effect of opioids is a well known fact in the medical world when considering administration of these drugs for symptom alleviation at end of life. This study described the patterns of opioid use among cancer patients referred to a hospital-based specialist palliative care service for symptom management. This study also examined whether opioid use among terminally ill cancer patients during the last 2 days of life had any influence on survival. Materials and Methods: A retrospective review of case notes of patients who were diagnosed with terminal cancer and had passed away in a 95-bedded oncology ward between September 2006 and September 2007 was conducted. Data were collected on patients’ characteristics and patterns of opioid use including opioid doses and dose changes at 48 hours and 24 hours before death. Results: There were 238 patients who received specialist palliative care, of whom 132 (55.5%) were females. At 48 hours and 24 hours before death, 184 (77.3%) patients and 187 (78.6%) patients had received opioids, respectively. The median daily doses at 48 hours and 24 hours were 48 mg and 57 mg oral morphine equivalent doses (OME), respectively. Indications for opioid use were pain (41.1%), dyspnoea, (29.1%) and both dyspnoea and pain (30.8%). In the final 24 hours, 22.3% patients had a reduction in their mean opioid dose while 22.7% required an increase in their mean opioid dose. Increased age was associated with decreasing opioid doses (P = 0.003). Patients with spinal metastases required higher doses of opioids (P = 0.03) while those with lung metastases required lower doses (P = 0.011). Survival analysis using Kaplan-Meier survival curve revealed no significant survival difference between those who were on opioids and those who were not. Log rank test (Mantel-Cox) (P = 0.69). Conclusion: Our results showed that opioids are safe medications for symptom alleviation in terminally ill cancer patients during the last days of life and have no deleterious influence on survival. Key words: Palliative care, Survival analysis, Terminal cancer

Comfort measures: practical care of the dying cancer patient

Most patients with advanced malignancy will die of their disease. Care of the dying is therefore a fundamental skill for the oncologist. Although protocols exist in other countries, there is no established protocol in the United States. We present a protocol for management of the dying that is clinically useful and review the existing evidence-base.

Symptom Variability During Repeated Measurement Among Hospice Patients With Advanced Cancer

Aim: In this prospective study, we explored symptom variability in patients with cancer during repeated measurements. Methods: Patients with cancer admitted to an inpatient hospice completed a daily questionnaire throughout their admission. The questionnaire consisted of 5 visual analogue scales (VAS) for anxiety, depression, nausea, pain, and sedation and 3 verbal rating scales (VRS) for depression, pain, and vomiting. Data from those who completed 5 consecutive days were used for the primary analysis. We used all available data points to compare VAS and VRS. An index was developed to assess for daily symptom variability. Results/Discussion: A total of 125 hospice inpatients were enrolled; 46 (38%) completed 3 consecutive daily questionnaires and 30 (24%), 5 days. We found (1) a statistically significant decrease in severity of symptoms present on admission, (2) new symptoms developed, (3) consequently overall symptom prevalence on days 1 and 5 appeared unchanged, (4) high daily symptom variability as demonstrated by the variability index and also changing daily symptom interrelationships, (5) demographic characteristics influenced symptom patterns on admission and subsequently, (6) severe pain predicted more frequent and severe symptom burden only on admission, (7) severe depression predicted more frequent and severe symptom burden on admission and thereafter, (8) VAS scores for depression and pain did not correspond with discrete VRS categories (mild, moderate, severe). Conclusions: (1) Symptom studies in advanced disease while difficult to conduct yield valuable information, (2) symptom relationships changed daily; strict timing of data collection is crucial for data analysis, (3) symptom monitoring following admission is an overlooked measure of risk assessment, (4) symptom prevalence studies alone for treatment follow-up may be misleading, (5) depression is an important predictor of symptoms and need to be more aggressively assessed and treated, (6) demographic characteristics may help identify symptom patterns and better direct treatment, (7) VRS rather than VAS was more reliable for assessing symptoms in hospice cancer patients.

