Symptom severity of patients with advanced cancer in palliative care unit: longitudinal assessments of symptoms improvement

Palliative care outcome measures used in head and neck cancer: A scoping review

BACKGROUND

The palliative care (PC) needs of patients with head and neck cancer (HNC) are complex, due to high and unique symptom burdens. Uniform outcome measures are critical to assessing the impact of PC interventions in HNC.

METHODS

A scoping review of outcome measures used in patients with HNC receiving PC was performed using PubMed, Embase, and Web of Science from 1980 to 2022.

RESULTS

Of 20 eligible studies, 19 unique instruments were identified which assessed 22 physical, 5 mental, 4 social, 7 related quality of life, and 9 advanced care planning outcomes. Instruments were underutilized, with a larger number of outcomes measurable for instruments used than were reported. The average instrument assessed three domains whereas the average study only reported outcomes from two domains.

CONCLUSIONS

Comparison across studies is limited due to heterogeneity in outcome measures. Future work is needed to develop core PC outcome measures for use in HNC care.

Symptoms of advanced cancer in palliative medicine: a longitudinal study

OBJECTIVES

This study aimed to examine the symptomatology of patients with advanced cancer at admittance to palliative care services and to investigate how the symptomatology changed during the first month, and whether these changes were associated with various patient characteristics.

METHODS

In a longitudinal study in Chile, outpatients with advanced cancer completed the questionnaires European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care and the Hospital Anxiety and Depression Scale. Prevalence and severity of symptoms and problems (S/Ps) at baseline were calculated. Differences in S/P scores from baseline to follow-up were calculated overall and according to patient characteristics. Multiple linear regression was used to study the associations between patient characteristics and changes in S/P scores.

RESULTS

At baseline, 201 patients answered the questionnaires and 177 completed the follow-up. Fatigue, pain and sleeping difficulties were the most prevalent S/Ps reported, and also had the highest mean scores at baseline. S/P scores at baseline varied significantly according to sex, age, civil status, residence, children, prior and current antineoplastic treatment. Emotional functioning, pain, sleeping difficulties, constipation and anxiety improved significantly during the first month of palliative care. Residence, cohabitation status, diagnosis and current antineoplastic treatment were associated with changes in S/P scores.

CONCLUSIONS

Patients reported moderate-to-severe levels of S/Ps at admittance to palliative care. Several S/Ps improved the first month. Certain patient characteristics were associated with changes in S/P scores. This information may guide clinicians to more effective interventions that can improve the quality of life of patients receiving palliative care.

Combined early palliative care for non-small-cell lung cancer patients: a randomized controlled trial in Chongqing, China

Purpose

More effective approaches are needed to improve the prognosis of non-small-cell lung cancer (NSCLC) patients. Thus, we used the E-warm model to assess how early integration of interdisciplinary palliative care was related to the quality of life (QoL), psychological functioning, pain management, and nutrition factors of NSCLC patients.

Methods

This randomized controlled trial enrolled 280 newly diagnosed NSCLC patients, which were randomly divided (1:1) into combined early palliative care (CEPC) and standard oncological care (SC) groups. At baseline and after 24 weeks, the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale, Hospital Anxiety and Depression Scale (HADS), and the Patient Health Questionnaire-9 (PHQ-9) were used to assess QoL and psychological function, respectively. The Numerical Rating Scale (NRS) and Patient-Generated Subjective Global Assessment (PG-SGA) were used to assess cancer patients' pain and nutrition levels. The primary outcome was overall survival (OS). Secondary outcomes comprised changes in the QoL, psychological functioning, pain, and nutrition state. The intention-to-treat method was applied for analysis. This study was registered at www.chictr.org.cn (ChiCTR2200062617).

Results

Of the 140 patients enrolled in the CEPC and SC groups, 102 and 82 completed the research. The CEPC group presented higher QoL than the SC group (p < 0.05). Additionally, fewer patients presented depressive symptoms in the CEPC group than in the SC group (p < 0.05), as well as better nutritional status (p = 0.007) and pain management (p = 0.003). Compared to the SC group, CEPC patients had significantly longer OS (20.4 vs. 24.6 months, p = 0.042; HR: 0.19; 95% CI: 0.04-0.85, p = 0.029).

Conclusion

With combined early palliative care, NSCLC patients lived longer, had better QoL, were psychologically stable, were in less pain, and were more nutritionally satisfied.

Phase IIb Randomized, Placebo-Controlled, Dose-Escalating, Double-Blind Study of Cannabidiol Oil for the Relief of Symptoms in Advanced Cancer (MedCan1-CBD)

PURPOSE

To determine whether cannabidiol (CBD) oil can improve symptom distress in patients with advanced cancer receiving palliative care.

METHODS

Participants were adults with advanced cancer and symptom distress (Edmonton Symptom Assessment Scale [ESAS] total score of ≥ 10/90) who received titrated CBD oil 100 mg/mL, 0.5 mL once daily to 2 mL three times a day, or matched placebo for 28 days. The primary outcome was ESAS total symptom distress score (TSDS) at day 14. Response was defined as a decrease in TSDS by ≥ 6 at day 14. Secondary outcomes were ESAS TSDS over time, individual symptom scores, patient-determined effective dose, opioid use, Global Impression of Change, depression, anxiety, quality of life, and adverse events.

RESULTS

Of the 144 patients randomly assigned, the planned sample size of 58 participants on CBD and 63 on placebo reached the primary analysis point (day 14). The unadjusted change in TSDS from baseline to day 14 was -6.2 (standard deviation, 14.5) for placebo and -3.0 (standard deviation, 15.2) for CBD with no significant difference between arms (P = .24). Similarly, there was no detected difference in proportion of responders (placebo: 37 of 63 [58.7%], CBD: 26 of 58 [44.8%], P = .13). All components of ESAS improved (fell) over time with no difference between arms. The median dose of participant-selected CBD was 400 mg per day with no correlation with opioid dose. There was no detectable effect of CBD on quality of life, depression, or anxiety. Adverse events did not differ significantly between arms apart from dyspnea that was more common with CBD. Most participants reported feeling better or much better at days 14 (53% CBD and 65% placebo) and 28 (70% CBD and 64% placebo).

