Early Incorporation to Palliative Care (EPC) in Patients With Advanced Non-Small Cell Lung Cancer: The PACO Randomized Clinical Trial

BACKGROUND

Patients with non-small cell lung cancer (NSCLC) experience a considerable disease burden, evident in symptomatic and psychological spheres. Advanced cancer represents a complex scenario for patients and the healthcare team. Early palliative care (EPC) has been proven as a clinically meaningful strategy in this context by several randomized trials but not in a resource-limited setting. This study aimed to evaluate the effect of EPC compared with standard oncological care (SOC) in patients with metastatic NSCLC in Mexico.

MATERIALS AND METHODS

A prospective, randomized clinical trial was conducted at Instituto Nacional de Cancerologia in Mexico. All patients had histologically confirmed metastatic NSCLC without previous treatment. Patients were randomly assigned (1:1) to receive SOC or SOC + EPC. The EPC group was introduced to the palliative care team at baseline after randomization, which was integrated by psychologists, bachelor's in nutrition, specialized nurses, and physicians. Patients randomized to this arm had programmed visits to meet with the team at baseline and through the 2nd, 4th-, and 6th cycles thereafter. The primary endpoint was overall survival (OS); secondary outcomes included quality of life (QoL), anxiety and depression, and symptom intensity. They were assessed using the instruments EORTC QLQ-C30 questionnaire, Edmonton Symptom Assessment Scale (ESAS), and the Hospital Anxiety and Depression Scale (HADS) (clinicaltrials.gov [NCT01631565]). Questionnaires were completed at baseline, at 2nd, 4th, and 6th cycles of treatment.

RESULTS

Between March 2012 and June 2015, 201 patients were assessed for eligibility and 146 were enrolled and allocated to receive EPC (73) or SOC (73). Median OS for patients in the EPC vs SOC arm was 18.1 months (95% CI, 7.9-28.4) and 10.5 months (95% CI, 4.7-16.2) (P = .029). Having a poor performance status (HR 1.7 [1.2-2.5]; P = .004) and allocation to the control group (HR 1.5 [1.03-2.3]; P = .034) were independently associated with a worse OS. Those patients with a global QoL > 70 at baseline had a better OS if they were In the EPC arm (38.7 months (95% CI, 9.9-67.6) vs SOC 21.4 months (95% CI, 12.4-30.3)). Mean QoL had a numerical improvement in patients allocated to EPC after 6 cycles of follow-up, nonetheless this difference was not statistically significant (55.1 ± 23.7 vs 56.9 ± 25.3; P = .753). There were no significant differences in anxiety and depression at all study points.

CONCLUSIONS

EPC is associated with a significant improvement in OS, although, we observed that the greatest benefit of providing EPC was observed in those with a global QoL > 70 at baseline. This study did not identify significant changes in terms of QoL or symptom burden between the study groups after follow-up. Evidence robustly suggests that EPC should be considered part of the multidisciplinary treatment of metastatic NSCLC patients since diagnosis. According to our study, EPC can be implemented in low- or middle-income countries (LMIC).

Appetite and its association with mortality in patients with advanced cancer - a Post-hoc Analysis from the Palliative D-study

BACKGROUND

Loss of appetite is a common nutrition symptom in patients with cancer. Understanding the trajectory of appetite could be of clinical use for prognostication in palliative cancer care. Our primary aim was to explore the association between self-assessed appetite and mortality in patients suffering from advanced cancer. Secondary aims included the relation between fatigue, albumin levels and CRP/albumin ratio and mortality. We also aimed to study potential sex-differences in the associations.

METHODS

Post-hoc analyses were performed using data from the Palliative D-study comprising 530 patients with cancer admitted to palliative care. Appetite and fatigue were assessed with the Edmonton Symptom Assessment System (ESAS). Cox proportional hazards models were used to calculate Hazard ratios (HR) with 95% confidence intervals (CI) for exposures of appetite, fatigue, albumin and CRP/albumin ratio, and time from study inclusion to death or censoring. Analyses were also performed stratified by sex.

RESULTS

The follow-up time ranged between 7 to 1420 days. Moderate and poor appetite were significantly associated with a higher mortality rate compared to reporting a good appetite; HR 1.44 (95%CI: 1.16-1.79) and HR 1.78 (95%CI: 1.39-2.29), respectively. A higher mortality rate was also seen among participants reporting severe fatigue compared to those reporting no fatigue; HR 1.84 (95%CI:1.43-2.36). Participants with low albumin levels (< 25 g/L) and those in the highest tertile of CRP/albumin ratio, had higher mortality rates, HR 5.35 (95%CI:3.75-7.63) and HR 2.66 (95%CI:212-3.35), compared to participants with high albumin levels (> 36 g/L) and those in lowest tertile of CRP/albumin ratio. These associations were more pronounced in men than in women.

CONCLUSION

Poor appetite, severe fatigue, low albumin level and a high CRP/albumin ratio were associated with increased mortality rates among patients with advanced cancer. All these variables might be clinically useful for prognostication in palliative cancer care.

TRIAL REGISTRATION

Clinicaltrial.gov. Identifier: NCT03038516;31, January 2017.

Impact of Community Palliative Care on Quality of Life among Cancer Patients in Bangladesh

Cancer, a leading cause of mortality worldwide, is often diagnosed at late stages in low- and middle-income countries, resulting in preventable suffering. When added to standard oncological care, palliative care may improve the quality of life (QOL) of these patients. A longitudinal observational study was conducted from January 2020 to December 2021. Thirty-nine cancer patients were enrolled in the Compassionate Narayanganj community palliative care group (NPC), where they received comprehensive palliative care in addition to oncological care. Thirty-one patients from the Dept. of Oncology (DO) at BSMMU received standard oncological care. In contrast to the DO group, the NPC group had a higher percentage of female patients, was older, and had slightly higher levels of education. At 10 to 14 weeks follow-up, a significant improvement in overall QOL was observed in the NPC group (p = 0.007), as well as in the psychological (p = 0.003), social (p = 0.002), and environmental domains (p = 0.15). Among the secondary outcomes, the palliative care group had reduced disability and neuropathic pain scores. Additionally, there were statistically significant reductions in pain, drowsiness, and shortness of breath, as well as an improvement in general wellbeing, based on the results of the Edmonton Symptom Assessment Scale-Revised. At the community level in Bangladesh, increased access to palliative care may improve cancer patient outcomes such as QOL and symptom burden.

Appetite in Palliative Cancer Patients and Its Association with Albumin, CRP and Quality of Life in Men and Women—Cross-Sectional Data from the Palliative D-Study

Albumin is an important biochemical marker in palliative cancer care, used for assessment of nutritional status, disease severity and prognosis. Our primary aim was to investigate sex differences in the association between appetite and albumin levels in palliative cancer patients. We also aimed to study associations between appetite and C-reactive protein (CRP), Quality of Life (QoL), pain and fatigue. In the Palliative D-cohort, consisting of 266 men and 264 women, we found a correlation between appetite and albumin; low appetite, measured with the Edmonton Symptom Assessment System, correlated significantly with low albumin in men: (r = −0.33, p < 0.001), but not in women (r = −0.03, p = 0.65). In a regression analysis adjusted for confounding factors, results were similar. Lower appetite was correlated with higher CRP in men (r = 0.27, p < 0.001), but not in women (r = 0.12, p = 0.05). Appetite was correlated with QoL, fatigue and pain in both men and women; those with a low appetite had a low QoL and high fatigue- and pain-scores (p < 0.001). In conclusion, our results indicated possible sex differences in the associations between appetite and albumin, and between appetite and CRP, in palliative care patients. Understanding these associations could provide additional value for clinical practice.