The management of constipation in palliative care: clinical practice recommendations

Constipation is one of the most common problems in patients receiving palliative care and can cause extreme suffering and discomfort. The aims of this study are to raise awareness of constipation in palliative care, provide clear, practical guidance on management and encourage further research in the area. A pan-European working group of physicians and nurses with significant experience in the management of constipation in palliative care met to evaluate the published evidence and produce these clinical practice recommendations. Four potentially relevant publications were identified, highlighting a lack of clear, practical guidance on the assessment, diagnosis and management of constipation in palliative care patients. Given the limited data available, our recommendations are based on expert clinical opinion, relevant research findings from other settings and best practice from the countries represented. Palliative care patients are at a high risk of constipation, and while general principles of prevention should be followed, pharmacological treatment is often necessary. The combination of a softener and stimulant laxative is generally recommended, and the choice of laxatives should be made on an individual basis. The current evidence base is poor and further research is required on many aspects of the assessment, diagnosis and management of constipation in palliative care.

Unrecognised cognitive impairment in hospice patients: a pilot study

The presence of cognitive impairment in patients who are receiving hospice care can affect numerous practical, ethical and legal aspects of their healthcare. A number of factors can contribute to cognitive impairment in these patients. Prevalence rates of cognitive impairment vary widely, but it remains under-recognised and under-treated. The aims of this pilot study were to evaluate the presence and nature of cognitive deficits in patients receiving inpatient hospice care who did not have a known current or past diagnosis of a cognitive disorder or any obvious cognitive impairments. A convenience sample of 30 patients receiving inpatient hospice care underwent bedside cognitive testing. A comprehensive battery of tests was used, including the Mini-Mental State Examination (MMSE) and standardised neuropsychological tests of pre-morbid intellectual functioning, immediate and delayed recall, digit span forward and backward, verbal reasoning and letter and category fluency. On average, subjects were impaired on the MMSE and on tests of learning, verbal reasoning and letter and category fluency. Furthermore, 12 of the 30 subjects met DSM-IV cognitive impairment criteria for dementia based on impaired performance in memory and at least one other cognitive domain on testing. The results of this pilot study suggest that a sizable proportion of patients receiving inpatient hospice care have undetected but clinically significant cognitive impairments. Assessing for and helping patients, families and caregivers deal with cognitive impairment might benefit patients' quality of life, relationships and overall care at the end of life. Future research in this population is needed to evaluate the causes and time course of cognitive impairment over time, as well as any relationship between cognitive impairment and decision-making capacity.

Global warming in the palliative care research environment: adapting to change

Advocates of palliative care research have often described the cold and difficult environment that has constrained the development of research internationally. The development of palliative care research has been slow over the last few decades and has met with resistance and sometimes hostility to the idea of conducting research in 'vulnerable populations'. The seeds of advocacy for research can be found in palliative care literature from the 1980s and early 1990s. Although we have much to do, we need to recognize that palliative care research development has come a long way. Of particular note is the development of well-funded collaboratives that now exist in Europe, Canada, Australia and the USA. The European Association for Palliative Care and the International Association for Hospice and Palliative Care has recognized the need to develop and promote global research initiatives, with a special focus on developing countries. Time is needed to develop good research evidence and in a more complex healthcare environment takes increasingly more resources to be productive. The increased support (global warming) evident in the increased funding opportunities available to palliative care researchers in a number of countries brings both benefits and challenges. There is evidence that the advocacy of individuals such as Kathleen Foley, Neil MacDonald, Balfour Mount, Vittorio Ventafridda, Robert Twycross and Geoff Hanks is now providing fertile ground and a much friendlier environment for a new generation of interdisciplinary palliative care research. We have achieved many of the goals necessary to avoid failure of the 'palliative care experiment', and need to accept the challenge of our present climate and adapt and take advantage of the change.

Caring for the Patient and the Family in the Last Hours of Life

Recognition of the signs and symptoms that are common in the final hours of life and a basic understanding of how to manage these signs and symptoms are important to helping the patient and family experience a good death in the home setting. The most common signs and symptoms, including pain, dyspnea, and terminal restlessness or delirium, and their management are discussed. Also addressed are other signs and symptoms, such as cardiovascular signs and symptoms including cold extremities, mottling, and changes in vital signs; respiratory signs and symptoms such as changes in breathing pattern, noisy breathing, and mandibular breathing; and neurological signs and symptoms such as disorientation, sensory changes, and semicomatose state. Changes in metabolism such as fatigue, surge of energy, and increased temperature are presented, along with decreased intake, excretion, and communication changes.

