Can family caregivers of terminally ill patients be a reliable source of information about the severity of patient symptoms?

Symptom Management Theory: Analysis, Evaluation, and Implications for Caring for Adults With Cancer

A detailed analysis of Symptom Management Theory (SMT) along with its extent of use and implications for adults with cancer as demonstrated in 20 oncology research studies is reported. SMT provides useful guidance for adult oncology research and nursing practice. Theory dimension most researched in cancer was symptom experience. Although theory assertions were demonstrated in 80% of the studies, it was used to an adequate extent only in 35% of them. Comparisons between cancer-related clinical outcomes with and without use of SMT, certain theory modifications, and future SMT-based studies involving longitudinal designs in this population are warranted.

Association Between Symptom Burden and Time to Hospitalization, Nursing Home Placement, and Death Among the Chronically Ill Urban Homebound

CONTEXT

Homebound adults experience significant symptom burden.

OBJECTIVES

To examine demographic and clinical characteristics associated with high symptom burden in the homebound, and to examine associations between symptom burden and time to hospitalization, nursing home placement, and death.

METHODS

Three hundred eighteen patients newly enrolled in the Mount Sinai Visiting Doctors Program, an urban home-based primary care program, were studied. Patient sociodemographic characteristics, symptom burden (measured via the Edmonton Symptom Assessment Scale), and incidents of hospitalization, nursing home placement, and death were collected via medical chart review. Multivariate Cox proportional hazards models were used to analyze the effect of high symptom burden on time to first hospitalization, nursing home placement, and death.

RESULTS

Of the study sample, 45% had severe symptom burden (i.e., Edmonton Symptom Assessment Scale score >6 on at least one symptom). Patients with severe symptom burden were younger (82.0 vs. 85.5 years, P < 0.01), had more comorbid conditions (3.2 vs. 2.5 Charlson score, P < 0.01), higher prevalence of depression (43.4% vs. 12.0%, P < 0.01), lower prevalence of dementia (34.3% vs. 60.6%, P < 0.01), and used fewer hours of home health services (73.6 vs. 94.4 hours/wk, P < 0.01). Severe symptom burden was associated with a shorter time to first hospitalization (hazard ratio = 1.51, 95% CI 1.06-2.15) in adjusted models but had no association with time to nursing home placement or death.

CONCLUSION

The homebound with severe symptom burden represents a unique cohort of patients who are at increased risk of hospitalization. Tailored symptom management via home-based primary and palliative care programs may prevent unnecessary health care utilization in this population.

CHESS improves cancer caregivers' burden and mood: results of an eHealth RCT

OBJECTIVE

Informal caregivers (family and friends) of people with cancer are often unprepared for their caregiving role, leading to increased burden or distress. Comprehensive Health Enhancement Support System (CHESS) is a Web-based lung cancer information, communication, and coaching system for caregivers. This randomized trial reports the impact on caregiver burden, disruptiveness, and mood of providing caregivers access to CHESS versus the Internet with a list of recommended lung cancer websites.

METHODS

A total of 285 informal caregivers of patients with advanced nonsmall cell lung cancer were randomly assigned to a comparison group that received Internet or a treatment group that received Internet and CHESS. Caregivers were provided a computer and Internet service if needed. Written surveys were completed at pretest and during the intervention period bimonthly for up to 24 months. Analyses of covariance (ANCOVAs) compared the intervention's effect on caregivers' disruptiveness and burden (CQOLI-C), and negative mood (combined Anxiety, Depression, and Anger scales of the POMS) at 6 months, controlling for blocking variables (site, caregiver's race, and relationship to patient) and the given outcome at pretest.

RESULTS

Caregivers randomized to CHESS reported lower burden, t(84) = 2.36, p = .021, d = .39, and negative mood, t(86) = 2.82, p = .006, d = .44, than those in the Internet group. The effect on disruptiveness was not significant.

CONCLUSIONS

Although caring for someone with a terminal illness will always exact a toll on caregivers, eHealth interventions like CHESS may improve caregivers' understanding and coping skills and, as a result, ease their burden and mood.

Patients who are near death are frequently unable to self-report dyspnea

BACKGROUND

Standard measures of dyspnea rely on the patient's self-report. Declining consciousness and/or cognitive function and nearness to death may interfere with dyspnea reporting making the patient vulnerable to undertreatment or overtreatment.

METHODS

An observational design was used with 89 consecutive patients referred for inpatient palliative care consultation. Patients were included if they were at risk for dyspnea because of one or more of the following: lung cancer, chronic obstructive pulmonary disease (COPD), heart failure, or pneumonia. Patients were asked "Are you short of breath?" and asked to quantify any distress by pointing to a visual analogue scale (VAS). Other measures included: consciousness, cognitive state, terminal illness severity, and patient demographics.

