Symptom management issues in hospice care

Hospice Care Experiences Among Cancer Patients and Their Caregivers

BACKGROUND

Little is known about the current quality of care for hospice cancer patients and how it varies across hospice programs in the USA.

OBJECTIVE

To examine hospice care experiences among decedents with a primary cancer diagnosis and their family caregivers, comparing quality across settings of hospice care.

DESIGN

We analyzed data from the Consumer Assessment of Healthcare Providers and Systems Hospice Survey (32% response rate). Top-box outcomes (0-100) were calculated overall and by care setting, adjusting for survey mode and patient case mix.

PARTICIPANTS

Two hundred seventeen thousand five hundred ninety-six caregiver respondents whose family member had a primary cancer diagnosis and died in 2017 or 2018 while receiving hospice care from 2,890 hospices nationwide.

MAIN MEASURES

Outcomes (0-100 scale) included 8 National Quality Forum-endorsed quality measures, as well as responses to 4 survey questions assessing whether needs were met for specific symptoms (pain, dyspnea, constipation, anxiety/sadness).

KEY RESULTS

Quality measure scores ranged from 74.9 (Getting Hospice Care Training measure) to 89.5 (Treating Family Member with Respect measure). The overall score for Getting Help for Symptoms was 75.1 with item scores within this measure ranging from 60.6 (getting needed help for feelings of anxiety or sadness) to 84.5 (getting needed help for pain). Measure scores varied significantly across settings and differences were large in magnitude, with caregivers of decedents who received care in a nursing home (NH) or assisted living facility (ALF) setting consistently reporting poorer quality of care.

CONCLUSIONS

Important opportunities exist to improve hospice care for symptom palliation and providing training for caregivers when their family members are at home or in an ALF setting. Efforts to improve care for cancer patients in the NH and ALF setting are especially needed.

Food pyramid for subjects with chronic pain: foods and dietary constituents as anti-inflammatory and antioxidant agents

Emerging literature suggests that diet constituents may play a modulatory role in chronic pain (CP) through management of inflammation/oxidative stress, resulting in attenuation of pain. We performed a narrative review to evaluate the existing evidence regarding the optimum diet for the management of CP, and we built a food pyramid on this topic. The present review also describes the activities of various natural compounds contained in foods (i.e. phenolic compounds in extra-virgin olive oil (EVO)) listed on our pyramid, which have comparable effects to drug management therapy. This review included 172 eligible studies. The pyramid shows that carbohydrates with low glycaemic index should be consumed every day (three portions), together with fruits and vegetables (five portions), yogurt (125 ml), red wine (125 ml) and EVO; weekly: legumes and fish (four portions); white meat, eggs and fresh cheese (two portions); red or processed meats (once per week); sweets can be consumed occasionally. The food amounts are estimates based on nutritional and practical considerations. At the top of the pyramid there is a pennant: it means that CP subjects may need a specific customised supplementation (vitamin B12, vitamin D, n-3 fatty acids, fibre). The food pyramid proposal will serve to guide dietary intake with to the intent of alleviating pain in CP patients. Moreover, a targeted diet can also help to solve problems related to the drugs used to combat CP, i.e. constipation. However, this paper would be an early hypothetical proposal due to the limitations of the studies.

A Discourse Analysis: One Caregiver's Voice in End-of-Life Care

Informal family caregivers make a significant contribution to the U.S. health care system, and the need for caregivers will likely increase. Gaining deeper insights into the caregiver experience will provide essential knowledge needed to support the future caregiver workforce delivering care. Discourse analysis is a viable approach in analyzing textual caregiver data that focuses on the end-of-life caregiving experience. The purpose of this study was to conduct an in-depth discourse analytic examination of 13 hours of caregiver interview data, which reveal the multiplicity of shifting stances and perceptions of one caregiver in the midst of end-of-life care, specifically with regard to his perceptions of self (caregiver) and other (care recipient). By isolating a specific but limited set of reference terms used throughout the discourse, we gained systematic glimpses into the mind and perceptions of this single caregiver in relation to his role as caregiver for his terminally ill wife.

Combining pain therapy with lifestyle: the role of personalized nutrition and nutritional supplements according to the SIMPAR Feed Your Destiny approach

Recently, attention to the lifestyle of patients has been rapidly increasing in the field of pain therapy, particularly with regard to the role of nutrition in pain development and its management. In this review, we summarize the latest findings on the role of nutrition and nutraceuticals, microbiome, obesity, soy, omega-3 fatty acids, and curcumin supplementation as key elements in modulating the efficacy of analgesic treatments, including opioids. These main topics were addressed during the first edition of the Study In Multidisciplinary Pain Research workshop: “FYD (Feed Your Destiny): Fighting Pain”, held on April 7, 2016, in Rome, Italy, which was sponsored by a grant from the Italian Ministry of Instruction on “Nutraceuticals and Innovative Pharmacology”. The take-home message of this workshop was the recognition that patients with chronic pain should undergo nutritional assessment and counseling, which should be initiated at the onset of treatment. Some foods and supplements used in personalized treatment will likely improve clinical outcomes of analgesic therapy and result in considerable improvement of patient compliance and quality of life. From our current perspective, the potential benefit of including nutrition in personalizing pain medicine is formidable and highly promising.