CONCLUSION

CBD oil did not add value to the reduction in symptom distress provided by specialist palliative care alone.

Symptom evolution in the dying

OBJECTIVE

Provide insight in the prevalence of symptoms in patients who are in the last days of life.

METHODS

A retrospective descriptive analysis of data on patients who died between 2012 and 2019 at the age of 18 or older in 1 of 20 Dutch healthcare facilities, including hospitals, inpatient hospices and long-term care facilities. We analysed data from 4 hourly registrations in the Care Programme for the Dying Person, to assess for how many patients symptom-related goals of care were not achieved. We looked at the first 4 hours episode after the start of the Care Programme and the last 4 hours episode prior to death.

RESULTS

We analysed records of 2786 patients. In the first 4 hours episode, at least one symptom-related care goal was not achieved for 28.5%-42.8% of patients, depending on the care setting. In the last 4 hours episode, these percentages were 17.5%-26.9%. Care goals concerning pain and restlessness were most often not achieved: percentages varied from 7.3% to 20.9% for pain and from 9.3% to 21.9% for restlessness.

CONCLUSIONS

Symptom control at the end of life is not optimal in a substantial minority of patients. Systematic assessment and attention as well as further research on symptom management are of the essence.

The adult and pediatric palliative care: differences and shared issues

Adult and pediatric palliative care (PC) share common aims and ethical principles but differ in many organizational and practical aspects. The aim of this narrative review is to analyze these differences and focus on which key aspects of pediatric palliative care could integrate adult services for a better care of suffering patients.Interventions which are peculiar of pediatric PC respect to adult PC include: an earlier referral to the PC service to identify the needs and plan the interventions at an earlier stage of the disease; consequently, a more systematic cooperation with the disease-specific physicians to reduce the burden of treatments; a better integration with the community and the social surroundings of the patients, to prevent social isolation and preserve their social role; a more dynamic organization of the PC services, to give patients the chance of being stabilized at in-hospital or residential settings and subsequently discharged and cared at home whenever possible and desired; the implementation of respite care for adults, to help the families coping with the burden of the disease of their beloved and promote the home-based PC.This review underlines the relevance of some key-aspects of pediatric PC that can be beneficial also within PC of adults. Its findings give the chance for a more dynamic and modern organization of adult PC services and may serve as a basis of future research for new interventions.

Hospice Care Improves Patients' Self-Decision Making and Reduces Aggressiveness of End-of-Life Care for Advanced Cancer Patients

The aim of the current study is to evaluate the different degrees of hospice care in improving patients' autonomy in decision-making and reducing aggressiveness of cancer care in terminal-stage cancer patients, especially in reducing polypharmacy and excessive life-sustaining treatments. This was a retrospective cross-sectional study conducted in a single medical center in Taiwan. Patients with advanced cancer who died in 2010-2019 were included and classified into three subgroups: hospice ward admission, hospice shared care, and no hospice care involvement. In total, 8719 patients were enrolled, and 2097 (24.05%) admitted to hospice ward; 2107 (24.17%) received hospice shared care, and 4515 (51.78%) had no hospice care. Those admitted to hospice ward had significantly higher rates of having completed do-not-resuscitate order (100%, p < 0.001) and signed the do-not-resuscitate order by themselves (48.83%, p < 0.001), and they had lower aggressiveness of cancer care (2.2, p < 0.001) within the 28 days before death. Hospice ward admission, hospice shared care, and age > 79 years were negatively associated with aggressiveness of cancer care. In conclusion, our study showed that patients with end-of-life hospice care related to higher patient autonomy in decision-making and less excessively aggressive cancer care; the influence of care was more overt in patients approaching death. Further clinical efforts should be made to clarify the patient and the families' satisfaction and perceptions of quality after hospice care involvement.

High-dimensional multinomial multiclass severity scoring of COVID-19 pneumonia using CT radiomics features and machine learning algorithms

We aimed to construct a prediction model based on computed tomography (CT) radiomics features to classify COVID-19 patients into severe-, moderate-, mild-, and non-pneumonic. A total of 1110 patients were studied from a publicly available dataset with 4-class severity scoring performed by a radiologist (based on CT images and clinical features). The entire lungs were segmented and followed by resizing, bin discretization and radiomic features extraction. We utilized two feature selection algorithms, namely bagging random forest (BRF) and multivariate adaptive regression splines (MARS), each coupled to a classifier, namely multinomial logistic regression (MLR), to construct multiclass classification models. The dataset was divided into 50% (555 samples), 20% (223 samples), and 30% (332 samples) for training, validation, and untouched test datasets, respectively. Subsequently, nested cross-validation was performed on train/validation to select the features and tune the models. All predictive power indices were reported based on the testing set. The performance of multi-class models was assessed using precision, recall, F1-score, and accuracy based on the 4 × 4 confusion matrices. In addition, the areas under the receiver operating characteristic curves (AUCs) for multi-class classifications were calculated and compared for both models. Using BRF, 23 radiomic features were selected, 11 from first-order, 9 from GLCM, 1 GLRLM, 1 from GLDM, and 1 from shape. Ten features were selected using the MARS algorithm, namely 3 from first-order, 1 from GLDM, 1 from GLRLM, 1 from GLSZM, 1 from shape, and 3 from GLCM features. The mean absolute deviation, skewness, and variance from first-order and flatness from shape, and cluster prominence from GLCM features and Gray Level Non Uniformity Normalize from GLRLM were selected by both BRF and MARS algorithms. All selected features by BRF or MARS were significantly associated with four-class outcomes as assessed within MLR (All p values < 0.05). BRF + MLR and MARS + MLR resulted in pseudo-R² prediction performances of 0.305 and 0.253, respectively. Meanwhile, there was a significant difference between the feature selection models when using a likelihood ratio test (p value = 0.046). Based on confusion matrices for BRF + MLR and MARS + MLR algorithms, the precision was 0.856 and 0.728, the recall was 0.852 and 0.722, whereas the accuracy was 0.921 and 0.861, respectively. AUCs (95% CI) for multi-class classification were 0.846 (0.805-0.887) and 0.807 (0.752-0.861) for BRF + MLR and MARS + MLR algorithms, respectively. Our models based on the utilization of radiomic features, coupled with machine learning were able to accurately classify patients according to the severity of pneumonia, thus highlighting the potential of this emerging paradigm in the prognostication and management of COVID-19 patients.

