Assessment and management of pain in palliative care patients

Assessment and Management of Chronic Pain in the Seriously Ill

The intent of this article is to help clinicians to have practical knowledge and skills related to both assessment and pharmacotherapy of chronic pain in the seriously ill patients. Treating patients with chronic pain and progressive disease should include assessment of "total pain" (physical, psychological, and spiritual suffering) and the care givers as part of treatment team. Effective management of chronic pain starts with thorough assessment and diagnosis of the pain syndrome. A worldwide consensus endorses use of multimodal approach and opioid pharmacotherapy as the mainstay approach to moderate to severe pain in cancer and pain associated with serious illness.

Palliative Care and Physiatry in the Oncology Care Spectrum: An Opportunity for Distinct and Collaborative Approaches

As cancer evolves from a terminal illness to a chronic medical condition, so too does the view of clinical services. Palliative care and physical medicine and rehabilitation (PM&R) will increase in acceptance because they provide a valuable resource. The overarching theme is improving cancer-related symptoms or treatment-related side effects, improving patient health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision making. Managing symptom burden may improve therapy participation/performance. PM&R and palliative care departments are well-equipped to develop patient-centered care protocols, and could play an important role in developing a universal measure of performance status.

Intranasal Ketamine and Its Potential Role in Cancer-Related Pain

Cancer-related pain continues to be a significant therapeutic challenge, made more difficult by contemporary opioid use and diversion concerns. Conventional treatment using a tiered approach of nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and adjuvant agents is limited; and alternatives are needed for patients with rapidly progressing pain and those who develop hyperalgesia and tolerance to opioids. Ketamine, an N-methyl-d-aspartate (NMDA) selective antagonist, has historically been used for anesthesia in adult and pediatric populations but has also been investigated for depression, bipolar disorder, and general and postoperative pain management. As an analgesic, low-dose ketamine decreases morphine requirements and rates of nausea and vomiting, suggesting a potentially beneficial role in cancer-related pain. Ketamine is typically administered intravenously and has a rapid onset of action with a relatively short half-life (2-3 hours) but is inconvenient for use in an ambulatory setting. Oral bioavailability is low and erratic, limiting application of this route for chronic use. Intranasal administration has a number of potential advantages, including avoidance of first-pass hepatic metabolism, no need for venous access, ability to repeat doses quickly, and rapid absorption. Although early studies of intranasal ketamine are promising in a number of indications, information is more limited in its use as an adjunct in cancer-related pain. We review the background, rationale, pharmacokinetics, and clinical and safety data using intranasal ketamine as an adjunctive agent and its potential in cancer-related pain.

Breast cancer in the global south and the limitations of a biomedical framing: a critical review of the literature

Public health researchers are devoting increasing attention to the growing burden of breast cancer in low-and middle-income countries (LMICs), previously thought to be minimally impacted by this disease. A critical examination of this body of literature is needed to explore the assumptions, advantages and limitations of current approaches. In our critical literature review, we find that researchers and public health practitioners predominantly privilege a biomedical perspective focused on patients' adherence (or non-adherence) to 'preventive' practices, screening behaviours and treatment regimens. Cost-effective 'quick fixes' are prioritized, and prevention is framed in terms of individual 'risk behaviours'. Thus, individuals and communities are held responsible for the success of the biomedical system; traditional belief systems and 'harmful' social practices are problematized. Inherently personal, social and cultural experiences of pain and suffering are neglected or reduced to the issue of chemical palliation. This narrow approach obscures the complex aetiology of the disease and perpetuates silence around power relations. This article calls for a social justice-oriented interrogation of the role of power and inequity in the global breast cancer epidemic, which recognizes the agency and experiences of women (and men) who experience breast cancer in the global south.

Pain assessment tools in palliative care: an urgent need for consensus

At present, there is no universally accepted cancer pain assessment tool for use in palliative care (PC). The European Palliative Care Research Collaborative (EPCRC), therefore, aims to develop an international consensus-based computerised pain assessment tool. As part of this process, we have performed (1) a literature review on pain assessment tools for use in the PC and (2) an international expert survey to gain information on the relevant dimensions for pain assessment in PC. 230 publications were identified, only six met the inclusion criteria. Three further articles were identified through manual searching, totalling 11 different pain assessment tools. Nine tools were multidimensional. Pain intensity was assessed in seven, using various numerical/verbal rating scales (NRS/VRS); five tools focused on pain management. Three publications did not identify the rationale for the need to develop a new tool, and the selection procedure for items/dimensions was not described in six tools. Patient and/or professional expert groups were involved in the development of five tools and only two tools were extensively validated or cross-culturally tested. Thirty-two experts (71%) completed the expert survey and identified 'intensity', 'temporal pattern', 'relief/exacerbation', 'pain quality' and 'location' as the five most relevant dimensions. Most preferred assessment of 'pain intensity' was by NRS rather than VRS. Time windows extending 24 h were regarded as less relevant. Development of PC pain assessment tools seems to be a continuous process, which does not adhere to systematic guidelines, thus does not contribute to a universally accepted tool. No tool contained all relevant dimensions as defined by the experts. Many tools focused on particular dimensions, suggesting that specific research interests may drive the tool development process. Extensive literature reviews, expert and patient input and clinical studies are a needed approach in the development of a new consensus-based pain assessment tool.