Effect of transcranial direct current brain stimulation of the motor cortex on chemotherapy induced nausea and vomiting in female patients with breast cancer

OBJECTIVE

Chemotherapy-induced nausea and vomiting (CINV) is a negative impact associated to chemotherapy and its management still challenging. This study aimed to research the additive impact of single-session tDCS (2 mA) over the motor cortex for 20 minutes before chemotherapy to antiemetic on CINV in female patients suffers from breast cancer who obtained highly emetogenic chemotherapy.

STUDY LAYOUT

Prospective randomized double-blind Sham-controlled study.

SETTING

Academic medical center.

METHOD

Sixty breast cancer patients prepared for chemotherapy treatment were selected and allocated randomly into two equal groups: a real and a sham group; tDCS became implemented over the primary motor area (M1) (2 mA) for 20 minutes. Patients' nausea was measured by cumulative index of nausea and visual analog scale for nausea (VAS-N), and vomiting by cumulative index of episodes of vomiting, and Edmonton symptoms Assessment Scale (ESAS) to assess symptoms like pain, malaise, and sense of well-being. Evaluation was done prestimulation and every 24 h for 72 h after end of infusion of chemotherapy.

RESULTS

Real tDCS group showed reduction of cumulative index of nausea (P < 0.001, F = 50), VAS-N (P < 0.001, F = 52) and for ESAS in malaise score (P < 0.001, F = 37.6) and sense of wellbeing score (P < 0.001, F = 25) than sham group. Six patients (20%) in the real group required rescue antiemtic therapy vs. 14 patients (46.7%) in the Sham group (P < 0.028).

CONCLUSION

Single session of real M1 tDCS could be suggested as an effective adjuvant maneuver in control of CINV in female patients suffers from breast cancer who obtained highly emetogenic chemotherapy.

TRIAL REGISTRATION

Clinical Trials.gov trial registry (identifier: NCT03405324).

Edmonton Symptom Assessment Scale Time Duration of Self-Completion Versus Assisted Completion in Patients with Advanced Cancer: A Randomized Comparison

INTRODUCTION

To compare the time duration of self-completion (SC) of the Edmonton Symptom Assessment Scale (ESAS) by patients with advanced cancer (ACPs) versus assisted completion (AC) with a health care professional.

MATERIALS AND METHODS

In this randomized comparison of ACPs seen in initial consultation at the outpatient Supportive Care Center at MD Anderson, ACPs who have never completed the ESAS at MD Anderson were allocated (1:1) to either SC of the ESAS form versus AC by a nurse. Time of completion was measured by the nurse using a stopwatch. Patients completed the Rapid Estimate of Adult Literacy in Medicine (REALM) test prior to administration of the ESAS. In the SC group, the nurse reviewed the responses to verify that the reported ESAS scores were correct.

RESULTS

A total of 126 ACPs were enrolled (69 patients to AC and 57 to SC). Seventy-one patients were female, median age was 60 years, and median REALM score was 65. Median (interquartile range) time (in seconds) of SC was significantly less than AC (73 [42.9-89.1] vs. 109 [79.5-136.7], p < .0001). With nurse review time included, median time of SC increased to 117 seconds, which was not significantly different from AC (p = .28). Lower literacy (REALM) score and shortness of breath were significantly associated with increased completion time (p = .007).

CONCLUSION

Regular use of ESAS will have minimal impact on clinical time, as it can be completed in about 1 minute and provides a concise yet comprehensive and multidimensional perspective of symptoms that affect quality of life of patients with cancer.

IMPLICATIONS FOR PRACTICE

Because the Edmonton Symptom Assessment Scale can be completed in less than 2 minutes, hopefully the routine use of this simple yet comprehensive and multidimensional symptom assessment tool will be used at all medical visits in all patients with cancer so that the timely management of symptoms affecting patients' lives and treatment courses can occur, further enhancing personalized cancer care.

The Efficacy of a Single Session of 20-Minute Mindful Breathing in Reducing Dyspnea Among Patients With Acute Decompensated Heart Failure: A Randomized Controlled Trial

Heart failure is the leading cause of morbidity and mortality worldwide. Standard treatment for heart failure includes pharmacotherapy and cardiac device implants. However, supportive approaches in managing dyspnea in heart failure are limited. This study aimed to test the efficacy of 20-minute mindful breathing in reducing dyspnea among patients admitted for acute decompensated heart failure. We conducted a parallel-group, non-blinded, randomized controlled trial of a single session of 20-minute mindful breathing plus standard care versus standard care alone among patients admitted for moderate to severe dyspnea due to acute decompensated heart failure, using the dyspnea score based on the Edmonton Symptom Assessment System (ESAS), at the Cardiology Unit of University Malaya Medical Centre in Malaysia. Thirty participants were randomly assigned to a single session of 20-minute mindful breathing plus standard care (n = 15) or standard care alone (n = 15), with no difference in their demographic and clinical characteristics. There was statistically significant reduction in dyspnea in the intervention group compared to the control group at minute 20 (U = 49.5, n1 = 15, n2 =15, median reduction in ESAS dyspnea score 1 = 2, median reduction in ESAS dyspnea score 2 = 0, mean rank 1 = 11.30, mean rank 2 = 19.70, z = −2.692, r = 0.4, P = 0.007). Our results provided evidence that a single session of 20-minute mindful breathing was efficacious in reducing dyspnea for patients admitted for acute decompensated heart failure.

Using Heart Failure Instruments to Determine when to Refer Heart Failure Patients to Palliative Care

Aim: The purpose of this study was to determine whether the Edmonton Symptom Assessment Scale (ESAS) or the Palliative Performance Scale (PPS) are associated with traditionally used scores for heart failure patients — specifically, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), an overall health visual analog scale (VAS), and the Seattle Heart Failure Model (SHFM). Furthermore, we sought to determine whether the PPS or the ESAS provided additional information on quality of life, symptom severity, or prognosis above that provided by the traditional scores for patients with heart failure. Methods: We administered the ESAS, MLHFQ, VAS, PPS, and SHFM in a shuffled manner to 78 New York Heart Association Functional Classification (NYHA-FC) III-IV ambulatory heart failure patients. Pearson's r correlation was used to determine whether the scores from the ESAS and PPS correlated with the scores from the MLHFQ, VAS, and SHFM. Results: The sample was predominately male (62.8 percent), mean age 60.1 ± 13 years, with a diagnosis of idiopathic cardiomyopathy (45 percent). Moderate correlations were found between the ESAS and MLHFQ (r=0.483, p<0.01), the ESAS and VAS (r=-0.345, p<0.01), the PPS and MLHFQ (r=-0.54, p<0.01), and the PPS and VAS (r=0.53, p<0.01). There was no significant correlation between the PPS and SHFM. Conclusion: The results of this study suggest that administration of the ESAS and PPS provides additional information on symptom severity and functional decline for patients with heart failure. Standardized administration of these scales may aid in the assessment and evaluation of heart failure patients.