Contribution of Synthetic Data Generation towards an Improved Patient Stratification in Palliative Care

AI model development for synthetic data generation to improve Machine Learning (ML) methodologies is an integral part of research in Computer Science and is currently being transferred to related medical fields, such as Systems Medicine and Medical Informatics. In general, the idea of personalized decision-making support based on patient data has driven the motivation of researchers in the medical domain for more than a decade, but the overall sparsity and scarcity of data are still major limitations. This is in contrast to currently applied technology that allows us to generate and analyze patient data in diverse forms, such as tabular data on health records, medical images, genomics data, or even audio and video. One solution arising to overcome these data limitations in relation to medical records is the synthetic generation of tabular data based on real world data. Consequently, ML-assisted decision-support can be interpreted more conveniently, using more relevant patient data at hand. At a methodological level, several state-of-the-art ML algorithms generate and derive decisions from such data. However, there remain key issues that hinder a broad practical implementation in real-life clinical settings. In this review, we will give for the first time insights towards current perspectives and potential impacts of using synthetic data generation in palliative care screening because it is a challenging prime example of highly individualized, sparsely available patient information. Taken together, the reader will obtain initial starting points and suitable solutions relevant for generating and using synthetic data for ML-based screenings in palliative care and beyond.

Compromised end-of-life syndrome: Concept development from the condition of adults and older adults in palliative care

PURPOSE

This study aimed to develop the nursing diagnosis concept "compromised end-of-life syndrome" in palliative care.

METHODS

The authors used the integrative strategy by Meleis to develop the concept in this study and identifying clinical indicators from a literature review. For data organization, we applied the Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA).

FINDINGS

Some clusters of unpleasant signs and symptoms in palliative care patients at the end of life, such as pain, dyspnea, depression, constipation, and anxiety, were identified. Through conceptualization, the authors propose a new nursing diagnosis, "compromised end-of-life syndrome." The manuscript includes a model case of a patient with nursing diagnosis syndrome as a clinical example.

CONCLUSIONS

Simultaneous patterns of signs and symptoms present in the literature reinforce the utility of the proposition of end-of-life syndrome as a nursing diagnostic construct.

IMPLICATIONS FOR NURSING PRACTICE

The concept development related to patients' unpleasant signs and symptoms critically ill at palliative care supports the proposition of a new nursing diagnosis relevant to selecting adequate nursing interventions and nursing outcomes. Some clusters of unpleasant signs and symptoms in palliative care patients at the end of life, such as pain, dyspnea, depression, constipation, and anxiety were identified. Conceptualization was used to propose a new nursing diagnosis, "compromised end-of-life syndrome." A model case of a patient with nursing diagnosis syndrome is described as a clinical example.

CONCLUSION

Simultaneous patterns of signs and symptoms present in the literature reinforce the utility of the proposition of end-of-life syndrome as nursing diagnostic construct.

IMPLICATIONS FOR NURSING PRACTICE

The concept development related to patients' unpleasant signs and symptoms critically ill at palliative care supports the proposition of a new nursing diagnosis relevant to selecting adequate nursing interventions and nursing outcomes.

Evaluation of online, publicly available cancer-related educational and self-management resources for symptom management

OBJECTIVE

The aims of this study were to evaluate the readability, suitability, and quality of publicly available online self-management (SM) resources for people with cancer.

METHODS

Resources were identified using two strategies: (1) a targeted search of 20 Canadian organizations and (2) a Google search. These were evaluated using the Suitability Assessment of Materials (SAM), the DISCERN tool for quality, and readability indices. The SM skills (e.g., problem-solving) and symptom management strategies addressed by each resource were also assessed. Descriptive and hierarchical cluster analyses were performed to identify resources of the highest suitability and quality as well as resource characteristics associated with higher quality and suitability.

RESULTS

A total of 92 resources were evaluated. The mean reading grade level for English resources was 10.29 (SD = 1.64, range of 7.05 to 15.09) and 12.62 for French resources (SD = 2.27, range of 10.12 to 15.65). The mean SAM score across the sample was 50.4% (SD = 10.6%), or 'adequate', and the mean DISCERN score was 61.1% (SD = 11.8%), or 'fair'. The cluster analysis indicated that 10 resources scored highly on both the SAM and the DISCERN. In total, 91 symptom management strategies were identified. On average, resources addressed 2.73 SM skills (SD = 1.58).

CONCLUSIONS

There is a need for plain language resources for people with lower reading ability and resources that incorporate more SM skills. Study findings will help healthcare professionals, patients, and their families identify optimal resources to address cancer-related symptoms.

Interventions and symptom relief in hospital palliative cancer care: results from a prospective longitudinal study

PURPOSE

To study the use of interventions and symptom relief for adult patients with incurable cancer admitted to an acute palliative care unit providing integrated oncology and palliative care services.