Measuring supportive care in medical oncology practice: lessons learned from the quality oncology practice initiative

We provide a brief review of the use of quality measures to assess supportive care in the medical oncology office. Specifically, we discuss the development and implementation of supportive care measures in the Quality Oncology Practice Initiative (QOPI), a voluntary quality measurement and improvement program of the American Society of Clinical Oncology. QOPI has demonstrated that medical oncologists voluntarily engage in self-assessment and often select measures related to supportive care for measurement and improvement. Results to date have demonstrated that there is room for improvement in this domain. Because supportive care measures appropriate for use through structured chart review in the outpatient oncology setting are not generally available in the published literature, measures have been developed and tested through the program. Additional measures are in development for implementation in QOPI in 2008.

Employment and cancer: findings from a longitudinal study of breast and prostate cancer survivors

We discuss how cancer affected the employment of almost 800 employed patients who participated in a longitudinal study. The greatest reduction in patients' labor supply (defined as employment and weekly hours worked) was observed 6 months following diagnosis. At 12 and 18 months following diagnosis, many patients returned to work. Based on these and other findings related to patients' employment situations, we suggest 4 areas for future research: 1) collection of employment information in cancer studies; 2) research into racial and ethnic minority patients and employment outcomes; 3) interventions to reduce the effects of cancer and its treatment on employment; and 4) investigations into the influence of employment-contingent health insurance on cancer treatment and recovery.

Pain management in the last six months of life among women who died of ovarian cancer

Previous studies indicate that the symptoms of many dying cancer patients are undertreated and many suffer unnecessary pain. We obtained data retrospectively from three large health maintenance organizations, and examined the analgesic drug therapies received in the last six months of life by women who died of ovarian cancer between 1995 and 2000. Subjects were identified through cancer registries and administrative data. Outpatient medications used during the final six months of life were obtained from pharmacy databases. Pain information was obtained from medical charts. We categorized each medication based on the World Health Organization classification for pain management (mild, moderate, or intense). Of the 421 women, only 64 (15%) had no mention of pain in their charts. The use of medications typically prescribed for moderate to severe pain ("high intensity" drugs) increased as women approached death. At 5-6 months before death, 55% of women were either on no pain medication or medication generally used for mild pain; only 9% were using the highest intensity regimen. The percentage on the highest intensity regimen (drugs generally used for severe pain) increased to 22% at 3-4 months before death and 54% at 1-2 months. Older women (70 or older) were less likely to be prescribed the highest intensity medication than those under age 70 (44% vs. 70%, P<0.001). No differences were found in the use of the high intensity drugs by race, marital status, year of diagnosis, stage of disease, or comorbidity. Our finding that only 54% of women with pain were given high intensity medication near death indicates room for improvement in the care of ovarian cancer patients at the end of life.

Pain assessment tools: is the content appropriate for use in palliative care?

Inadequate pain assessment prevents optimal treatment in palliative care. The content of pain assessment tools might limit their usefulness for proper pain assessment, but data on the content validity of the tools are scarce. The objective of this study was to examine the content of the existing pain assessment tools, and to evaluate the appropriateness of different dimensions and items for pain assessment in palliative care. A systematic search was performed to find pain assessment tools for patients with advanced cancer who were receiving palliative care. An ad hoc search with broader search criteria supplemented the systematic search. The items of the identified tools were allocated to appropriate dimensions. This was reviewed by an international panel of experts, who also evaluated the relevance of the different dimensions for pain assessment in palliative care. The systematic literature search generated 16 assessment tools while the ad hoc search generated 64. Ten pain dimensions containing 1,011 pain items were identified by the experts. The experts ranked intensity, temporal pattern, treatment and exacerbating/relieving factors, location, and interference with health-related quality of life as the most important dimensions. None of the assessment tools covered these dimensions satisfactorily. Most items were related to interference (231) and intensity (138). Temporal pattern (which includes breakthrough pain), ranked as the second most important dimension, was covered by 29 items only. Many tools include dimensions and items of limited relevance for patients with advanced cancer. This might reduce compliance and threaten the validity of the assessment. New tools should reflect the clinical relevance of different dimensions and be user-friendly.

