A Rapid Review on the Management of Constipation for Hospice and Palliative Care Patients

Constipation is a distressing symptom that has a high prevalence in patients receiving hospice and palliative care services, particularly in cases of opioid use. A thorough assessment, root cause analysis, monitoring, and prophylactic approach are essential for symptom management and quality of life. This rapid review assessed studies published between 2018 and 2023 to identify strategies implemented by health care professionals to prevent and/or mitigate this distressing symptom. We identified 12 articles that addressed constipation in palliative and end-of-life settings and reported on the need for multifactorial management approaches with a focus on patient-centered care that includes the caregiver(s). Bedside nurses play a key role in assessing, identifying, and managing constipation. Proper documentation and communication with the interdisciplinary team help direct earlier intervention and ongoing awareness of constipation issues. Additional research is needed on specific tools and enhanced guidelines to ensure constipation is frequently addressed and preemptively managed.

Cultural Competency Models at the End of Life

This chapter examines the need and importance of cultural competency in providing End of Life care. The United States is diverse in culture. As we evolve into a multiethnic society, our healthcare providers must be able to manage this shift in establishing and providing care that is culturally appropriate and effective. Americans have the rights to provide autonomy and independent decision-making related to their healthcare; however, these core values may not align with ethnic and culturally diverse groups in the United States. Conflicts often lead to health disparities and resulting in care that is fragmented and inadequate. The difference in values result in improper management and miscommunication with patients and families that significantly affect care, especially during end-of-life.

Comparing the safety and efficacy of intravenous naloxone administration in opioid-naive and opioid-tolerant hospitalized oncology patients

OBJECTIVE

To compare naloxone doses and clinical outcomes after emergency opioid reversal in opioid-naïve and opi-oid-tolerant inpatients.

DESIGN

Cross-sectional, retrospective chart review.

SETTING

Comprehensive cancer center.

PATIENTS

In-patients who received ≥1 dose of intravenous naloxone for emergency opioid reversal between 2014 and 2018.

METHODS

Patients were classified as opioid-tolerant based on opioid dosing history ≥60 morphine milligram equivalents/day for ≥7 consecutive days prior to naloxone administration. Response to naloxone was based on documentation of improvement in respiratory rate to >10 breaths/min or improved response to stimuli.

OUTCOMES

Naloxone doses and clinical outcomes after naloxone administration.

RESULTS

Ninety-three naloxone episodes (58 opioid-naive and 35 opioid-tolerant) in 80 unique patients were included. No differences between opioid-naïve and opioid-tolerant groups were found for naloxone mean starting doses (0.14 mg vs 0.19 mg, p = 0.35), total doses (0.50 mg vs 0.32 mg, p = 0.07), and response rates (74.1 percent vs 77.1 percent, p = 0.81). Naloxone adverse reactions were more frequent in the opioid-tolerant group than the opioid-naïve group (opioid withdrawal symptoms (OWSs): 14.3 percent vs 0 percent; increase in pain: 20 percent vs 8.6 percent, p = 0.002).

CONCLUSIONS

In opioid-tolerant patients, naloxone total doses required and response rates were similar to opioid-naïve patients. Use of opioid dosing history to identify potentially opioid-dependent patients should be considered prior to naloxone administration to guide dosing and reduce the risk for precipitating OWSs.

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.

Impact of a patient and family meeting program for patients with metastatic genitourinary cancer receiving treatment in the ambulatory care setting

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Background: Palliative care in the ICU is recognized as a vital aspect of care delivery but less evidence exists regarding utilization in ambulatory care. Family meetings are considered a relevant strategy to discuss concerns around patients’ illness and treatment. This pilot study sought to describe preliminary results of the Patient and Family Meeting Program (FMP) implemented in October, 2017 in a genitourinary oncologic clinic. Methods: FMP is offered for high-risk patients with ≤ two year prognosis. Program includes: (1) patient identification, (2) orientation, (3) family meeting, and (4) post-meeting follow-up. After identification, social worker orients the patient/family, addresses advance directives, and assesses values regarding care. During the meeting, social worker introduces and elicits understanding of medical situation, physician provides medical information and recommendations, and social worker assists reconciling medical recommendations with patient values. During follow-up, educational materials are provided, referrals are made as indicated, and follow-up meetings are held by request. Results: 51 patients were identified. Most of them were male (69%) with a median age of 68 years, and diagnosed with renal cell carcinoma (47%), prostate cancer (27%), or urothelial cancer (26%). 48 orientations were conducted, and 18 family meetings were held. Hospice was recommended to 16 patients, and 69% were admitted. 6 cases were referred to supportive medicine. Oncologists spent on average 21 minutes with each family. In the inpatient setting, 3 family meetings were requested; all patients were referred to hospice, and 2 were enrolled. Conclusions: Findings indicate the feasibility/benefit of FMP; a high prevalence of patients were referred and enrolled in hospice. Meetings require little extra time for the physician. Also, this program favored better integration between the health care team and patient/family. Results provide support for expanding this program to other specialties. Extending the value of family meetings in ambulatory care is a unique opportunity to enhance essential psychosocial support to oncology patients with greatest need.