How should we measure emesis in palliative care?

There are many assessment tools available to measure emesis. This Association for Palliative Medicine Science Committee Task Group undertook a review of the validity and suitability of the assessment tools available to measure nausea, vomiting and retching within a palliative care population. Electronic databases were searched from 1970 to 2004. Both specific and global tools were identified and reviewed for their validity, reliability and suitability for our patient population where coexisting cognitive impairment and significant co-morbidities may make accurate assessment of symptoms difficult. Within specific palliative care scenarios namely daily clinical assessment, prevalence surveys and randomized controlled trial settings, the team reached a consensus on which tools had the greatest evidence to recommend them, either for immediate use or for further validation studies. An ideal measurement tool for the assessment of nausea, vomiting and retching has not yet been developed.

Palliative sedation in a southern Appalachian community

Of 1200 palliative care patients, 28 received palliative sedation. They were more likely than patients without palliative sedation to have an Eastern Cooperative Oncology Group performance status of at least 3, a cancer diagnosis, an expected survival of weeks or less, to have been monitored by the palliative care team for at least 1 week, to have delirium as the cause of decreased communication, to have dyspnea as a non-pain symptom, and to be less able to communicate symptoms. Almost 90% received palliative sedation for at least 24 hours for a median of 3 days (range, 0 to 24 days). Home patients received palliative sedation longer. Symptoms were controlled in 82% and improved in the rest. Sedation developed in 79% but was not required for symptom control in 5. Patient survival from palliative care consultation was a median of 8 days (range, 0 to 32 days).

Cancer symptom assessment instruments: a systematic review

PURPOSE

A variety of assessment instruments have been created to identify cancer symptoms. We reviewed systematically cancer symptom assessment instruments published in English.

METHODS

A systematic search of the MEDLINE database, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and EMBASE was performed. Non-peer-reviewed articles were identified through BIOSIS. Articles were accessed through the related article links in PubMed and references were searched by hand. Studies were included if the instrument had symptom assessment as the primary outcome. Quality-of-life instruments were excluded.

RESULTS

We identified 21 instruments; some had undergone modification or validation. An additional 28 studies examined symptom prevalence and interrelations; many involved symptom checklists. Studies varied in design, patient characteristics, symptoms, and outcome. Meta-analysis was not possible due to heterogeneity in design, study outcomes, and validation. Seventy-six articles and two conference abstracts (derived from MEDLINE, Cochrane, CINAHL, EMBASE, BIOSIS, related articles link in PubMed, and search by hand) met inclusion/exclusion criteria. The electronic search (without related links) yielded only 26% of those articles and conference abstracts that met inclusion criteria. Searches by hand of related articles identified 59% of studies.

CONCLUSION

Twenty-one instruments were identified as appropriate for clinical use. The instruments vary in symptom content and extent of psychometric validation. Both comprehensive and shorter instruments have been developed, and some instruments are intended for specific symptom assessment or symptoms related to treatment. There is no ideal instrument, and the wide variety of instruments reflects the different settings for symptom assessment. Additional research is necessary.

Tolerability of the Compound ABHR in Hospice Patients

BACKGROUND

Compounded formulations comprised of multiple medications may be useful for some patients with refractory nausea and vomiting. The combination of lorazepam, diphenhydramine, haloperidol, and metoclopramide (ABHR) has been used for more than a decade in the management of nausea and vomiting, but the tolerability of this combination in hospice patients has not been examined.

OBJECTIVE

Determine the tolerability of the ABHR compound in both younger and elderly hospice patients.

DESIGN

Retrospective cohort study.

SETTING/SUBJECTS

A total of 11,181 ABHR prescriptions dispensed to 8600 hospice patients in the home care setting were analyzed.