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.

The evaluation of A Triage Tool for A Community Palliative Care Service Provider

Introduction: Triage, widely used by the military and emergency departments, has not been reported in community palliative care services. Policy designed to improve equitable provision of this care has led to the development of a triage tool. Methods: Retrospective data were collected (50 percent of referrals, n=204) and analyzed using the Wilcoxon signed-rank test to determine the accuracy of the tool in predicting patient status at the first visit. Semi-structured interviews (n=7) with palliative care service staff added qualitative data. Results: Although significant differences between triage scores compared to outcomes at first visit were observed, issues such as upgrading of triage category compared to priority score occurred in more than 30 percent of cases. When correction for this was made, the tool was found to be an accurate guide to patient needs. Conclusion: This tool, when used as intended, was effective in assessing the urgency of need, and it is potentially useful on a wider scale, subject to further evaluation.

Consensus document of the Italian Association of Medical Oncology and the Italian Society of Palliative Care on early palliative care

A consensus document on early palliative care was produced by a committed Working Group of the Italian Society of Medical Oncology and the Italian Society of Palliative Care to improve the early integration of palliative care in medical oncology and to stimulate and guide the choices of those who daily face the problems of advanced stage cancer patients. The simultaneous administration of antineoplastic treatments and early palliative care was shown to be beneficial in metastatic cancer pathway outcomes. Patients who could benefit from early palliative care are those with an advanced cancer at presentation, a compromised PS for cancer, and/or morbidities, and who are too frail to receive treatment. According to the Bruera practice models, in which the combination of cancer management with early palliative care can be offered, three groups of patients needing simultaneous care were identified and three different models of the delivery of palliative care were proposed. In patients with good prognosis and low need of simultaneous care, the solo practice model and the request for consultations were suggested, while in patients with poor prognosis disease with high need of simultaneous care and in conditions with high need of simultaneous care, regardless of cancer prognosis, the integrated care approach should be offered. Palliative care consultation services are seldom accessible in the majority of Italian hospitals; thus the application of various practice models depends on available resources, and a shared care model with the structures of palliative care operating in the area is often required.

Congruence of multiple patient-related outcomes within a single day

OBJECTIVE

Clinic-based collection of patient-reported outcome (PRO) quantifying symptom burden provide crucial information for effective care. We have pioneered point-of-care electronic assessment using the Edmonton Symptom Assessment Scale (ESAS) with direct linkage to the electronic medical record (EMR) which has been readily adopted by our oncology patients. As some patients may complete more than one ESAS per day in different clinics, the goal of the current analyses was to compare the within-patient congruence of ESAS assessments completed on the same day.

METHODS

A total of 9621 ESAS records from 4021 patients of the Supportive Care Medicine and Radiation Oncology clinics between February and November 2017 were retrieved from the EMR. Patients completed the ESAS-r-CSS, which added sleep disturbance, constipation, and spiritual well-being domains to the standard ESAS-r.

RESULTS

A total of 65 patients provided more than one ESAS report within the same day. The data were curated, removing those sporadic missing data and those with obvious technical error. This process left 130 samples for analysis. There was no statistical difference among different ESAS collection intervals for domains of tiredness, nausea, appetite, overall well-being, spiritual well-being, constipation, and difficulty sleeping, but there was a significant difference for pain, drowsiness, shortness of breath, depression, and anxiety. Repeat tests that occurred within 1 h of one another demonstrated higher congruence than those completed over longer periods.

CONCLUSION

Patients reported significant worsening of several symptoms over the course of the day, with greatest concordance observed within smaller time periods.

Utility of the revised Edmonton Symptom Assessment System (ESAS-r) and the Patient-Reported Functional Status (PRFS) in lung cancer patients

BACKGROUND

Symptom palliation is an important objective of treatment in advanced/metastatic lung cancer (LC). Significant psychological, minor physical symptoms and several social/emotional issues often go unnoticed. This prospective study aimed to evaluate utility of patients' perspectives [self-reported symptom assessment by revised Edmonton Symptom Assessment System (ESAS-r) and self-reported functional status by Patient-Reported Functional Status (PRFS)] amongst LC patients undergoing chemotherapy.

METHODS

Consecutive newly diagnosed treatment-naïve LC patients attending a tertiary referral center in North India from January 2014 to March 2015 were included. All patients received standard histology-guided platinum-doublet chemotherapy. ESAS-r and PRFS questionnaires were administered under guidance, once at the time of initial assessment/diagnosis, repeated at start of chemotherapy, before C4, and after completion of chemotherapy (end of chemotherapy (EOCTx)). Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire was also administered. Baseline and post-treatment scores were compared.

RESULTS

Majority of 133 patients enrolled were males (86.5%,n = 115), were current/ex-smokers (81.2%, n = 108), had advanced stage [IIIB = 30.1% (n = 40), IV = 52.6% (n = 70)], and were of non-small-cell type (NSCLC;84.2%,n = 112). On baseline ESAS-r, the highest mean symptom scores were observed for tiredness followed by anorexia. Mean ESAS-r scores before C4 as well as at EOCTX were significantly better than baseline ESAS-r scores in all its components except nausea. Similarly, PRFS before C4 and EOCTx was significantly improved compared to baseline. However, Karnofsky Performance Scale (KPS) and Eastern Cooperative Oncology Group Performance Status assessed at baseline did not show significant improvement at treatment completion. FACT-L score at EOCTx showed significant improvement from baseline in physical and functional well-being domains but not for social/family and emotional well-being domains.

CONCLUSION

This study validated utility of ESAS-r and PRFS in Indian LC patients. These instruments should be used in routine clinical practice besides physicians' assessment of PS (KPS/ECOG).

Evaluation of the Utility of the Edmonton Symptom Assessment System (revised) Scale on a Tertiary Palliative Care Unit

Aim

The aim of this study was to evaluate the utility of the Edmonton Symptom Assessment System (ESAS-r) Scale on a tertiary palliative care unit.

Method

There were 92 admitted patients who participated in the study; the scale was administered to those able to participate on day 1 (n=35, 38 percent), on day 4 (n=20, 21 percent), and weekly. Patient comfort level with the ESAS-r tool was assessed using a 5-point Likert scale (strongly disagree to strongly agree) on day 4. Nurses’ and physicians’ perceptions of clinical assessment pre- and postimplementation of the scale were surveyed using a 5-point Likert scale.

Results

Of the participating physicians, 75 percent (n=3) found that the ESAS-r Scale did not enhance clinical assessment; the proportion of nurses with that response was 37.5 percent (n=6). Among these care providers, 50 percent of the physicians (n=2) and 62 percent of the nurses (n=10) thought that the scale was burdensome to patients; but 60 percent of the patients who were able to complete the comfort-level survey (n=12) indicated that they did not find the scale burdensome.

Conclusion

Patient acuity, team expertise, perceived burden to patients, and time commitment all influenced staff's recommendation not to implement the ESAS-r tool on the palliative care unit.