Caregivers' perspectives on oral health problems of end-of-life cancer patients

PURPOSE

The purpose of this study was to determine caregivers' perspectives on oral health problems in cancer patients at the end of life and explore factors that contribute to those perspectives.

METHODS

A cross-sectional, observational clinical study design was used. We recruited dyads of lay caregivers and patients with advanced cancer who were receiving hospice or palliative care in their homes. Caregivers [N = 104, mean age = 55.4 ± 15.0 years (18-100); n = 50 (48 %) African-American; and n = 80 (77 %) female] completed the proxy version of the Oral Problems Scale to provide their perspectives regarding their care recipients' xerostomia, orofacial pain, and taste change in the past week.

RESULTS

More than half of the caregivers reported that care recipients' oral hygiene was a very important responsibility for caregivers, and over 80 % reported that it was very important to evaluate their care recipients' oral problems. However, caregivers reported that they asked their care recipients about oral problems infrequently. There were statistically significant correlations between caregivers' and care recipients' ratings on xerostomia, orofacial pain, taste change, and functional/social impact. Caregivers' age and well-being predicted their awareness of care recipients' oral health problems.

CONCLUSIONS

Future research efforts should focus on understanding the challenges that prevented caregivers from translating their awareness of the importance of care recipients' oral health to frequent evaluation and provision of oral care.

Delirium, agitation, and symptom distress within the final seven days of life among cancer patients receiving hospice care

Objective:

Knowledge of symptom prevalence and adequate assessment of such symptoms at the end of life is important in clinical practice. We determined the frequency and severity of symptom distress and delirium using the Edmonton Assessment Scale (ESAS) and the Memorial Delirium Assessment Scale (MDAS) and evaluated the clinical utility of the Nursing Delirium Screening Scale (Nu-DESC) as scored by a caregiver as a screening tool for delirium.

Method:

We conducted a secondary analysis of the data from a previous randomized controlled trial on parenteral hydration at the end of life of patients admitted to home hospice. Only patients that had assessments within the last week of life were included. We collected the ESAS, MDAS, Nu-DESC, and Richmond Agitation Sedation Scale (RASS) results. The sensitivity and specificity of the Nu-DESC were then calculated.

Results:

Some 78 of 261 patients were included in our study, 62 (80%) of which had moderate-to-severe symptoms corresponding to an ESAS score >4. These symptoms include: 73 (94%) anorexia, 63 (81%) fatigue, 56 (73%) drowsiness, 58 (75%) decreased well-being, and 39 (51%) pain. Delirium was diagnosed in 34 (44%) of patients using the MDAS. The Nu-DESC was found to have a sensitivity of 35%, a specificity of 80%, a positive predictive value (PPV) of 58%, and an negative predictive value (NPV) of 61% when used by caregivers.

Significance of Results:

Hospice patients at the end of life have a high rate of symptom distress and delirium. The Nu-DESC is not a reliable tool for screening delirium when scoring is conducted by a caregiver. Our study illustrates the need for routine use of assessment tools to improve care.

Racial/ethnic minority access to end-of-life care: a conceptual framework

Minority underutilization of hospice care has been well-documented; however, explanations addressing disparities have failed to examine the scope of factors in operation. Drawing from previous health care access models, a framework is proposed in which access to end-of-life care results from an interaction between patient-level, system-level, and societal-level barriers with provider-level mediators. The proposed framework introduces an innovative mediating factor missing in previous models, provider personal characteristics, to better explain care access disparities. This article offers a synthesis of previous research and proposes a framework that is useful to researchers and clinicians working with minorities at end of life.

High-Dose Propofol Drip for Palliative Sedation: A Case Report

Oftentimes, patients at the end of life may present with challenging symptoms refractory to conventional therapies. Agitation and terminal restlessness, 2 common symptoms encountered in the hospice population, are frequently managed using benzodiazepines or typical antipsychotics. In clinical scenarios that either preclude their use or in which they prove ineffective, alternative pharmacotherapy must be considered. Propofol, a sedative-hypnotic unrelated to any other class of drug, may provide palliation of agitation and terminal restlessness refractory to benzodiazepines or antipsychotics. Here, the authors present a hospice patient admitted to the general medical floor of a small community hospital for pain and symptom management. A history of polysubstance abuse contributes to rapidly escalating doses of opioids and midazolam. Failure to control her symptoms resulted in the initiation and successful titration of propofol.