RESULTS

A total of 42 ABHR prescriptions were discontinued secondary to adverse drug reactions (ADRs) in 39 patients. Older patients appear to be more sensitive to the effects of ABHR, however, this trend did not achieve statistical significance when looking at extrapyramidal symptoms (EPS) specifically in these patients. The overall incidence of EPS was low, as only 0.1% of all prescriptions discontinued secondary to an ADR were consistent with EPS.

CONCLUSIONS

The compound ABHR is generally well tolerated in the majority of hospice patients. More investigation is warranted to determine the efficacy and tolerability of similar pharmaceutical compounds used commonly in the hospice patient population.

Symptom distress in patients attending an outpatient palliative radiotherapy clinic

Patients with advanced cancer are often polysymptomatic. Different symptoms occur with varying frequency, intensity, and impact. Despite the high prevalence of symptoms in this population, reports of symptomatology in palliative outpatients have been limited. We report the symptom distress in metastatic cancer patients attending an outpatient palliative radiotherapy clinic. Patients referred for palliative radiotherapy for symptom control to the Rapid Response Radiotherapy Program (RRRP) were asked to rate symptom distress using the Edmonton Symptom Assessment Scale (ESAS) at the time of initial consultation. Patient demographics, cancer history, disease status, and analgesic consumption during the previous 24 hours were recorded. Between January 1999 and January 2002, 1,296 patients were seen at the RRRP and consented to participate in the study. Mean symptom distress rates ranged from 1.41 to 5.04. Fatigue, poor sense of well-being, pain, and poor appetite were the highest scored symptoms consecutively. Patients with poorer performance status (KPS < or = 60) had significantly higher symptom distress scores for all nine symptoms (P < 0.001). We conclude that the symptoms of metastatic cancer, including pain, fatigue, depression, anxiety, drowsiness, poor appetite, and sense of well-being, are common among patients attending outpatient palliative clinics. Symptom assessment tools, such as the ESAS, allow for the identification of symptoms and their severity. The appropriate regimen for management of pain and symptoms in metastatic cancer patients can then be planned.

Common symptoms in advanced cancer

The key points of this article are anorexia and cachexia are: A major cause of cancer deaths. Several drugs are available to treat anorexia and cachexia. Dyspnea in cancer usually is caused by several factors. Treatment consists of reversing underlying causes, empiric bronchodilators, cortico-steroids--and in the terminally ill patients-opioids, benzodiazepines,and chlorpromazine. Delirium is associated with advanced cancer. Empiric treatment with neuroleptics while evaluating for reversible causes is a reasonable approach to management. Nausea and vomiting are caused by extra-abdominal factors (drugs,electrolyte abnormalities, central nervous system metastases) or intra-abdominal factors (gastroparesis, ileus, gastric outlet obstruction, bowel obstruction). The pattern of nausea and vomiting differs depending upon whether the cause is extra- or intra-abdominal. Reversible causes should be sought and empiric metoclopramide or haloperidol should be initiated. Fatigue may be caused by anemia, depression, endocrine abnormalities,or electrolyte disturbances that should be treated before using empiric methylphenidate. Constipation should be treated with laxatives and stool softeners. Both should start with the first opioid dose.

Symptom distress as rated by advanced cancer patients, caregivers and physicians in the last week of life

OBJECTIVES

To study the symptom distress as rated by patients with advanced cancer during their last week of life, and to compare patients' ratings with those perceived by caregivers and physicians.

METHOD

This was a prospective study on all patients admitted to the Hospice Unit of the Caritas Medical Centre with an estimated life expectancy of two weeks or less from May 2002 to September 2002. A questionnaire with a list of 13 symptoms, including pain, dyspnoea, nausea, vomiting, dry mouth, cough, fatigue, cachexia, anorexia, constipation, diarrhoea, insomnia and haemoptysis, was administered to assess the distress. Distress was rated by a verbal rating scale consisting of five grades (grade 0 to grade 4). Patients, caregivers and physicians completed the questionnaire weekly until the patient died. Only the questionnaires completed in the last week of life were included for analysis.