METHODS

All admissions during 1 year were assessed. The use of interventions was evaluated for all hospitalizations. Patients with assessments for worst and average pain intensity, tiredness, drowsiness, nausea, appetite, dyspnea, depression, anxiety, well-being, constipation, and sleep were evaluated for symptom development during hospitalization. Descriptive statistics was applied for the use of interventions and the paired sample t-test to compare symptom intensities (SIs).

RESULTS

For 451 admissions, mean hospital length of stay was 7.0 days and mean patient age 69 years. More than one-third received systemic cancer therapy. Diagnostic imaging was performed in 66% of the hospitalizations, intravenous rehydration in 45%, 37% received antibiotics, and 39% were attended by the multidisciplinary team. At admission and at discharge, respectively, 55% and 44% received oral opioids and 27% and 45% subcutaneous opioids. For the majority, opioid dose was adjusted during hospitalization. Symptom registrations were available for 180 patients. Tiredness yielded the highest mean SI score (5.6, NRS 0-10) at admission and nausea the lowest (2.2). Significant reductions during hospitalization were reported for all assessed SIs (p ≤ 0.01). Patients receiving systemic cancer therapy reported symptom relief similar to those not on systemic cancer therapy.

CONCLUSION

Clinical practice and symptom relief during hospitalization were described. Symptom improvements were similar for oncological and palliative care patients.

Palliative Care in the Greater China Region: A Systematic Review of Needs, Models, and Outcomes

CONTEXT

There is rapidly increasing need for palliative care in Greater China because of rapidly aging populations.

OBJECTIVES

This study aimed to systematically review and appraise evidence for palliative care needs, models of care, interventions, and outcomes in Greater China.

METHODS

Four databases (MEDLINE, EMBASE, CINAHL, and PsycINFO) were searched, with hand searching of local journals and databases. Narrative synthesis was applied to the qualitative and quantitative evidence.

RESULTS

Nineteen qualitative studies and 47 quantitative studies were retained. With respect to care needs, nine themes were synthesized: pain control, reduced aggressive end-of-life care, truth telling, physical, emotional, and spiritual supports, and achieving preferred place of care/death. Informal caregivers expressed their needs for education and burden reduction. Health care professionals called for training and national policy support. Twenty-four studies evaluated interventions, mostly among patients with advanced cancer. Positive effects were suggested for improvements in quality of life, pain, anxiety and depression, readmission rate, and costs. Models of care evaluated were mostly specialist palliative care delivered in various settings (hospitals, residential care, and home). Outcome measures used were grouped into six categories of construct: quality of life, pain, physical assessment, psychospiritual assessment, quality of care, and implementation assessment. Limited rigorous randomized controlled trials are available to document intervention outcomes, and some problems (such as high attrition rates) reduced the strength of the evidence.

CONCLUSION

Palliative care services within Greater China should pay more attention to management of nonmalignant disease and to integration into primary services. Policy support is key to establishing culturally appropriate person-centered services.

Longitudinal Symptom Burden Trajectories in a Population-Based Cohort of Women with Metastatic Breast Cancer: A Group-Based Trajectory Modeling Analysis

Understanding the symptom burden trajectory for metastatic breast cancer patients can enable the provision of appropriate supportive care for symptom management. The aim of this study was to describe the longitudinal trajectories of symptom burden for metastatic breast cancer patients at the population-level. A cohort of 995 metastatic breast cancer patients with 16,146 Edmonton Symptom Assessment System (ESAS) assessments was constructed using linked population-level health administrative databases. The patient-reported ESAS total symptom distress score (TSDS) was studied over time using group-based trajectory modeling, and covariate influences on trajectory patterns were examined. Cohort patients experienced symptom burden that could be divided into six distinct trajectories. Patients experiencing a higher baseline TSDS were likely to be classified into trajectory groups with high, uncontrolled TSDS within the study follow-up period (χ2 (1, N = 995) = 136.25, p < 0.001). Compared to patients classified in the group trajectory with the highest relative TSDS (Group 6), patients classified in the lowest relative TSDS trajectory group (Group 1) were more likely to not have comorbidities (97.34% (for Groups 1-3) vs. 91.82% (for Group 6); p < 0.05), more likely to receive chemotherapy (86.52% vs. 80.50%; p < 0.05), and less likely to receive palliative care (52.81% vs. 79.25%; p < 0.0001). Receiving radiotherapy was a significant predictor of how symptom burden was experienced in all identified groups. Overall, metastatic breast cancer patients follow heterogeneous symptom burden trajectories over time, with some experiencing a higher, uncontrolled symptom burden. Understanding trajectories can assist in establishing risk-stratified care pathways for patients.

Hospitalised patients with palliative care needs: Spain and Sweden compared

OBJECTIVES

This study aimed to describe and compare symptoms, care needs and types of diagnoses in hospitalised patients with palliative care needs in Spain and Sweden.

METHODS

A cross-sectional, population-based study was carried out at two hospitals in both Spain and Sweden. Using a questionnaire, we performed 154 one-day inventories (n=4213) in Spain and 139 in Sweden (n=3356) to register symptoms, care needs and diagnoses. Descriptive analyses were used.

RESULTS

The proportion of patients with care needs in the two countries differed (Spain 7.7% vs Sweden 12.4%, p<0.001); however, the percentage of patients with cancer and non-cancer patients was similar. The most prevalent symptoms in cancer and non-cancer patients in both countries were deterioration, pain, fatigue and infection. The most common cancer diagnosis in both countries was lung cancer, although it was more common in Spain (p<0.01), whereas prostate cancer was more common among Swedish men (p<0.001). Congestive heart failure (p<0.001) was a predominant non-cancer diagnosis in Sweden, whereas in Spain, the most frequent diagnosis was dementia (p<0.001). Chronic obstructive pulmonary disease was common in both countries, although its frequency was higher in Spain (p<0.05). In total, patients with cancer had higher frequencies of pain (p<0.001) and nausea (p<0.001), whereas non-cancer patients had higher frequencies of deterioration (p<0.001) and infections (p<0.01).