Validation of the French Version of the Edmonton Symptom Assessment System

CONTEXT

The Edmonton Symptom Assessment System (ESAS) is a brief, widely adopted, multidimensional questionnaire to evaluate patient-reported symptoms.

OBJECTIVES

The objective of this study was to define a standard French version of the ESAS (F-ESAS) to determine the psychometric properties in French-speaking patients.

METHODS

In a first pilot study, health professionals (n = 20) and patients (n = 33) defined the most adapted terms in French (F-ESAS). In a prospective multicentric study, palliative care patients completed the three forms of F-ESAS (F-ESAS-VI, F-ESAS-VE, and F-ESAS-NU, where VI is visual, VE, verbal, and NU, numerical), the Hospital Anxiety and Depression Scale. All patients had a test-retest evaluation during the same half-day. Standardized distraction material was used between each scale.

RESULTS

One hundred twenty-four patients were included (mean age [±SD]: 68.3 ± 12; 70 women; 54 men). Test-retest reliability was high for all three F-ESAS, and the correlation between these scales was nearly perfect (Spearman rs = 0.66-0.91; P < 0.05). F-ESAS-VI, F-ESAS-VE, and F-ESAS-NU performed similarly and were equally reliable, although there was a trend toward lower reliability for F-ESAS-VI. Correlation between F-ESAS depression and anxiety and HADS depression and anxiety, respectively, were positive (Spearman rs = 0.38-0.41 for depression; Spearman rs = 0.48-0.57 for anxiety, P < 0.05). Among patients, 59 (48%), 45 (36%), and 20 (16%) preferred to assess their symptoms with F-ESAS-VE, F-ESAS-NU, and F-ESAS-VI, respectively.

CONCLUSION

The F-ESAS is a valid and reliable tool for measuring multidimensional symptoms in French-speaking patients with an advanced cancer. All forms of F-ESAS performed well with a trend for better psychometric performance for F-ESAS-NU, but patients preferred the F-ESAS-VE.

Benefits of home-based multidisciplinary exercise and supportive care in inoperable non-small cell lung cancer - protocol for a phase II randomised controlled trial

Background

Lung cancer is one of the most commonly diagnosed cancers, and is a leading cause of cancer mortality world-wide. Due to lack of early specific symptoms, the majority of patients present with advanced, inoperable disease and five-year relative survival across all stages of non-small cell lung cancer (NSCLC) is 14%. People with lung cancer also report higher levels of symptom distress than those with other forms of cancer. Several benefits for survival and patient reported outcomes are reported from physical activity and exercise in other tumour groups. We report the protocol for a study investigating the benefits of exercise, behaviour change and symptom self-management for patients with recently diagnosed, inoperable, NSCLC.

Methods

This multi-site, parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aims to assess functional and patient-reported outcomes of a multi-disciplinary, home-based exercise and supportive care program for people commencing treatment. Ninety-two participants are being recruited from three tertiary-care hospitals in Melbourne, Australia. Following baseline testing, participants are randomised using concealed allocation, to receive either: a) 8 weeks of home-based exercise (comprising an individualised endurance and resistance exercise program and behaviour change coaching) and nurse-delivered symptom self-management intervention or b) usual care. The primary outcome is the between-group difference in the change in functional exercise capacity (six-minute walk distance) from baseline to post-program assessment. Secondary outcomes include: objective and self-reported physical activity levels, physical activity self-efficacy, behavioural regulation of motivation to exercise and resilience, muscle strength (quadriceps and grip), health-related quality of life, anxiety and depression and symptom interference.

Discussion

There is a lack of evidence regarding the benefit of exercise intervention for people with NSCLC, particularly in those with inoperable disease receiving treatment. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a home-based program including three components not yet combined in previous research, for people with inoperable NSCLC receiving active treatment and involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting.

Trial registration

This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12614001268639: (4/12/14).

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3651-4) contains supplementary material, which is available to authorized users.

Managing Symptoms During Cancer Treatments: Barriers and Facilitators to Home Care Nurses Using Symptom Practice Guides

Nurses are instrumental in helping clients safely manage at home and triage potentially life-threatening symptoms from cancer. The purpose of this study was to assess factors influencing home care nurses’ use of 15 evidence-informed symptom practice guides for providing telephone or in-home nursing services to clients with cancer. A mixed-methods descriptive study was guided by the Knowledge-to-Action Framework. All six nursing agencies within a regional home care authority participated. Data collection included retrospective audit of symptom management in 50 patient records, 14 interviews, and barriers survey from 150 of 243 (61.7%) registered nurses and registered practical nurses providing cancer symptom support in home care. Chart audit revealed more than 80% of clients were on chemotherapy and common symptoms were nausea/vomiting (44%), constipation (32%), fatigue (32%), loss of appetite (32%), and pain (20%). Nurses had positive intentions ( M = 5.4 out of 7; SD = 1.3) and felt capable of using the symptom practice guides ( M = 5.4; SD = 1.0), held strong beliefs about the consequences ( M = 5.8; SD = 1.1) and moral norms of using them ( M = 5.7; SD = 1.1), and identified neutral to low social influence ( M = 3.0; SD = 1.6). Common barriers were inadequate time in practice, learning curve, need to integrate into documentation, and competing system changes. Common facilitators were being comprehensive, an evidence-based resource for use in practice, and having consistent symptom management guides across settings. Overall, the symptom guides were well received by the nurses. Interventions nurses identified to overcome barriers were education, clear organizational mandate for implementation, and integration with documentation.

Modified Edmonton Symptom Assessment System including constipation and sleep: validation in outpatients with cancer

CONTEXT

The Edmonton Symptom Assessment System (ESAS) measures the severity of nine symptoms. Constipation and sleep disturbance are common in patients with cancer, but are not currently included in the ESAS.

OBJECTIVES

To validate the numerical rating scale (NRS) versions of ESAS and its revised version (ESAS-r), with the additional symptoms of constipation and sleep (CS), and to assess patient preference for either version.

METHODS

Outpatients with advanced cancer (N = 202) completed three assessments during a single clinic visit: ESAS-CS, and an added time window of "past 24 hours"; ESAS-r-CS, with a time window of "now" and symptom definitions; and the Memorial Symptom Assessment Scale (MSAS). Internal consistency was calculated using Cronbach's alpha. Paired t-tests compared ESAS-CS and ESAS-r-CS scores; these were correlated with MSAS using Spearman correlation coefficients. Test-retest reliability at 24 hours was assessed in 26 patients.

RESULTS

ESAS-CS and ESAS-r-CS total scores correlated well with total MSAS (Spearman's rho 0.62 and 0.64, respectively). Correlation of individual symptoms with MSAS symptoms ranged from 0.54-0.80 for ESAS-CS and 0.52-0.74 for ESAS-r-CS. Although participants preferred the ESAS-r-CS format (42.8% vs. 18.6%) because of greater clarity and understandability, the "past 24 hours" time window (52.8%) was favored over "now" (21.3%). Shortness of breath and nausea correlated better for the "past 24 hours" time window (0.8 and 0.72 vs. 0.74 and 0.64 in ESAS-r-CS, respectively). The 24-hour test-retest of the ESAS-CS demonstrated acceptable reliability (intraclass correlation coefficient = 0.69).