RESULTS

More than half of the patients (54%) were unable to provide a yes or no response. Only 20 of 41 (49%) able to respond with yes or no were able to quantify any distress with the VAS. Ability to self-report was positively associated with consciousness (p < 0.01), cognitive state (p < 0.01), and terminal illness severity (p < 0.01). A significant inverse relationship was found between consciousness and terminal illness severity (p < 0.01). Declines in consciousness and cognitive state were strongly correlated with nearness to death (p < 0.01).

CONCLUSIONS

Declining consciousness and/or cognitive state are expected when patients are near death. The ability to give even the simplest self-report (yes or no) about dyspnea is lost in the near-death phase of terminal illness, yet the ability to experience distress may persist and may be overlooked and undertreated or overtreated. Other methods for symptom assessment are needed in this context.

Patient-surrogate agreement of predictors of decision delay among patients with acute myocardial infarction: a questionnaire survey

BACKGROUND

Studies that assessed predictors of patient delay to seek healthcare for acute myocardial infarction lack generalization to all patient population as it investigated patients who survived coronary events.

OBJECTIVES

To evaluate utility of using surrogates to proxy patients who cannot be interviewed and to examine patients-surrogate agreement.

DESIGN

A cross-sectional descriptive survey study. The cognitive and emotional domains of the modified Response to Symptoms Questionnaire were used to interview participants.

PARTICIPANTS AND SETTINGS

A convenient sample of patient-surrogate pairs was collected (n=109). Hospitalized patients with acute myocardial infarction were eligible if they were at least 18 years old, hemodynamically stable, pain free or controlled pain during interview, and could identify a surrogate. Exclusions (n=45) were patients transferred from other hospitals or those who had acquired heart attack following their admission. A surrogate was defined as an individual who witnessed the onset of symptoms and whom the patient has articulated symptoms with prior to admission.

METHODS

Patient and surrogate were interviewed independently. Decision delay time was assessed by assisting participants and surrogates to triangulate the time of symptom onset and time of decision to seek help by placing it in the context of events that they would remember. The intraclass correlation coefficient was used to assess agreement.

RESULTS

Patients were mainly men (81%), married (79%) and ranged in age from 39 to 78 years while surrogates were mostly women (74%) and 55% of them were patients' spouses. Surrogates ranged in age from 18 to 75 years. Intraclass correlation coefficients levels varied across different variables ranging from lack of agreement (p>0.05) to almost perfect agreement with decision delay time having the highest correlation coefficient (86%, p<0.05). Cognitive variables had higher agreement than emotional variables. Significant emotional variables' agreement ranged form 28% to 39% and significant cognitive variables' agreement ranged form 64% to 68%. Female surrogates (n=81) had higher agreement levels with their respective patients than male surrogates (n=28).

CONCLUSIONS

Utilizing surrogates to proxy patients' account of decision delay time and its cognitive predictors is practical and feasible.

Caregiver assessment of patients with advanced cancer: concordance with patients, effect of burden and positivity

Background

Clinicians and researchers often have to rely on information from caregivers to assess patients with advanced cancer. This study aims to assess the validity (using patients' assessment as the gold standard) of caregiver reports of patient concerns and the roles of caregiver burden and positivity.

Methods

A total of 64 advanced cancer patient and informal caregiver dyads were recruited from regional palliative care services and interviewed. Patients' outcomes were assessed with both the patient and the caregiver version of the Palliative Outcome Scale (POS); caregiver burden and positivity were collected with the Zarit Burden interview (ZBI) and three questions on achievements and relationships. The agreement between patient- and caregiver-rated POS was measured with weighted kappa statistics. The roles of caregiver burden and positivity in POS agreement were studied with logistic regression controlling for potential confounders; adjusted odds ratios were estimated from the models.

Results

Agreement was substantial for pain, moderate for four items, fair for three items and slight for two items. Compared with patients self-ratings, caregivers described more problems with information given and sharing feelings and were less likely to assess the patient felt their life was worthwhile or felt good about themselves. Disagreement for three POS item ratings was significantly associated with higher caregiver burden: "feeling anxious"(OR: 4.5; 95%CI: 1.3 to 15.6), "life worthwhile"(OR: 12.4; 95%CI: 2.9 to 54.3) and "felt good" (OR: 7.7; 95%CI: 2.0 to 29.6). Caregivers with higher positivity scores were more likely to agree patients' rating of "felt good"(OR: 0.3; 95%CI: 0.1–0.9) but at increased risk of disagreeing about patient's "practical problems"(OR: 4.2; 95%CI: 1.1 to 16.6).

Conclusion

Caregiver burden and positivity affect their assessments, especially of psychological patient domains and whether patients assess their life as worthwhile. Awareness of this might help clinicians and researchers better interpret caregiver assessments.