CONCLUSIONS

The similarities in symptoms among the patients indicate that the main focus in care should be on patient care needs rather than diagnoses. Integrating palliative care in hospitals and increasing healthcare professional competency can result in providing optimal palliative care.

Nurses' experiences of providing "sensitive nursing care" for terminally-ill individuals with cancer: A qualitative study

PURPOSE

To explore the sensitive nursing care provided by nurses who care for terminally-ill individuals with cancer.

METHODS

In-depth interviews were conducted using Colaizzi's phenomenological approach. Participants were 16 hospice specialists and four non-specialist nurses with experience in caring for terminal cancer patients in hospice specialized institutions in South Korea.

RESULTS

Eight theme clusters were drawn from the data and these clusters had two dimensions consisting of sensitive attitudes and sensitive nursing behaviors. The sensitive attitudes included reflecting on past experiences, developing an accepting attitude toward death, using intuition to address critical situations, and having an open mind regarding collaborating with colleagues. The sensitive nursing behaviors contained listening to patients' needs, responding to patients in a manner suitable to their conditions, quickly responding to patients' problem, and providing a moment saying farewell.

CONCLUSIONS

Teamwork and role models can help hospice specialists and non-specialist nurses caring for terminally-ill individuals with cancer to improve the sensitive nursing care. The sensitive attitudes and behaviors can be used as basic data for training programs designed to enhance nurses' sensitivity.

Symptom prevalence and management in older adult patients in Lebanon

OBJECTIVE

The purpose of this study is to explore symptoms and the effectiveness of their management in older adult palliative care candidates in Lebanon. The aims of this study were to: (1) determine symptom prevalence in Lebanese older adults who qualify for palliative care; (2) identify the severity and distress of symptoms; (3) identify the prevalence of symptom management and its efficacy; and (4) explore the relationship between overall symptom burden and its correlates.

METHOD

This study uses an observational cross-sectional design using convenience sampling (N = 203) to recruit older adults qualifying for palliative care from three major medical centers in Lebanon.

RESULT

The mean age of the sample was 78.61 years. The most prevalent symptoms were lack of energy (93.5%), worrying (83.2%), and pain (71.4%). Psychological symptoms had the highest mean scores, preceded only by the physical symptoms and lack of energy. The most treated symptoms were physical with pain having the highest treatment prevalence (91%). Although psychological symptoms were the most burdensome, they were poorly treated. Multiple regression analysis showed that symptom scores had significant positive associations with financial status, social functioning, and comorbidities; there was a negative association with age.

SIGNIFICANCE OF RESULTS

Lack of energy and psychological symptoms were the most prevalent, with the latter having the highest mean total symptom scores. Treatment was poor for psychological symptoms and effective for physical ones. Associations were found between age, comorbidity, financial problems, social functioning, and total physical and psychological mean symptom burden scores. More attention needs to be given to psychological symptoms and their management among older adults receiving palliative care.

A Longitudinal Study of Predictors of Constipation Severity in Oncology Outpatients With Unrelieved Pain

CONTEXT

Although constipation is a common symptom in oncology patients, it often goes unrecognized and untreated. In addition, little is known about characteristics associated with interindividual differences in constipation severity.

OBJECTIVES

To describe prevalence, characteristics, and management of constipation; evaluate interindividual differences in constipation severity over 10 weeks; and identify demographic, clinical, and symptom characteristics associated with higher constipation severity scores.

METHODS

In this prospective, longitudinal study, 175 oncology patients with unrelieved pain were recruited from eight outpatient cancer settings in the U.S. Patients completed demographic and symptom questionnaires at enrollment. Constipation severity was evaluated over 10 weeks using the Constipation Assessment Scale (CAS). Hierarchical linear modeling was used to identify characteristics associated with higher CAS scores.

RESULTS

At enrollment, 70.1% of the patients reported constipation [i.e., CAS score of >2; mean CAS score: 3.72 (±3.11)]. While over the first week of the study patients used one to two constipation treatments per day, a large amount of interindividual variability was found in CAS scores. Higher percentage of days with no bowel movement, higher number of constipation treatments, higher state anxiety scores, and higher analgesic side effects scores were associated with higher CAS scores at enrollment. Higher percentage of days with no bowel movement was associated with interindividual differences in the trajectories of constipation.

CONCLUSION

Our findings underscore the high prevalence of and large amount of interindividual variability in constipation severity. The characteristics associated with worse CAS scores can assist clinicians to identify high-risk patients and initiate prompt interventions.

Family sense of coherence and its associations with hope, anxiety and symptoms of depression in persons with cancer in palliative phase and their family members: A cross-sectional study

BACKGROUND

There is evidence indicating that family sense of coherence predicts quality of family life and promotes family well-being. In families living with the palliative phase of cancer, low hope, anxiety and symptoms of depression are common in both persons with cancer and their family members.

AIM

To determine whether family sense of coherence was associated with hope, anxiety and symptoms of depression, respectively, in persons with cancer in the palliative phase and their family members.

DESIGN

An observational, cross-sectional, multicentre study was conducted. Nested linear regression analyses were performed in two blocks to determine whether family sense of coherence was associated with hope, anxiety and symptoms of depression.

SETTING/PARTICIPANTS

Persons with cancer (n = 179) and their family members (n = 165) were recruited from two oncology clinics and two palliative centres in three regions in Sweden.

RESULTS

The main findings showed that family sense of coherence was significantly and independently associated with hope, anxiety and symptoms of depression. Stronger family sense of coherence was associated with higher hope and lower anxiety and symptoms of depression levels in both persons with cancer and their family members.