CONCLUSION

The ESAS-CS and ESAS-r-CS NRS versions are valid and reliable for measuring symptoms in this population of outpatients with advanced cancer. Although the ESAS-r-CS was preferred, patients favored the 24-hour time window of the ESAS-CS, which also may best characterize fluctuating symptoms.

Reduction in symptoms for homebound patients receiving home-based primary and palliative care

BACKGROUND

Increasing numbers of patients are living with multiple, chronic medical conditions and functional impairments that leave them homebound. Home-based primary and palliative care (HBPC) programs provide access to health care services for this vulnerable population. Homebound patients have high symptom burden upon program enrollment. Yet little is known as to how individual symptoms are managed at home, especially over longer time periods.

OBJECTIVES

The purpose of this study was to determine whether high symptom burden decreases following HBPC enrollment.

METHODS

All patients newly enrolled in an HBPC program who reported at least one symptom on the Edmonton Symptom Assessment Scale (ESAS) were eligible for telephone ESAS follow-up. Patients received a comprehensive initial home visit and assessment by a physician with subsequent follow-up care, interdisciplinary care management including social work, and urgent in-home care as necessary. Multivariate linear mixed models with repeated measures were used to assess the impact of HBPC on pain, depression, anxiety, tiredness, and loss of appetite among patients with moderate to severe symptom levels at baseline.

RESULTS

One hundred forty patients were followed. Patient pain, anxiety, depression, and tiredness significantly decreased following intervention with symptom reductions seen at 3 weeks and maintained at 12 weeks. (p<0.01) Loss of appetite trended toward an overall significant decrease and showed significant reductions at 12 week follow-up.

CONCLUSION

In a chronically ill population of urban homebound, patient symptoms can be successfully managed in the home. Future work should continue to explore symptom assessment and management over time for the chronically ill homebound.

Initial Assessment of Patients Without Cognitive Failure Admitted in Palliative Care

Aim:

To develop a screening tool that was short, not time consuming but able to detect the patients’ main problems at admission.

Methods:

A list of 106 symptoms/problems derived from a review of the literature was created and shortened using a Delphi process.

Results:

Thirteen experts scored each item with a numeric rating scale of 0 to 10 for relevance. After 3 rounds, the list was shortened to 14 items: general question—what bothers you the most? symptoms/problems—pain, lack of appetite, vomiting, tiredness/fatigue, nausea, constipation, shortness of breath, depression, anxiety, difficulty sleeping; activity (dressing, washing, etc); support from family/friends; and well-being.

Conclusion:

The final tool is short and seems to include the relevant items that would make it useful for clinical practice.

The Spanish version of the Edmonton Symptom Assessment System-revised (ESAS-r): first psychometric analysis involving patients with advanced cancer

CONTEXT

The Edmonton Symptom Assessment System (ESAS) is a measure widely used in palliative care for the assessment of symptoms in patients with advanced cancer. The tool has been validated in different languages, including Spanish. A revised version (ESAS-r) was developed by Watanabe et al. in 2010.

OBJECTIVES

To develop the Spanish version of the ESAS-r and examine its psychometric properties.

METHODS

Based on the original English version, a group of experts created a Spanish version of the ESAS-r and administered it to a group of advanced cancer patients. Patients completed the ESAS and ESAS-r and were asked for their perceptions of the tool. The psychometric properties of the ESAS-r that were analyzed were equivalence, internal consistency, and discriminant validity.

RESULTS

Sixty-six patients from Spain and Guatemala participated in the survey. Patients perceived the ESAS-r to be significantly easier to understand and easier to complete than the ESAS. Significantly, patients preferred the ESAS-r (47%) to the ESAS (15%; P<0.0007). As to reliability, we found good internal consistency (Cronbach's alpha 0.86), and the equivalence of the two versions was between 0.71 and 0.94. The ESAS-r discriminates between inpatients and outpatients (Mann-Whitney U test; P=0.02) and among those with different palliative performance status (Spearman's rho for pain, tiredness, drowsiness, lack of appetite, well-being; P<0.01).

CONCLUSION

The ESAS-r is a valid instrument with adequate psychometric characteristics. This version is preferred by patients with advanced cancer. The Spanish version of the ESAS-r can, therefore, replace the use of the ESAS.

A new palliative care consultation team at the oncology department of a university hospital: an assessment of initial efficiency and effectiveness

PURPOSE

Palliative care consultation teams (PCCT) in acute hospitals have increased in number over recent years. To assess whether these teams are both efficient in their role within a palliative care centre and effective in the care that is provided for patients, we reviewed the initial activity of a new PCCT at the Oncology Department of Clínica Universidad de Navarra, a European Society for Medical Oncology-designated centre of integrated oncology and palliative care.

METHODS

All patients evaluated by the PCCT over the first 3 years of its activity were included. Data about diagnosis, demographic characteristics, survival and initial symptom burden were evaluated using the Edmonton Symptom Assessment System (ESAS); whenever possible, a follow-up ESAS for inpatients was collected within 1 week from the electronic charts and analysed retrospectively.

RESULTS

The PCCT evaluated 611 cancer patients within the initial 3 years of the service commencing. On the first visit, 392 patients (64%) completed the ESAS evaluation. Of those that completed the ESAS, 43% were outpatients, 52% had gastrointestinal tumours, and 16% died within a month. The evaluated patients had an average of six uncontrolled symptoms (≥4/10). The most common moderate to severe symptoms were fatigue (80%), anorexia (67%) and depression (62%); 70% of patients presented with pain (14% with severe pain). Of the 225 inpatients evaluated, 110 (49%) completed the follow-up ESAS within 1 week. A statistically significant decrease was observed for pain, nausea, depression, anxiety and somnolence as well as in the number of uncontrolled symptoms and in the symptom distress score. The patient's perception of his/her general well-being was better as meassured with the specific question of ESAS.

CONCLUSION

From the initial stages, the PCCT was both efficient in its role within the palliative care centre and effective in the care that was provided for patients. A significant number of patients were evaluated, many of them with severe symptoms and/or at the end of life. Inpatients receiving care from the PCCT experienced an improvement in symptom control within just a few days.

Association between patient-reported symptoms and nurses' clinical impressions in cancer patients admitted to an acute palliative care unit

BACKGROUND

Clinicians typically rely on their own or the nurses' clinical impression (NI) of symptoms rather than patient self-reports. It is unclear whether these means of assessment yield similar results.

OBJECTIVE

To prospectively compare patient-reported symptoms on a modified Edmonton Symptom Assessment System (ESAS) with NI scores.

METHODS

Consecutive patients with advanced cancer admitted to our acute palliative care unit between April and July 2010 were studied. We collected the results of the ESAS on the day of admission (D1) to the unit and 2 days later (D3). We also collected the NI of each patient's physical and psychological distress on D1 and D3.

RESULTS

One hundred eighteen patients completed the ESAS on D1 and 116 on D3. On D1 there was no significant association between NI score and ESAS assessment except for dyspnea, which was weakly correlated with NI score for physical distress (r=0.22, p=0.02). The median ESAS physical and psychosocial scores were 31 and 12 in patients with NI of low or no physical distress, versus 34 (p=0.07) and 15 (p=0.18) in patients with NI of moderate or severe distress, respectively. On D3, we found a significant association between ESAS and NI only for pain (r=0.32, p<0.001) and anxiety (r=0.30, p=0.001). Sensitivity and specificity of the NIs for ESAS scores were low on both days.