RESULTS

Of 82 patients who were recruited in the study, 30 patients were able to complete the questionnaire within the last week of life. Their median age was 69 years and the gender ratio was 1:1. Lung cancer was the most common primary tumour. Fatigue, cachexia and anorexia caused distress of all grades in nearly all 30 patients and caused significant distress of grade 3 and above in two-thirds of patients. Neither the caregivers nor the physicians gave congruent distress scores for these three symptoms (kappa<0.4). Caregivers' ratings agreed well with those of patients for five symptoms (kappa>0.4, P<0.005), including dyspnoea, cough, dry mouth, constipation and insomnia. For physicians, good agreement was found for three symptoms only, including pain, dyspnoea and cough. Moreover, physicians tended to underrate the distress.

CONCLUSION

Fatigue, cachexia and anorexia were the three most distressful symptoms in the last week of life in this group of patients, but caregivers and physicians failed to rate them in agreement with patients.

Low-dose levomepromazine in refractory emesis in advanced cancer patients: an open-label study

Seventy patients with advanced cancer and refractory emesis were treated with subcutaneous boluses of levomepromazine (median daily dose: 6.25 mg; range: 3.12-25) in an open-label prospective study. Treatment was associated with a decrease in nausea from a median of 8/10 at baseline (IQR 7-8) to a median of 1 (IQR 0-2) after two days of treatment (P<0.0001); vomiting ceased in 92% of cases. It was possible to remove the nasogastric tube from all 11 patients who had one. The most frequently reported side effect was sedation, with a median of 2/10 (25-75% percentile 1-3), which was not correlated with the dose of levomepromazine. This study suggests that treatment with low-dose levomepromazine is an effective and safe option for advanced cancer patients who fail to respond to first-line antiemetic treatment.

Terminal dyspnea and respiratory distress

Dyspnea is a subjective experience that can be reported by the patient. Respiratory distress is an observable corollary, and represents the physical or emotional suffering that results from the experience of dyspnea. Recognizing and understanding this subjective phenomenon poses a challenge to intensive care unit (ICU) clinicians when caring for the patient who is dying in the ICU. Dyspnea and cognitive impairment are highly prevalent in the terminally ill ICU patient. A Respiratory Distress Observation Model may provide a theoretical foundation for the assessment of this phenomenon that is grounded in emotional and autonomic domains of neurologic function. Treatment of dyspnea and respiratory distress relies on nonpharmacologic interventions and opioids and sedatives. As with pain, the treatment of dyspnea and respiratory distress relies on close evaluation of the patient and treatment to satisfactory effect. Empirical evidence suggests that quality care with control of distressing symptoms does not hasten death. Withholding opioids or sedatives in the face of unrelieved dyspnea or respiratory distress has no moral foundation.

Impaired communication capacity and agitated delirium in the final week of terminally ill cancer patients: prevalence and identification of research focus

The maintenance of intellectual activity is an important area in the "good death" concept. To clarify the communication capacity levels of terminally ill cancer patients in their final week, and to identify factors contributing to the development of communication capacity impairment and agitated delirium, a retrospective study was performed on 284 consecutive hospice inpatients. The data were collected by chart review, and two independent raters measured the degree of communication capacity and agitation in the last week, using multiple items from the Memorial Delirium Assessment Scale, the Communication Capacity Scale, and the Agitation Distress Scale. The percentages of patients who could achieve complex communication were 43%, 28%, and 13% at 5 days, 3 days, and 1 day before death, respectively. Agitated delirium was identified in 20%. Patients receiving opioids at a dose of > or =120 mg oral morphine equivalents/day one week before death were significantly unable to communicate clearly 3 days before death (0.48 [0.28-0.84], P=0.011). Male gender and the presence of icterus were identified as significant contributors to the development of agitated delirium (odds ratios [95% C.I.]=2.6 [1.4-5.0], P<0.01; 2.4 [1.3-4.4], P< 0.01). These findings demonstrate that communication capacity impairment and agitated delirium are frequently observed in terminally ill cancer patients, and are significantly correlated with a higher dose requirement of opioids and the presence of icterus. To explore the best management to maintain the intellectual activity of dying patients, research should focus on a homogeneous sample of patients receiving high-dose opioids and those with hepatic encephalopathy. In the meanwhile, clinicians should educate patients and family members about the nature of the dying process and help facilitate the completion of life purposes requiring complex mental activities before the latest stages of cancer.