CONCLUSION

Health care providers should strive to identify families with weak family sense of coherence, because of its associations with hope, anxiety and symptoms of depression, in order to offer them professional support and thereby achieve increased well-being during the palliative phase of cancer. Future studies should expand our knowledge of family sense of coherence and how to identify families at risk of lower levels of well-being.

Natural products as a perspective for cancer pain management: A systematic review

BACKGROUND

Cancer is the leading cause of death in the world and one of the main symptoms affecting these individuals is chronic pain, which must be evaluated and treated in its various components. Several drugs are currently used, but beyond the high cost, they have harmful side effects to patients or are transitorily effective. Ergo, there is a need to look for new options for cancer pain relief. Natural products (NPs) present themselves as strong candidates for the development of new drugs for the treatment of chronic pain, such as cancer pain.

PURPOSE

This systematic review aimed to summarize current knowledge about the analgesic profile of NPs in cancer pain.

METHODS

The search included PubMed, Scopus and Web of Science (from inception to June 2018) sought to summarize the articles studying new proposals with NPs for the management of oncological pain. Two independent reviewers extracted data on study characteristics, methods and outcomes.

RESULTS

After an extensive survey, 21 articles were selected, which described the analgesic potential of 15 natural compounds to relieve cancer pain. After analyzing the data, it can be suggested that these NPs, which have targets in central and peripheral mechanisms, are interesting candidates for the treatment of cancer pain for addressing different pharmacological mechanisms (even innovative), but ensuring the safety of these compounds is still a challenge. Likewise, the cannabinoids compounds leave the front as the most promising compounds for direct applicability due to the clinical studies that have already been developed and the background already established about these effects on chronic pain.

CONCLUSION

Regarding these findings, it can be concluded that the variability of possible biological sites of action is strategic for new perspectives in the development of therapeutic proposals different from those available in the current market.

Sedation for terminally ill cancer patients: A multicenter retrospective cohort study in South Korea

Sedation therapy is a potential solution to providing relief from refractory symptoms at end of life. The aim of this study was to investigate actual sedation practice and physician characteristics associated with the use of sedation for terminally ill cancer patients in South Korea.A retrospective review was conducted on consecutive patients who had died from cancer at seven tertiary medical centers between January 2010 and October 2015. The use of sedation was defined as the administration of sedative agents to relieve intolerable symptoms within the last 2 weeks preceding death. Patients and physician characteristics and information on the use of sedation were collected.A total of 8309 patients were included in the study. Sedatives were administered in 1334 patients (16.1%) for the following indications: delirium in 39.3%, intractable pain in 23.1%, and dyspnea in 21.9%. Median duration of sedation from initiation to death was 3 days. The use of sedation depended on physician specialty and experience. Family physicians used sedation most often (57.6%), followed by medical oncologists (13.9%), other internists (10.7%), and surgical oncologists (9.4%). The use of sedation was highest for physicians with >5 to 10 years practice experience (22.1%) and lowest for those in practice for 5 years or less (10.2%). The proportion of patients receiving sedation also varied markedly across participating institutions (range, 7.0%-49.7%).This large cohort study provides insight into sedation practice for terminally ill cancer patients in South Korea. Our study shows that the use of sedation depends on physician background and institution. A nation-wide guidelines and continued education on end-of-life sedation are required in South Korea.

Craving Behavior from Opioid Addiction Controlled with Olanzapine in an Advanced Cancer Patient: A Case Report

Opioid addiction, although uncommon in cancer patients, can be a significant challenge for optimal pain management in certain patients. We present a case of a 59-year-old man with advanced colon cancer whose compulsive craving for the buccal tablet of fentanyl citrate (BTFC) was improved with the use of olanzapine. He was hospitalized for abdominal pain caused by disease progression. He had visited several times at outpatient follow-up to obtain a prescription for BTFC because he took all medications before the appointed times. After admission, intravenous infusion of oxycodone and opioid rotation were applied to the patient to control his pain. However, he complained that the pain was not relieved at all and persistently asked for only BTFC 7 to 15 times per day. With the diagnosis of opioid addiction, the transdermal buprenorphine patch was applied, but was ineffective for controlling the addictive behaviors. Finally, olanzapine (10 mg/day per os), a dopamine receptor antagonist, was given to control the craving behavior because psychological dependence is mediated by the dopaminergic system. Three days later, opioid craving was reduced from five to one on a 5-point Likert scale. The pain was well controlled to numeric rating scale 1 or 2 without cravings for BTFC. Craving behavior as a result of opioid addiction may be controlled with olanzapine. Further prospective studies on this issue are warranted.

Sleep quality with WHO Step III opioid use for cancer pain

OBJECTIVE

Sleep is often disturbed in patients with advanced cancer. There is limited knowledge about sleep in patients with cancer treated with strong opioids. This study examines sleep quality in patients with advanced cancer who are treated with a WHO Step III opioid for pain.

METHODS

An international, multicentre, cross-sectional study with 604 adult patients with cancer pain using WHO Step III opioids. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) global score (range; 0-21; score >5 indicates poor sleep). PSQI includes sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medications and daytime dysfunction. Pain and quality of life were assessed by Brief Pain Inventory and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core30.

RESULTS

The median age was 62 years, 42% were female, mean Karnofsky performance score (KPS) was 62.5 (±14.2) and mean oral daily morphine equivalent dose was 303 mg/24 hours (±543.8 mg). The mean PSQI global score was 8.8 (±4.2) (range 0-20). Seventy-eight per cent were poor sleepers. All PSQI components were affected, and 44% reported trouble sleeping caused by pain. In the multiple regression model, predictors of PSQI global scores were pain intensity, emotional function, constipation, financial difficulties and KPS (adjusted R²=0.21).