CONCLUSION

The clinical impression of highly trained palliative care nurses showed poor association with patient-reported symptom intensity. Validated symptom assessment tools are needed for bedside clinical assessment.

Assessing agreement between terminally ill cancer patients' reports of their quality of life and family caregiver and palliative care physician proxy ratings

CONTEXT

Proxy ratings, if valid, may provide an alternative approach to evaluating patient quality of life (QoL) at the end of life.

OBJECTIVES

To examine agreement between terminally ill cancer patients' self-reported QoL and proxy assessment of patient QoL by their family caregiver (FCG) and palliative care physicians (PCPs) at two time points.

METHODS

Patients admitted to an acute palliative care unit and their FCGs and PCPs completed the McGill Quality of Life Questionnaire (MQOL) at Days 3 and 6 after admission. Response bias and response precision were examined at the individual and group levels. Furthermore, we examined patient factors affecting agreement and responsiveness of proxy MQOL scores to changes in patients' QoL between Days 3 and 6.

RESULTS

Statistically and clinically significant mean differences were detected between the patient and both proxy groups' reports of QoL on Day 3, with the magnitude of the differences decreasing somewhat by Day 6. Proxies underestimated patients' QoL compared with patients' self-report. Response precision based on intraclass correlation values and proportion of approximate agreement was poor to fair at both time points. Agreement was better for patients with greater physical burden and more cognitive difficulties. Proxies' responsiveness to change from Day 3 to Day 6 was low, and proxies were not able to detect minimally important changes in QoL.

CONCLUSION

The findings suggest that moderate agreement between patient and proxy ratings of QoL develops over time but that precision at the individual level, which is more clinically relevant, is less reliable. New strategies for improving proxy reliability are needed.

The Edmonton Symptom Assessment System, a proposed tool for distress screening in cancer patients: development and refinement

OBJECTIVE

The Edmonton Symptom Assessment System (ESAS) has been proposed as one element of a distress screening strategy in cancer patients. It consists of 11-point numerical rating scales for self-report of nine common symptoms of cancer, with a 10th scale for a patient-specific symptom. The ESAS has undergone widespread adoption internationally for clinical, research and administrative purposes. Despite its rapid uptake, validity evidence has lagged behind, and concerns have been raised about feasibility and usefulness. The objective of this paper is to provide a synthesis of a program of research focusing on the psychometric properties of the ESAS.

METHODS

We describe and discuss a series of three ESAS studies undertaken by our group: (i) a review of ESAS validation studies (1991-2006); (ii) a think-aloud study conducted in 20 advanced cancer patients; and (iii) a prospective multicenter study conducted in 160 patients in different palliative care settings, comparing the ESAS with a revised version (ESAS-r).

RESULTS

The review identified 13 articles focusing on gathering reliability and/or validity evidence; the need to standardize the ESAS and conduct further validation research was apparent. The think-aloud study elucidated the complex cognitive processes by which patients arrive at symptom ratings and areas of potential difficulty in understanding and completing the ESAS. The multicenter study demonstrated that the ESAS-r was significantly easier for patients to understand.

CONCLUSIONS

Overall, our findings support consideration of the ESAS and its successor, the ESAS-r, for use in distress screening in cancer patients. Areas for future research will be presented. Copyright © 2011 John Wiley & Sons, Ltd.

Association between self-reported sleep disturbance and other symptoms in patients with advanced cancer

CONTEXT

Sleep disturbance (SD) is a significant source of distress for patients with cancer. Studies of patients with advanced cancer receiving palliative care to identify symptoms associated with the severity of SD are limited.

OBJECTIVES

In this study, we sought to identify the symptoms measured by the Edmonton Symptom Assessment Scale (ESAS) that are associated with SD, as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary aims of the study were to determine the association between occurrences of SD with occurrences of other symptoms and screening performance of the ESAS-Sleep item against the PSQI.

METHODS

We reviewed the completed ESAS and PSQI assessments of 101 patients with advanced cancer who were receiving palliative care and had been admitted to prospective clinical trials previously initiated by us. Patients with a PSQI score of ≥ 5 were considered to have an SD. The frequency and severity of the ESAS symptoms items, their correlation with each other, the PSQI score, and the screening performance of the ESAS-Sleep item were calculated.

RESULTS

The median age of patients was 60 years. Most were white non-Hispanic (73%), had lung or breast cancer (41%), and were diagnosed with SD (85%). The PSQI score was correlated with the ESAS items of pain (r=0.27, P=0.006), dyspnea (r=0.25, P<0.001), well-being (r=0.35, P<0.0001), and sleep (r=0.44, P<0.0001). Compared with patients without SD, those with SD were more likely to report pain (P=0.0132), depression (P=0.019), anxiety (P=0.01), and a poorer sense of well-being (P=0.035). An ESAS-Sleep item cutoff score of ≥ 3 (of 10) resulted in a sensitivity of 74% and a specificity of 73%.

CONCLUSION

SD is associated with increased frequency of pain, depression, anxiety, and a worse sense of well-being. These four symptoms should be assessed in all patients with advanced cancer with a complaint of SD. The ideal cutoff point of the ESAS-Sleep item for screening for SD is a score of ≥ 3. More research is needed to better characterize this frequent and distressing syndrome.

Development and validation of a modified version of the Edmonton Symptom Assessment Scale in a Flemish palliative care population

Palliative cancer patients are faced with multiple symptoms that threaten their quality of life. To manage these symptoms, a reliable and valid way of registration is crucial. In this study, the Edmonton Symptom Assessment Scale (ESAS) has been translated, modified, and tested on content, face, criterion, construct validity, and internal consistency for patients admitted to Flemish palliative care units. These aspects are tested in a descriptive, comparative, longitudinal study based on 3 convenience samples. The first consisted of 8 palliative care experts. The second sample checked the face validity and consisted of 4 patients, 5 family members, and 5 nurses. The last sample involved 23 patients admitted to 3 Flemish palliative care units. Heedful of the "new-wave" vision on validity, the translated and altered ESAS seemed a suitable instrument for the symptom assessment of patients with cancer admitted to a palliative care unit.

Anti-emetic effect of ginger powder versus placebo as an add-on therapy in children and young adults receiving high emetogenic chemotherapy

PURPOSE

Chemotherapy-induced nausea and vomiting (CINV) are major adverse effects of chemotherapy. Ginger has been used in postoperative and pregnancy-induced nausea and vomiting. Data on its utility in reducing CINV in children and young adults are lacking.

PATIENTS AND METHODS

Sixty chemotherapy cycles of cisplatin/doxorubicin in bone sarcoma patients were randomized to ginger root powder capsules or placebo capsules as an additional antiemetic to ondensetron and dexamethasone in a double-blind design. Acute CINV was defined as nausea and vomiting occurring within 24 hr of start of chemotherapy (days 1-4) and delayed CINV as that occurring after 24 hr of completion of chemotherapy (days 5-10). CINV was evaluated as per Edmonton's Symptom Assessment Scale and National Cancer Institute criteria respectively.