Challenging the representations of cancer pain: Experiences of a multidisciplinary pain management group in a palliative care unit

Objective:This article describes how a Multidisciplinary Pain Management Group was set up in a palliative care unit, and outlines the ways that the group works with different patients. We place these comments in the context of the wider representations of pain.

Methods:Our observations of patients seen by the multidisciplinary team.

Results:We tentatively propose that where the patient's pain has certain characteristics it may require a different approach. Patients who are older, with a lengthy treatment history, may require a different input than younger patients, who may have a number of factors that further complicate their experience of pain. We use our extensive experience with mesothelioma patients to draw a further important distinction between this patient group and other patients.

Significance of research:Our observations suggest the need to allow sufficient time for intensive psychological work to be done with mesothelioma patients in order for pharmacological interventions to be effective.

The Norwegian Doloplus-2, a tool for behavioural pain assessment: translation and pilot-validation in nursing home patients with cognitive impairment

BACKGROUND

Pain assessment is challenging in cognitively impaired (CI) patients due to inadequate self-report skills and observational ratings are an alternative. The Doloplus-2 is developed for pain assessment in the CI and rates somatic, psychomotor and psychosocial behaviours as indicators of pain.

AIMS

To translate the Doloplus-2 into Norwegian, to test the Doloplus-2 with regard to criterion validity and to obtain the administrators' evaluation of the clinical performance of the Doloplus-2.

METHODS

Nurses at three nursing homes, in collaboration with two research assistants, administered the Doloplus-2 to 59 patients with dementia. The results were compared against experienced clinicians' pain ratings. Regression analyses were performed to explore each different item's contribution to the total pain score. The administrators also completed a debriefing questionnaire.

RESULTS

The instrument was translated according to international guidelines. Regression analyses demonstrate that the Doloplus-2 score accounts for 62% (R2) of the expert score and that the four most informative items could explain 68% of the expert score. Analyses of the different Doloplus-2 items indicate that facial expressions explain most and social life least of the expert's pain ratings. The administrators reported that Doloplus-2 was helpful and easy to administer, but questioned the validity of the psychosocial domain.

CONCLUSIONS

The Norwegian Doloplus-2 demonstrates satisfactory criterion validity and clinical value in this pilot study. However, the content of the instrument needs a general re-evaluation, especially with regard to the psychosocial items.

Psychosocial supportive care for children receiving stem cell transplantation: practice patterns across centers

Although pediatric stem cell transplantation is associated with elevated risks for quality-of-life (QOL) deficits, morbidity, and late effects, little is known about how supportive care needs are addressed across different pediatric centers. This study examined practice patterns among centers enrolled in the Pediatric Blood and Marrow Transplant Consortium. In all, 65 centers (response rate=82.2%) were surveyed regarding QOL screening, psychosocial intervention services, and long-term follow-up care. Approximately 80% of centers provided routine screening for psychological difficulties and pain. A smaller number screened for fatigue (69.2%), cognitive deficits (52.3%), sleep difficulties (60.0%) or spiritual concerns (38.5%). Screening was conducted predominantly via interview; little use was made of standardized measures. Community-based centers screened some deficits more frequently than did academic ones (all P's</=0.09). In all, 60% of centers provided support groups and 49.2% offered arts-in-medicine programs. Most centers provided extended follow-up care. In some, follow-up continued until age 21 (45.4%), while in others it was sustained indefinitely (40.6%). Findings suggest that QOL screening would be enhanced by greater attention to domains that currently receive limited scrutiny, and by increased use of validated measures to supplement interview information. The proportion of centers that provide extended follow-up is encouraging, and offers opportunities to study long-term outcomes.

A population-based study of pain and quality of life during the year before death in men with prostate cancer

In order to explore how health-related quality of life changes towards the end of life, a questionnaire including the EuroQOl form and the Brief Pain Inventory form was sent to all men with prostate cancer in the county of Östergötland, Sweden, in September 1999. Responders who had died prior to 1 January 2001 were later identified retrospectively. Of the 1442 men who received the questionnaire, 1243 responded (86.2%). In the group of responders, 167 had died within the study period, 66 of prostate cancer. In multivariate analysis, pain as well as death within the period of study were found to predict decreased quality of life significantly. Of those who died of prostate cancer, 29.0% had rated their worst pain the previous week as severe. The same figure for those still alive was 10.5%. On a visual analogue scale (range 0–100), the mean rating of quality of life for those who subsequently died of prostate cancer was 54.0 (95% confidence interval ±5.2) and those still alive was 70.0 (±1.2). In conclusion, health-related quality of life gradually declines during the last year of life in men with prostate cancer. This decline may partly be avoided by an optimised pain management.