CONCLUSION

The majority (78%) of these patients with cancer treated with Step III opioids experienced poor sleep quality. Pain intensity, emotional function, constipation, financial difficulties and KPS predicted poor PSQI global scores. The clinical implication is that healthcare personnel should routinely assess and treat sleep disturbance in patients with advanced cancer disease.

Symptom Distress in Patients With Hepatocellular Carcinoma Toward the End of Life

PURPOSE/OBJECTIVES

To describe the presence, frequency, severity, and distress of symptoms in outpatients with advanced hepatocellular carcinoma toward the end of life, and the variability in psychological and physical symptom distress between and within patients over time. 
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DESIGN

A prospective, longitudinal, descriptive design. 
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SETTING

Outpatient clinics at two healthcare institutions. 
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SAMPLE

18 patients (15 men and 3 women) with hepatocellular carcinoma and a mean age of 63.3 years (range = 54-81 years).
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METHODS

Data were collected monthly for six months. Patients completed the Memorial Symptom Assessment Scale, which reports a total score, and three subscales that provide global distress, psychological distress, and physical distress scores.
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MAIN RESEARCH VARIABLES

Global, psychological, and physical distress.
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FINDINGS

Patients reported lack of energy and pain as the most frequent and distressing symptoms. Problems with sexual interest or activity was the fourth most present symptom after drowsiness. Global Distress Index mean scores had notable variability between and within patients over time. During data collection, six patients died. None were referred to palliative care.
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CONCLUSIONS

Gaining knowledge about symptom distress and prevalent symptoms experienced by patients with advanced hepatocellular carcinoma is critical for designing symptom management strategies that are comprehensive and tailored to patients to optimize their quality of life as they approach death.
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IMPLICATIONS FOR NURSING

Nurses play a vital role in advocating for, initiating, and providing comprehensive holistic care based on individual patient needs by facilitating discussions about apparent and less apparent distressing symptoms, including those related to sexuality.

Assessment and management of constipation for patients receiving palliative care in specialist palliative care settings: A systematic review of the literature

BACKGROUND

Constipation is an important issue for patients receiving palliative care within specialist palliative care settings. Questions and ambiguity, however, persist about international best practice and management.

AIM

To synthesise the current evidence base on the assessment and management of constipation for palliative care patients within a specialist palliative care setting.

DESIGN

This is a systematic review.

DATA SOURCES

MEDLINE, Embase, CINAHL, Scopus and Cochrane databases were systematically searched in April 2017 for empirical studies, written in English, on the assessment and management of constipation in specialist palliative care settings, published between 2007 and 2017. Two researchers independently reviewed and critically appraised all studies, conducted data extraction, and undertook a thematic analysis.

RESULTS

In total, 13 studies were included in the review comprising randomised trials ( n = 3), observational ( n = 4) and descriptive studies ( n = 6). Most research was conducted in specialist palliative care units, targeting either healthcare professionals or patients. The analysis highlighted a lack of standard definition of constipation, raising questions on the existence and comparability of baseline prevalence figures, the physical and psychological impact on patients, resource impact on staff and service, the subjective and objective methods of assessing constipation, and key aspects of constipation management, including a lack of focus on non-pharmacological management in this setting.

CONCLUSION

The results of this review are being used to inform the development of an educational intervention targeting healthcare professionals. Gaps in the evidence base include lack of consistent definition of constipation, constipation prevention, non-pharmacological management, and the consideration of the management of constipation for the dying patient.

Symptoms in Advanced Cancer Patients in a Greek Hospital: a Descriptive Study

Background:

Advanced cancer patients experience several physical or psychological symptoms which require palliative care for alleviation.

Purpose:

To assess the prevalence and intensity of symptoms among cancer patients receiving palliative care in a Greek hospital and to examine the association between reported symptoms and social clinical and demographic characteristics.

Material-methods:

This descriptive research was conducted during a six-month period using a convenient sample of 123 advanced cancer patients. All participants were assessed for their symptoms using the Edmonton Symptom Assessment System (ESAS) with a questionnaire covering demographic and clinical characteristics.

Results:

The mean age was 63.8± 10.8 years, with lung and breast (58.5% and 11.4%, respectively) as the most common primary cancer types. The most severe symptoms were fatigue, sleep disturbance, dyspnea, depression and anxiety. Negative correlations were revealed between age and the following symptoms: pain (r = -0.354, p = 0.001), fatigue (r = -0.280, p = 0.002), nausea (r = -0.178, p = 0.049), anorexia (r = -0.188, p = 0.038), dyspnea (r = -0.251, p = 0.005), and depression (r = -0.223, p = 0.013). Advanced breast cancer patients scored higher in pain, fatigue and dyspnea compared to those with other cancers.

Conclusions:

Hospitalized cancer patients in Greece experience several symptoms during the last months of their life. These are influenced by demographic characteristics. Appropriate interventions are strongly advised with appropriate recognition and evaluation of symptoms by health professionals.

Patient-reported symptoms before palliative radiotherapy predict survival differences

BACKGROUND

Widely used prognostic scores, e. g., for brain or bone metastases, are based on disease- and patient-related factors such as extent of metastases, age and performance status, which were available in the databases used to develop the scores. Few groups were able to include patient-reported symptoms. In our department, all patients were assessed with the Edmonton Symptom Assessment System (ESAS, a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0-10) at the time of treatment planning since 2012. Therefore, we analyzed the prognostic impact of baseline ESAS symptom severity.

METHODS

Retrospective review of 102 patients treated with palliative radiotherapy (PRT) between 2012 and 2015. All ESAS items were dichotomized (below/above median). Uni- and multivariate analyses were performed to identify prognostic factors for survival.