RESULTS

Acute moderate to severe nausea was observed in 28/30 (93.3%) cycles in control group as compared to 15/27 (55.6%) cycles in experimental group (P = 0.003). Acute moderate to severe vomiting was significantly more in the control group compared to the experimental group [23/30 (76.7%) vs. 9/27 (33.33%) respectively (P= 0.002)]. Delayed moderate to severe nausea was observed in 22/30 (73.3%) cycles in the control group as compared to 7/27 (25.9%) in the experimental group (P < 0.001). Delayed moderate to severe vomiting was significantly more in the control group compared to the experimental group [14/30 (46.67%) vs. 4/27 (14.81%) (P = 0.022)].

CONCLUSION

Ginger root powder was effective in reducing severity of acute and delayed CINV as additional therapy to ondensetron and dexamethasone in patients receiving high emetogenic chemotherapy (ClinicalTrials.gov identifier: NCT00940368).

A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients

CONTEXT

The Edmonton Symptom Assessment System (ESAS) is a widely used, self-report symptom intensity tool for assessing nine common symptoms in palliative care, with ratings ranging from 0 (none, best) to 10 (worst). Based on a "think-aloud" study of 20 advanced cancer patients, the ESAS was revised (ESAS-r).

OBJECTIVES

To compare the consistency of patients' symptom ratings and obtain patient perspectives regarding ease of understanding and completion between the ESAS and ESAS-r.

METHODS

Cognitively intact patients (n=160) were recruited from eight palliative care sites in Canada and Switzerland, using cross-sectional sampling (20 per site). Consenting patients completed the ESAS, ESAS-r, and a structured interview. Intraclass correlation coefficients (ICCs) were calculated to assess rating consistency.

RESULTS

In total, 1046 patients were screened. One hundred sixty were enrolled and evaluable (female 51%, median age 61 [range 34-92], lung cancer 26%, gastrointestinal cancer 22%). Mean ESAS scores ranged from 1.2 (nausea, standard deviation [SD] 2.1) to 4.3 (appetite, SD 3.3). ICCs ranged from 0.65 to 0.83, with lowest scores (<0.8) for drowsiness, appetite, and well-being. Although most patients rated both versions as very easy or easy to understand and complete, the ESAS-r was significantly easier to understand than the ESAS (P=0.008). Significantly, more patients preferred the ESAS-r (39%) than the ESAS (14%, P<0.001) because of its definitions, clarity, and format.

CONCLUSION

The ESAS-r retains core elements of the ESAS, with improved interpretation and clarity of symptom intensity assessment. It represents the next generation of ESAS development, with further validation recommended for drowsiness, appetite, and well-being.

Experience with palliative care in patients with advanced cancer at a tertiary care hospital in a developing country

The importance of palliative care in patients with advanced cancer is established. Reports on the experience with palliative care in the Middle East region are limited. A prospective study was performed to characterize the palliative care experience at a tertiary care center in Lebanon and to identify the profile of patients requiring palliative care. This communication highlights the results of the study. Authors conclude that the profile of needs for individuals requiring palliative care in Lebanon is similar to westernized countries. Revisiting the continuum of cancer care is called for to better identify the optimal timing of intervention and avoid end of life distress.

Effectiveness of palliative care services in symptom control of patients with advanced terminal cancer: a spanish, multicenter, prospective, quasi-experimental, pre-post study

CONTEXT

In implementing the National Strategy of Palliative Care in Spain, there needs to be an evaluation of services, especially of their effectiveness, efficiency, and satisfaction of patients and families.

OBJECTIVES

To assess the effectiveness of palliative care services (PCS) in improving symptom control in Spain.

METHODS

This multicenter, prospective, quasi-experimental, pre-post intervention study evaluated symptoms, such as pain, breakthrough pain, anorexia, nausea/vomiting, constipation, insomnia, dyspnea at rest and with movement, anxiety, and depression, using patient-reported numeric rating scales on Days 0, 7, and 14 after referral to a PCS.

RESULTS

Of the 318 PCSs included in the National Directory for 2004, 105 services in the 17 autonomous regions of Spain were able to report 265 eligible (treatment-naïve) patients. Nonparticipation by some centers was because of excessive workload or because their patients were not treatment-naïve. Median survival was 42 days. Pain severity and number of crises of breakthrough pain significantly improved, as did other indicators of patient satisfaction. Symptom improvement was independent of type of service (in acute bed hospitals, medium-term stay facilities, hospital support teams, home care support teams, and outpatient clinics).

CONCLUSION

Our national plan appears to be successful in reducing symptoms irrespective of the type of organization providing the PCS. An area for improvement could be to lessen the workload of individual teams.

Assessment of symptom control in patients with cancer in Northwestern Turkey

AIM

The main purpose of this cross-sectional study was to compare symptoms occurring before and after chemotherapy treatment and to investigate the factors affecting those symptoms. The secondary purpose was to determine the most commonly occurring symptoms experienced by the patients with cancer after chemotherapy.

METHODS

Fifty inpatients and outpatients receiving chemotherapy for the first time with various cancer diagnoses and hospitalized in the oncology unit of Trakya University Medical Faculty Hospital between July 2006 and April 2007 were attended to the study. Data were collected using the Edmonton Symptom Assessment Scale (ESAS).

RESULTS

It was discovered that symptoms of fatigue, nausea, loss of appetite, impaired sense of well-being, changes in skin and nails, stomatitis and numbness in hands among chemotherapy patients increased by a statistically significant margin after treatment (p<0.05). Post-chemotherapy symptoms increased markedly (p<0.05) among patients within groups determined by age, gender, marital status, stage of cancer and date of diagnosis. Cross-group comparisons of post-chemotherapy participants analyzed in terms of marital status, clinical stage of disease, and date of diagnosis revealed that fewer symptoms (drowsiness and shortness of breath) increased compared to other symptoms measured along with treatment (p<0.05).

CONCLUSION

We conclude that by considering personal characteristic (i.e. age, gender, etc.) as well as disease-related characteristics (i.e. clinical stage of the disease, etc.), individual nursing care might significantly contribute to the alleviation and management of symptoms.

Development and validation of a questionnaire for quantitative assessment of perceived discomforts in critically ill patients

PURPOSE

To develop and validate the IPREA (Inconforts des Patients de REAnimation) questionnaire for the assessment of discomfort perceived by patients related to their intensive care unit (ICU) stay.

METHODS

This was a two step-study comprising a phase of item generation conducted in one ICU and a phase of psychometric evaluation during a multicenter prospective cohort study in 14 ICUs. Patients were unselected consecutive adult surviving ICU patients. On the day of ICU discharge, a nurse asked patients to rate the severity of 16 discomfort sources, from 0 to 100. Ten percent of patients were randomly chosen to be questioned again to assess the reproducibility.

RESULTS

Of 1,380 eligible patients, 1,113 survived and 868 patients could be questioned. The highest scores were for sleep deprivation (35 ± 33), being restrained by tubing, wires, and cables (33 ± 30), pain (32 ± 30), and thirst (32 ± 34). No multidimensional structure was identified. The mean overall score of discomfort was 22 ± 14. Internal consistency was satisfactory using Cronbach's alpha coefficient (0.78). The test-retest reliability study found average measure intraclass correlations ranging from 0.70 to 0.92. The mean duration of the questionnaire administration was 10 ± 7 min.