Spiritual needs of persons with advanced cancer

Spiritual needs, spiritual distress, and spiritual well-being of patients with terminal illnesses can affect their quality of life. The spiritual needs of patients with advanced cancer have not been widely studied. This study assessed the spiritual needs of 90 patients with advanced cancer who were newly admitted to hospice home care. They completed a demographic data form and the Spiritual Needs Inventory shortly after hospice admission. Scores could range from a low of 17 to a high of 85; study scores were 23 to 83. Results showed great variability in spiritual needs. Being with family was the most frequently cited need (80%), and 50% cited prayer as frequently or always a need. The most frequently cited unmet need was attending religious services. Results suggest the importance of a focus on the spiritual more than the religious in providing care to patients at the end of life.

Interventions to facilitate family caregiving at the end of life

Informal family caregivers provide care in a variety of situations, including care for patients receiving active curative treatment for cancer and other life-threatening diseases, for Alzheimer's patients over the long trajectory of their disease, and for hospice patients who are near the end of life. Especially at the end of life, these caregivers are essential because they provide needed help with activities of daily living, medications, eating, transportation, and emotional support, as well as communicating with health care professionals about the patients' condition. As health care increasingly moves out of acute care settings and into homes, the role of the caregiver becomes more critical and the burden becomes heavier. There is a paucity of data regarding which caregivers are at greatest risk for distress and which interventions are likely to relieve that distress. Although both educational and supportive interventions have been tested, including both telephone and face-to-face meetings, it still is not clear which approach is best for which groups of caregivers. Much of the research that has been done has been descriptive and evaluative, and only a very limited number of clinical trials have been conducted with caregivers of patients near the end of life. There is limited evidence about whether caregiver interventions at the end of the patient's life have the potential to provide long-term benefits to caregivers. In addition, issues exist in adapting such interventions to work with culturally diverse populations. Sadly, there appears to be a limited number of investigators doing this important work. More research is needed to provide complete evidence on which to base practice and policy decisions.

Development of a clinical protocol for home hospice care for Koreans

As the Korean government's recognition of the importance of hospice service grows, the government has initiated a variety of hospice services in Korea. Each hospice organization has shown a significant difference in its health care delivery methods, constitution and care content. Developing a clinical protocol is essential for establishing standardized hospice services. A preliminary protocol was drawn up by examining the records of terminal patients (n=541) in a home hospice organization while elucidating the health problems as well as classifying them through the Home Health Care Classification (HHCC), and by reviewing the relevant nursing interventions and medical treatments in the literature concerning the clinical protocols. Korea's leading hospice specialty groups participated in four rounds of content validity verification processes in order to establish a protocol. A guideline was developed through a team approach, integrating the opinions of doctors, nurses, ministers, volunteers, patients' families, nutritionists and pharmacists. Eighteen health problems and a total of 223 interventions (173 major treatments and nursing interventions, and 50 optional interventions) were included in the final clinical protocol. This study is expected to contribute to the overall qualitative improvement of home hospice care and the subsequent shortening of documentation time. Evaluation tools and a regulatory feedback system need to be developed in order to maintain consistent evaluation procedures based on the continuous promotion and use of the protocol.

Burden and depression among caregivers of patients with cancer at the end of life

PURPOSE/OBJECTIVES

To examine the patient and family caregiver variables that predicted caregiver burden and depression for family caregivers of patients with cancer at the end of life.

DESIGN

A prospective, longitudinal study was implemented with an inception cohort of patients and their family caregivers who were followed after the diagnosis and treatment of cancer.

SETTING

Community oncology sites in the midwestern United States.

SAMPLE

152 family caregivers of patients with cancer who died during the course of the study.

METHODS

Telephone interviews were conducted with patients at 6-8, 12-16, 24-30, and 52 weeks following diagnoses. In addition, patient medical records and state death certificates were reviewed.

MAIN RESEARCH VARIABLES

Effect of caregiver age, gender, education, relationship to the patient, employment status, reports of patient symptoms, patient cancer type, stage of cancer, time from the patient's diagnosis to death, caregiver burden, and depression.

FINDINGS

Caregivers aged 45-54 reported the highest levels of depressive symptoms, and caregivers aged 35-44 reported the strongest sense of abandonment. Caregivers who were the adult children of patients with cancer and those who were employed reported high levels of depressive symptoms. Feeling abandoned (a portion of caregiver burden) was more prevalent in female, nonspouse, and adult children caregivers, and adult children caregivers of patients with early-stage cancer and patients with multiple symptoms reported a high perception of disruption in their schedule because of providing care. Caregivers whose patients died early following diagnosis reported the highest depressive symptoms, burden, and impact on schedule.