RESULTS

The most common tumor types were prostate, breast and non-small cell lung cancer, predominantly with distant metastases. Median survival was 6 months. Multivariate analysis resulted in six significant prognostic factors. These were ESAS pain while not moving (median 3), ESAS appetite (median 5), Eastern Cooperative Oncology Group (ECOG) performance status, pleural effusion/metastases, intravenous antibiotics at start or within 2 weeks before PRT and no systemic cancer treatment.

CONCLUSIONS

Stronger pain while not moving and reduced appetite (below/above median) predicted significantly shorter survival. Development of new prognostic scores should include patient-reported symptoms and other innovative parameters because they were more important than primary tumor type, age and other traditional baseline parameters.

Continuous palliative sedation for patients with advanced cancer at a tertiary care cancer center

Background

Palliative sedation (PS) is an intervention to treat refractory symptoms and to relieve suffering at the end of life. Its prevalence and practice patterns vary widely worldwide. The aim of our study was to evaluate the frequency, clinical indications and outcomes of PS in advanced cancer patients admitted to our tertiary comprehensive cancer center.

Methods

We retrospectively studied the use of PS in advanced cancer patients who died between March 1st, 2012 and December 31st, 2014. PS was defined as the use of continuous infusion of midazolam or neuroleptics for refractory symptoms in the end of life. This study was approved by the Research Ethics Committee of our institution (project number 2481–15).

Results

During the study period, 552 cancer patients died at the institution and 374 met the inclusion criteria for this study. Main reason for exclusion was death in the Intensive Care Unit. Among all included patients, 54.2% (n = 203) received PS. Patients who received PS as compared to those not sedated were younger (67.8 vs. 76.4 years-old, p < 0.001) and more likely to have a diagnosis of lung cancer (23% vs. 14%, p = 0.028). The most common indications for sedation were dyspnea (55%) and delirium (19.7%) and the most common drugs used were midazolam (52.7%) or midazolam and a neuroleptic (39.4%). Median initial midazolam infusion rate was 0.75 mg/h (interquartile range – IQR - 0.6-1.5) and final rate was 1.5 mg/h (IQR 0.9–3.0). Patient survival (length of hospital stay from admission to death) of those who had PS was more than the double of those who did not (33.6 days vs 16 days, p < 0.001). The palliative care team was involved in the care of 12% (n = 25) of sedated patients.

Conclusions

PS is a relatively common practice in the end-of-life of cancer patients at our hospital and it is not associated with shortening of hospital stay. Involvement of a dedicated palliative care team is strongly recommended if this procedure is being considered. Further research is needed to identify factors that may affect the frequency and outcomes associated with PS.

Electronic supplementary material

The online version of this article (10.1186/s12904-017-0264-2) contains supplementary material, which is available to authorized users.

Palliative care needs in hospitalized cancer patients: a 5-year follow-up study

PURPOSE

The aims of this study were to describe and compare diagnoses, symptoms, and care needs in palliative cancer patients in two medium-sized hospitals in a county council with no specialized palliative care available 24/7; to analyze the relationships between diagnosis and symptoms/care needs; and to compare results and trends from two datasets (from 2007 and 2012).

METHODS

The study was population-based with a cross-sectional design and was conducted at two acute care hospitals. We performed 142 one-day inventories (n = 2972) in 2007 and 139 in 2012 (n = 2843) to register symptoms, care needs, and diagnosis based on a questionnaire. Multiple logistic regression models were used in the analysis.

RESULTS

During 2007 and 2012 combined, 10% (n = 589) of hospitalized patients were assessed as having cancer in a palliative phase. Prostate (12%) and colorectal (12%) cancers were most common. Pain (42%) and deterioration (42%) were the most prevalent symptoms and were associated with pancreas cancer in our regression models (p = 0.003 and p = 0.019, respectively). Other cancers had different associations: hematologic malignancies were associated with infections and blood transfusions (p < 0.001), breast cancer with pleurocentesis (p = 0.002), and stomach/esophagus cancer with nausea (p < 0.001). Nausea was more common in women than in men (p < 0.01). The mean number of symptoms/care needs was 2.9; patients with stomach/esophagus cancer had the highest number of symptoms/care needs (3.5).

CONCLUSIONS

Acute care hospitals still play an important role for patients requiring palliative care. Symptoms and care needs were not strongly associated with specific diagnoses. Therefore, symptoms, rather than the specific cancer diagnoses, should be the focus of care.

Patients in palliative care-Development of a predictive model for anxiety using routine data

Introduction

Anxiety is one of the most common psychological symptoms in patients in a palliative care situation. This study aims to develop a predictive model for anxiety using data from the standard documentation routine.

Methods

Data sets of palliative care patients collected by the German quality management benchmarking system called Hospice and Palliative Care Evaluation (HOPE) from 2007 to 2011 were randomly divided into a training set containing two-thirds of the data and a test set with the remaining one-third. We dichotomized anxiety levels, proxy rated by medical staff using the validated HOPE Symptom and Problem Checklist, into two groups with no or mild anxiety versus moderate or severe anxiety. Using the training set, a multivariable logistic regression model was developed by backward stepwise selection. Predictive accuracy was evaluated by the area under the receiver operating characteristic curve (AUC) based on the test set.

Results

An analysis of 9924 data sets suggests a predictive model for anxiety in patients receiving palliative care which contains gender, age, ECOG, living situation, pain, nausea, dyspnea, loss of appetite, tiredness, need for assistance with activities of daily living, problems with organization of care, medication with sedatives/anxiolytics, antidepressants, antihypertensive drugs, laxatives, and antibiotics. It results in a fair predictive value (AUC = 0.72).

Conclusions

Routinely collected data providing individual-, disease- and therapy-related information contain valuable information that is useful for the prediction of anxiety risks in patients receiving palliative care. These findings could thus be advantageous for providing appropriate support for patients in palliative care settings and should receive special attention in future research.