The integrated care service: Impact of a multidisciplinary supportive care service for medical oncology patients in a NCI-designated cancer center

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Background: Palliative care (PC) has shown benefits to inpatient length of stay (LOS), symptom burden reduction, utilization decrease, and time on hospice. It has shown less impact on the rate of hospice referrals. We assessed the impact of an integrated care model on these outcomes. Methods: From Jan-July, 2018, the Department of Supportive Care Medicine collaborated with medical oncology (med onc), nursing and administration to create the Integrated Care Service (ICS). Multi-disciplinary rounds include med onc, supportive care (PC, social work, spiritual care, psychiatry, psychology, hospice liaison), nursing, case management, nutrition, and physical and occupational therapy. The admission criteria include: 1) Later-stage disease; 2) Non-curative intent therapy; 3) High distress burden; and 4) Poor prognosis. The ICS was designed to have geographic co-location, morning PC and med onc rounds, multidisciplinary rounds, and post-acute management. The ICS was compared with other med onc patients (non-ICS) and Mantel-Haenszel Chi-Square statistical significance (p<0.05) was calculated using Epi Info StatCalc. Results: In 6 months, 190 med onc patients (pts) were admitted to ICS versus 537 non-ICS pts. Compared with non-ICS, the ICS pts had a higher Case Mix Index (1.81 vs. 1.56) and metastatic disease incidence (95% vs. 78%, p=0.008). Discharge to hospice was higher from ICS versus non-ICS (23% vs. 7%, p=<0.001), and average time on hospice increased from 9 to 15 days. No chemotherapy was given in the last two weeks of life to any pts on ICS (0 vs. 6 non-ICS pts). Length of stay (LOS) was higher on ICS as compared to non-ICS (8.45 vs. 5.26 days) and readmission rates were similar (12% vs. 13%). Conclusions: For medical oncology pts in a comprehensive cancer center, the ICS, an integrated, multidisciplinary supportive care service, significantly improved discharge rates to hospice, increased LOS on hospice by almost a week, avoided patients receiving chemotherapy, and maintained similar readmission rates. LOS was higher for complex ICS patients as compared to non-ICS. Based on this pilot, the ICS is planning for expansion to include hematology and surgical services.

Integration of Next-generation Sequencing and Immune Checkpoint Inhibitors in Targeted Symptom Control and Palliative Care in Solid Tumor Malignancies: A Multidisciplinary Clinician Perspective

The molecular characterization of solid tumor malignancies with respect to tumorgenesis, risk stratification, and prognostication of chemotherapeutic side effects is multi-faceted. Characterizing these mechanisms requires a detailed understanding of cytogenetics and pharmacology. In addition to the standard palliative care interventions that address issues such as fatigue, neuropathy, performance status, depression, nutrition, cachexia, anxiety, and medical ethics, we must also delve into individual chemotherapy side effects. Comprehending these symptoms is more complex with the advent of broader targeted therapies. With the advent and initiation of Foundation Medicine (FMI) testing, we have been able to tailor regimens to the individual genetics of the patient. Next-generation sequencing (NGS) is a bioinformatic analysis used in order to create a targeted effort to understand the complex genetics of a vast array of malignancies. Through the process known as high-throughput sequencing we, as clinicians, can obtain more real-time genetic data and incorporate the information into our reasoning process. The process involves a broad manner in which deoxyribonucleic acid (DNA) sequence data is obtained including genome sequencing and resequencing, protein-DNA or proteinomics, chromatin immunoprecipitation (ChIP)-sequencing, ribonucleic acid (RNA) sequencing, and epigenomic analysis. High-throughput sequencing techniques including single molecule real-time sequencing, ion semiconductor sequencing, pyrose sequencing, sequencing by synthesis, sequencing by ligation, nanopore sequencing, and chain termination (otherwise known as Sanger sequencing) have expanded the realm of NGS and clinicians options.