CONCLUSION

The psychometric properties and acceptability of the IPREA questionnaire make it a potential instrument for measuring discomfort perceived by unselected ICU patients.

A system for symptom assessment in advanced palliative home healthcare using digital pens

Symptom control is one of the most important components of delivering effective palliative care, and adequate symptom assessment is a prerequisite for good symptom control. Patients receiving treatment in palliative home healthcare is geographically separated from the caregivers making symptom control a challenge, a challenge that could be met by the use of information and communication technology. Technologies of today offer different ways for patients to assess their symptoms at home and send the assessments to the healthcare provider. Examples are the use of a PC, a touch-tone telephone, and a digital pen, which require different kinds of infrastructure in the patient's home, and which differ in strengths and weaknesses. As part of an ongoing quality assurance work within the hospital-based home care clinic at Linköping University Hospital, the project has designed, developed and implemented an IT-support system for pain assessments for patients at home using digital pen and mobile Internet technology. A questionnaire study indicated that pain assessment using digital pens was accepted by patients and that problems mainly arose from the use of the visual-analogue scale.

Prevalence of distressing symptoms in hospitalised patients on medical wards: A cross-sectional study

Background

Many patients with advanced, serious, non-malignant disease belong to the population generally seen on medical wards. However, little research has been carried out on palliative care needs in this group. The aims of this study were to estimate the prevalence of distressing symptoms in patients hospitalised in a Department of Internal Medicine, estimate how many of these patients might be regarded as palliative, and describe their main symptoms.

Methods

Cross-sectional (point prevalence) study. All patients hospitalised in the Departments of Internal Medicine, Pulmonary Medicine, and Cardiology were asked to do a symptom assessment by use of the Edmonton Symptom Assessment System (ESAS). Patients were defined as "palliative" if they had an advanced, serious, chronic disease with limited life expectancy and symptom relief as the main goal of treatment.

Results

222 patients were registered in all. ESAS was completed for 160 patients. 79 (35.6%) were defined as palliative and 43 of them completed ESAS. The patients in the palliative group were older than the rest, and reported more dyspnea (70%) and a greater lack of wellbeing (70%). Other symptoms reported by this group were dry mouth (58%), fatigue (56%), depression (41%), anxiety (37%), pain at rest (30%), and pain on movement (42%).

Conclusion

More than one third of the patients in a Department of Internal Medicine were defined as palliative, and the majority of the patients in this palliative group reported severe symptoms. There is a need for skills in symptom control on medical wards.

Application of quality audit tools to evaluate care quality received by terminal cancer patients admitted to a palliative care unit

GOALS

We aimed to evaluate the palliative care quality for terminal cancer patients as a reference for prospective service improvements.

PATIENTS AND METHODS

A prospective study was conducted to analyze the quality audit data collected from 1,476 samples in one medical center's palliative care unit. Lai's modified version of the support team assessment schedule was utilized for 2-year data collection, applying 17 categories of audit criteria rated on a scale of 0 to 4 (0-no symptoms, 4-significant symptoms). The quality audit criteria were scored weekly for 2 weeks following patient admission.

RESULTS

Average scores of quality audit criteria from admission to week 2 were 10.05, 8.85, and 8.49, respectively, with statistical differences noted weekly. Efficacy of palliative care was most evident 2 weeks after hospitalization. Factors with statistically significant differences between admission and week 1 included: pain control, constipation, vomiting, anorexia, other symptom control, patient anxiety, self awareness and preparation of patient for illness, self awareness and preparation of family for illness, and satisfaction of patient's spiritual belief and life philosophy. Factors with statistically significant differences between weeks 1 and 2 included: pain control, other symptom control, self awareness and preparation of family for illness, and satisfaction of patient's spiritual belief and life philosophy.

CONCLUSIONS

Patients in hospice care received adequate symptom relief. Total quality audit scores declined progressively over the 2 weeks following patient admission, indicating efficacy of palliative care quality.

Use of a modified ESAS in cancer patients: a pilot study of patient and staff experiences

AIM

To evaluate the feasibility of a modified Edmonton Symptom Assessment Scale (ESAS) for monitoring symptoms in oncological palliative care.

METHODS

A modified ESAS was delivered daily to 28 patients with advanced cancer. A questionnaire to discover staff members' opinions on the ESAS was delivered at the end of the study. Structured interviews were used to examine patients' opinions on the ESAS.

RESULTS

The mean total ESAS score was 28.9 on inclusion day and 25.8 on Day 3 (p=0.531). Eleven of 21 of the staff considered the ESAS to be a 'good' or 'very good' way to obtain information about patients' symptoms. Seventeen of 24 patients who participated in the interview felt that ESAS was easy to fill in, and that there were no missing questions.

CONCLUSION

The patients felt that the modified ESAS contained relevant symptoms, and that the questionnaires were easy to fill in. The staff considered the modified ESAS to be a useful instrument for obtaining information about patients' symptom distress. The modified ESAS is a good instrument for use as part of the daily clinical routine, as well as for monitoring symptoms in palliative oncological care.

The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy

Intractable breathlessness is a common, devastating symptom of advanced cancer causing distress and isolation for patients and families. In advanced cancer, breathlessness is complex and usually multifactorial and its severity unrelated to measurable pulmonary function or disease status. Therapeutic advances in the clinical management of dyspnea are limited and it remains difficult to treat successfully. There is growing interest in the palliation of breathlessness, and recent work has shown that a systematic, evidence-based approach by a committed multidisciplinary team can improve lives considerably. Where such care is lacking it may be owing to therapeutic nihilism in clinicians untrained in the management of chronic breathlessness and unaware that there are options other than endurance. Optimum management involves pharmacological treatment (principally opioids, occasionally oxygen and anxiolytics) and nonpharmacological interventions (including use of a fan, a tailor-made exercise program, and psychoeducational support for patient and family) with the use of parenteral opioids and sedation at the end of life when appropriate. Effective care centers on the patient's needs and goals. Priorities in breathlessness research include studies on: neuroimaging, the effectiveness of new interventions, the efficacy, safety, and dosing regimens of opioids, the contribution of deconditioning, and the effect of preventing or reversing breathlessness.

The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991--2006)

INTRODUCTION

The purpose of this review was to identify and critique validation studies focusing on the Edmonton Symptom Assessment System (ESAS), a commonly used symptom assessment tool for advanced cancer and palliative patients.

METHODS

Using a comprehensive literature search, the authors identified and screened 87 publications. Thirteen articles were selected for in-depth review, based on the following inclusion criteria: psychometric studies with a primary focus on the ESAS, 1991--2006 publication dates and peer-reviewed English language publications.

RESULTS

Most studies involved cancer patients (n = 11). The ESAS format varied across studies, in terms of scale format, item number, item selection and language. Studies focused on gathering reliability estimates (n = 8), content validity evidence (n = 1), concurrent validity evidence (n = 5), predictive validity evidence (n = 1), and sensitivity and/or specificity (n = 3). None of these studies involved patients' perspectives as a source of validity evidence.

DISCUSSION

The use of varying instrument formats and limited psychometric evidence support the need for further ESAS validation studies, including the involvement of patients.

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.