CONCLUSIONS

Caregivers reported levels of depression at thresholds for screening of clinical depression. The number of patient symptoms was related to levels of caregiver depressive symptoms. An association also was found between depression and employment status. Caregiver distress was not dependent on demands of care.

IMPLICATIONS FOR NURSING

Very little research exists that prospectively analyzes family caregiver experiences of burden and depression when providing end-of-life cancer care for a family member. Interventions aimed at decreasing caregiver depressive symptoms should be targeted to caregivers who are middle-aged, adult children, and employed. Interventions aimed at decreasing the burden associated with feeling abandoned and having schedules disrupted while providing care should be targeted to caregivers who are female, nonspouse, and adult children, and caregivers of patients with early-stage cancer and multiple symptoms.

Nurses' knowledge of prevention and management of constipation

Constipation is often a preventable problem in health care; therefore health professionals must have the appropriate knowledge to help patients prevent this common complaint occurring. The purpose of this study was to assess nurses' knowledge of constipation in a teaching hospital in Northern Ireland. A knowledge questionnaire on constipation was obtained and adapted for use in this study using a non-experimental survey design to assess a convenience sample of nurses (n = 131) within various hospital specialities. The results demonstrated gaps in nurses' knowledge of constipation and also indicated that knowledge varied between specialties and between nursing grades. Educational initiatives must not allow bowel care, often labelled 'basic nursing care', to be neglected in postregistration education and training.

Dyspnea and quality of life indicators in hospice patients and their caregivers

This study describe the assessment of dyspnea, symptom distress, and quality of life measures in 163 hospice patients with cancer who reported dyspnea. Mean age of the hospice patient sample was 70.22 years and 61.86 for caregivers (65% were spouses). The majority of patients and caregivers were white: 87%, 63% of the patients were male while 78% of caregivers were female. Mean dyspnea intensity as reported by patients was 4.52 (SD 2.29) and caregivers, 4.39 (SD 2.93). Patients' and caregivers' ratings of the patient's dyspnea intensity revealed no significant differences in ratings thus verifying that caregivers can assess dyspnea severity accurately. Patients' perceived quality of life ratings were not significantly correlated with ratings of their caregivers' perceived quality of life. For patients, symptom distress and education were significant predictors of variance in quality of life (R2 =.35, p =.04). However, mastery, symptom distress, age, and education were found to be significant predictors of variance in quality of life of caregivers (R2 =.40, p =.02).

Pain reports by older hospice cancer patients and family caregivers: the role of cognitive functioning

PURPOSE

Prior research in nursing homes has shown that cognitive impairment may reduce self-reported pain, but this relation has not been systematically explored among hospice patients. The assessment and treatment of pain is a primary goal of hospice care, and both disease processes and the use of opioid analgesics may lead to cognitive impairment among hospice patients. However, little is known about how cognitive functioning may impact the self-report of pain or the report of care recipient pain by family caregivers.

DESIGN AND METHODS

We explored the associations between pain, cognitive functioning, and gender among cancer patients and their family caregivers (N = 176 dyads) during in-home hospice care. This was a cross-sectional, correlational study.

RESULTS

Contrary to expectation, care recipients with cognitive impairment reported more intense pain than care recipients with intact cognitive functioning. However, cognitive impairment among care recipients had no impact on the pain report of family caregivers. Care recipient cognitive impairment was related to greater discrepancy in the pain reports of caregivers and care recipients. No gender differences in pain intensity report were found.

IMPLICATIONS

Measurement issues and implications for assessing self-reported pain among hospice cancer patients with impaired cognitive functioning and the report of care recipient pain by family caregivers are discussed. Specifically, hospice staff must educate family caregivers regarding the potential impact of care recipient cognitive impairment on pain reports in order to facilitate accurate pain assessment and management.

Enhancing caregiver outcomes in palliative care

BACKGROUND

Families are increasingly replacing skilled health care workers in the delivery of unfamiliar complex care to their relatives with cancer, despite other obligations and responsibilities that characterize their lives.

METHODS

The authors review the needs of cancer caregivers and describe intervention strategies not only presented in the literature, but also implemented in their own program of research to address those needs during the palliative phase of cancer.

RESULTS

Research suggests that developing interventions that teach caregivers to become proficient in the physical and psychological aspects of patient care will benefit both patients and caregivers.

CONCLUSIONS

Despite the fact that a cancer diagnosis can cause major changes in family roles and functioning,as well as increased responsibility for complex care being absorbed by family caregivers, data supporting the effectiveness of caregiver interventions have been limited.