Supportive Care for the Head and Neck Cancer Patient

Patients with head and neck cancers (HNC) face multiple psychosocial and physical challenges that require multidisciplinary attention and care throughout their disease process. The psychoemotional symptoms may be triggered by cosmetic disfigurement and/or functional deficits related to the cancer itself or cancer-directed treatments. These physical and emotional symptoms can be demoralizing and require acute and long-term professional assistance throughout a patient's lifespan. HNC remains one of the most challenging cancers to treat due to disfigurement, emotional suffering, social isolation, and loss of self-esteem. The emotional and physical symptoms a supportive care team can address are discussed in this chapter.

The advance directive completion rates in the hematopoietic stem cell transplant population in a major transplant cancer center

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Background: Advance Care Planning (ACP) is central to patient-centered care and helps assure treatment aligns with a patient’s goals, values, and priorities. ACP is often poorly incorporated into the hematopoietic stem cell transplantation (HSCT) population, with reported advance directive (AD) rates of 23-50%. At City of Hope National Medical Center (COH), concerted efforts to improve the overall number of ADs in HSCT was undertaken and evaluated. Methods: The Department of Supportive Care Medicine at COH, in collaboration with medical faculty and administrative support, created a patient-centered ACP program. The first two years (2013/2014) broadly focused on all new COH patients. The last two years (2015/2016) included a specific focus on patients undergoing HSCT. The primary goal was a completed AD in the electronic medical record before day 0 of transplant. In addition to provider and transplant team engagement, major time points for supportive care integration to facilitate AD completion were identified including: 1) registration, 2) new patient orientation, 3) the clinical visit when transplant was decided, 4) pre-transplant education class, 5) clinical social work psychosocial assessment visit, and 6) the pre-transplant hospital days. AD completion rates were calculated with Odds Ratio and Mantel-Haenszel Chi-Square using Epi Info StatCalc. Results: Between 2012 and 2016 at COH, 1784 transplants were performed. For HSCT patients in 2012, baseline AD capture rate before day 0 of transplant was 28.6%. With the institutional AD program, the AD capture rate before day 0 of transplant was 31.6% for 2014, compared with 2012 [odds ratio, 1.17(95% CI, 0.85-1.60); p = .33]. With both institutional and hematology specific programs, AD capture rate before day 0 was 69.5% for 2016, compared to 2014[odds ratio, 4.30 (95% CI, 3.14-5.91); p < .001]. Conclusions: Compared to 2012, the institutional AD program in 2014 insignificantly impacted HSCT AD completion rates. Improving the rate of AD completion from 28.6% to 69.5% in HSCT patients required both institutional AD efforts and a targeted program. Nevertheless, more work is needed to improve AD completion rates before transplant to 100%.

The effects of global and targeted advance care planning efforts at a national comprehensive cancer center

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Background: Advance Care Planning is a central component of patient centered care and helps assure treatment aligns with a patient’s goals, values, and priorities. Various studies demonstrate advance care planning decreases stress and anxiety, increases satisfaction, improves awareness and implementation of a patient’s end of life wishes, and reduces costs in select populations. At City of Hope (COH) National Medical Center, we made concerted efforts over the last four years to improve the overall number of advance directives(ADs), and have additionally focused on improving AD capture rates in clinically relevant populations (patients undergoing surgery, those with metastatic disease, and those undergoing hematologic transplant). Methods: The Department of Supportive Care Medicine with executive team endorsement and in collaboration with medical oncology, hematology, anesthesia, surgery, nursing, marketing, and informatics created a patient-centric advance care planning program. We developed disease specific workflows, created multi-lingual AD workshops in the Sheri & Les Biller Patient and Family Resource Center, changed policy to provide complimentary patient/caregiver and staff notarizations for ADs, leveraged the electronic medical record (assured providers were able to document discussions, know when ADs were absent, and easily retrieve ADs when present), deploy AD specific screening questions, and most recently created a culturally sensitive branding campaign coined “Plan Today for Tomorrow.” Results: The rate of advance directive capture for all patients new to COH has continuously improved from 12% in 2012 to 22% in 2016. In transplant patients, AD capture rate increased to 63%. In a pilot for bladder cancer patients undergoing cystectomy, ADs were increased to 68%, and in the pre-anesthesia testing clinic, ADs were increased to 35%. Conclusions: We have made significant strides in the capture of advance directives at City of Hope with markedly higher capture rates in selectively targeted, clinically relevant populations. We anticipate improved patient centric care as a result, with the unintended consequence of cost savings and decreased resource utilization.

Final Journey: A reference booklet for families of dying patients

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Background: Family members will carry the memory of the death of their loved-one with them for the rest of their lives. If they perceive their loved-one suffered as they died there is a risk they will develop Post Traumatic Stress Disorder or other psychological dysfunctions. It is crucial the family be educated and holistically supported during the dying process. Health care providers and care givers require information that will enable them to act as patient advocates and work effectively with families toward the common goal of a peaceful death. Resources that provide basic explanations, suggestions for care, open communication, and prepare families and care givers about the dying process are essential. Methods: Final Journey is a patient and family centric booklet developed based on the CARES tool, which is a guide to help medical teams better care for the dying and their family. CARES stands for comfort, airway, restlessness and delirium, emotional and spiritual support, and self-care. Final Journey details in each section what patients and families may experience, helps families understand what constitutes suffering, and suggests what families can do to help their loved ones. Results: There is a need for education tools that are easily understood, pertinent, and made accessible to help improve the dying experience for all parties involved. Final Journey helps assure families are informed and more emotionally prepared. Furthermore, the booklet expands the available resources available to medical providers, allowing them to more effectively address the challenges of caring for the dying. Final Journey will be available as a free download from the Department of Supportive Care Medicine website. Conclusions: We anticipate utilization of the Final Journey booklet will improve knowledge and understanding for health care providers, care givers, and families regarding a normal dying process and how to distinguish this from suffering, provide them suggestions on how to offer support and comfort during the dying process, promote communication between health care providers, care givers, and families of dying patients and supply resources and information on the importance of self-care when working with a dying patient.

Using touch-based technology to screen patients in the ICU

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Background: The intensive care unit (ICU) is associated with high mortality rates, significant costs, along with occasionally futile and non-indicated care. Surveys of patients indicate the majority wish to focus on comfort and being at home at the end of life as opposed to the aggressive interventions received in the hospital. Although a small percentage of patients may be awake, medical teams look to the families to provide the direction of care for a patient in the ICU. City of Hope National Medical Center has utilized tablet-based screening of caregivers for years, and now in conjunction with delirium screening has started to roll out tablet-based screening for patients who are awake and do not have delirium. Methods: In parallel with a task force working to assess and address delirium in the hospital, team members from the Department of Supportive Care Medicine and the ICU developed and tested a survey on a tablet-based screening platform. Awake patients are screened for delirium using the confusion assessment method (CAM-ICU). If patients are awake and have a “negative” CAM-ICU, they are provided a tablet to take a five question survey. The questions were written to the sixth grade language level, reviewed by the Patient and Family Advisory Council and non-ICU patients commented on comprehension and emotional response prior to implementation in the ICU. The questions covered topics including orientation, symptoms to be addressed and confidence level in communicating wishes and values. Results: We have successfully administered tablet-based screening for five patients in the ICU, including one on a ventilator with a tracheostomy. Responses are electronically sent to the medical team. By the time of the conference, we will have screened over 50 patients, including patients who are intubated. Conclusions: Assessment of patient wishes and values should be done far before a patient enters the ICU. Unfortunately this does not always occur. This tablet-based screening pilot was a test of concept for feasibility. Although not ideal, capturing a patient’s values and wishes in the ICU has the potential to further assure care plans are individualized, minimize unwanted treatment options and facilitate possible transitions and improved care.

Adult cancer pain

Pain is a common symptom associated with cancer and its treatment. Pain management is an important aspect of oncologic care, and unrelieved pain significantly comprises overall quality of life. These NCCN Guidelines list the principles of management and acknowledge the range of complex decisions faced in the management oncologic pain. In addition to pain assessment techniques, these guidelines provide principles of use, dosing, management of adverse effects, and safe handling procedures of pharmacologic therapies and discuss a multidisciplinary approach for the management of cancer pain.

The management of pain in metastatic bone disease

BACKGROUND

Metastatic bone disease is a common cause of pain in cancer patients. A multidisciplinary approach to treatment is often necessary because simplified analgesic regimens may fail in the face of complex pain generators, especially those involved in the genesis of neuropathic pain. From the origins of formalized guidelines by the World Health Organization (WHO) to recent developments in implantable therapies, great strides have been made to meet the needs of these patients.

METHODS

The authors review the existing literature on the pathophysiology and treatment options for pain generated by metastatic bone disease and summarize classic and new approaches.

RESULTS

Relatively recent animal models of malignant bone disease have allowed a better understanding of the intimate mechanisms involved in the genesis of pain, resulting in a mechanistic approach to its treatment. Analgesic strategies can be developed with specific targets in mind to complement the classic, opioid-centered WHO analgesic ladder obtaining improved outcomes and quality of life. Unfortunately, high-quality evidence is difficult to produce in pain medicine, and these concepts are evolving slowly.

CONCLUSIONS

Treatment options are expanding for the challenging clinical problem of painful metastatic bone disease. Efforts are concentrated on developing alternative nonopioid approaches that appear to increase the success rate and improve patients' quality of life.