Journal of Pain and Symptom Management - Articles in Press

Significance of Symptom Clustering in Palliative Care of Advanced Cancer Patients - Corrected Proof

Jaw-Shiun Tsai, Chih-Hsun Wu, Tai-Yuan Chiu, Ching-Yu Chen — 2010-03-12

Abstract: Patients with advanced cancer often experience multiple concurrent symptoms. To explore this symptom clustering and its associated parameters, we prospectively surveyed 427 consecutive patients on admission to the Palliative Care Unit. There were 222 males (52.0%) and 205 females (48.0%), with a median age of 66 years (range: 27–93 years). The main tumor sites were lung (19.9%), liver (18.0%), and colorectum (11.0%). The median survival was 13 days (1–418 days). Symptoms were assessed using a face-valid Symptom Reporting Form. We identified five symptom clusters by exploratory factor analysis. Clusters were named “loss of energy,” “poor intake,” “autonomic dysfunction,” “aerodigestive impairment,” and “pain complex.” We used nonhierarchical cluster analysis to divide the 394 patients with complete data into six groups. Each group was characterized by a particular pattern that was composed of different symptom clusters. Survival, functional performance, bone metastasis, and fluid accumulation were significantly associated with symptom clustering in six groups of patients. The severity of psychological distress also related to their physical deterioration. These data suggest that different underlying mechanisms associate with symptom clustering. Further elucidation of these processes may assist in symptom management.

How Much Does It Cost a Specialist Palliative Care Unit to Manage Constipation in Patients Receiving Opioid Therapy? - Corrected Proof

2010-03-12

Abstract: The burden of constipation from the patient's perspective has been well described. The aim of this study was to evaluate the cost of managing constipation in patients taking opioids in a specialist palliative care inpatient unit. A retrospective review of the medical records of 58 patients (70 admissions) who died during a six-month period was undertaken to identify prescribing patterns for opioids and oral laxatives and tasks associated with managing constipation in these patients. A prospective time and motion study was also undertaken, whereby staff recorded the time and resources required to perform each task. These data were then applied to the actual frequency recorded in the retrospective review to calculate the direct cost of managing constipation in those 70 admissions during that six-month period. There was no discernable pattern in oral laxative prescribing. The mean cost of managing constipation was £29.81 (48.74 USD) per admission, with staff time accounting for 85% of the cost. The most time-consuming activity was staff discussion about bowel management, which occurred at least once daily for doctors and twice for nurses and involved up to eight members of staff at a time. The cost of managing constipation is skewed in that it costs £30 (49 USD) or less in 71% of admissions but exceeded £100 (163 USD) in 5%. In the latter group, earlier and/or more effective intervention for constipation could lead to clinical and economic benefits.

Antipsychotics for Acute and Chronic Pain in Adults - Corrected Proof

2010-03-12

Abstract: Context: The role of antipsychotics as adjuvant analgesics is a subject of longstanding controversy. Antipsychotics have been used to treat chronic pain (e.g., chronic headache, fibromyalgia, and painful diabetic neuropathy). With atypical antipsychotics, a new class of antipsychotics, with fewer extrapyramidal side effects and additional benefits, may be available.Objectives: This review aimed to assess analgesic efficacy and adverse effects of antipsychotics in acute or chronic pain.Methods: Randomized controlled trials of adults prescribed any dose of oral antipsychotics for acute or chronic pain, describing subjective pain assessment as either the primary or a secondary outcome, were included in this review.Results: We included 11 studies involving a total number of 770 participants. Data from five randomized, double-blind studies showed beneficial effects of antipsychotics in the treatment of acute and chronic pain. Because of the clinical heterogeneity of painful conditions studied and significant statistical heterogeneity, the intended meta-analysis was omitted. The most frequently reported adverse effects were extrapyramidal (i.e., involuntary movements, parkinsonism, and akathisia) and sedating effects.Conclusion: Because of limitations in the available evidence, further research is needed to understand whether antipsychotics are effective for acute or chronic pain or specific pain conditions.

Outcomes of a Cancer-Related Fatigue Clinic in a Comprehensive Cancer Center - Corrected Proof

2010-03-12

Abstract: Cancer-related fatigue (CRF) is a significant issue for cancer patients and frequently precipitates increased stress and anxiety for patients and caregivers alike. CRF may present well after the initial phase of cancer diagnosis and treatment, regardless of whether the cancer is in remission, widely metastatic, or somewhere in between. Determining whether the etiology of fatigue is potentially reversible and whether it is an effect of treatment or another unrelated cause is often perplexing. Because of the significant impact of CRF on patients at our institution, we organized a CRF clinic and began evaluating patients for fatigue in 1998. Our goal has been to initiate a more focused and, at the same time, more comprehensive effort in educating, evaluating, and treating CRF. The purposes of this report were to present a retrospective review of patients treated in our CRF clinic between 1998 and 2005, to examine the outcomes of our patients, and to briefly describe some of the challenges encountered in treating these patients. This information may help reassess and improve approaches in addressing CRF and subsequently improve fatigue in these patients.

Symptom Cluster Patterns During the First Year After Diagnosis with Cancer - Corrected Proof

Alex Molassiotis, Yvonne Wengstrom, Nora Kearney — 2010-03-12

Abstract: Context: Research about clusters of symptoms in oncology is an emerging field of study. However, there is still conceptual confusion about clusters of symptoms and little agreement across studies.Objectives: The aim of the present study was to explore clusters of symptoms over time in a large heterogeneous group of patients with cancer and thereby contribute to the conceptual and methodological debate in this research area.Methods: A longitudinal design was used to assess symptoms in cancer patients over four time points during the first year after diagnosis using the Memorial Symptom Assessment Scale. The study recruited 143 patients from five U.K. cancer centers and provided 504 symptom assessments at the beginning of treatment and 3, 6, and 12 months later.Results: Six symptom clusters were identified at the first assessment, which were maintained across the assessment points with slight variations. These included gastrointestinal, hand/foot, body image, respiratory, nutritional, and emotional symptom clusters. The behavior of the clusters over time highlighted the complexities of symptom cluster assessment and the dynamic relationships between symptoms. Frequency, severity, and distress from symptoms were significantly higher (up to 75% higher) in patients who experienced a cluster of symptoms than in the overall sample, suggesting that symptom assessments in unselected patients underestimate the symptom burden in subgroups of patients.Conclusion: We propose attention to symptom clusters that are stable across time and include core or defining symptoms within the cluster, and we further discuss the usefulness and applicability of conceptual and methodological criteria used in this study for future symptom cluster research.

Paraneoplastic Raynaud's Phenomenon—Good Palliation After a Multidisciplinary Approach - Corrected Proof

Eva K. Schildmann, Andrew N. Davies — 2010-03-04

Abstract: Paraneoplastic Raynaud's phenomenon is a rare complication of a number of different malignancies (carcinomas, sarcomas, lymphomas, and leukemias). We present a case of paraneoplastic Raynaud's phenomenon in a patient with non-small-cell lung cancer that was associated with significant morbidity, involved a multidisciplinary approach, and eventually responded to a specialized intervention (i.e., iloprost trometamol).

Provider Communication and Patient Understanding of Life-Limiting Illness and Their Relationship to Patient Communication of Treatment Preferences - Corrected Proof

2010-02-22

Abstract: Medical decision making in the context of serious illness ideally involves a patient who understands his or her condition and prognosis and can effectively formulate and communicate his or her care preferences. To understand the relationships among these care processes, we analyzed baseline interview data from veterans enrolled in a randomized controlled trial of a palliative care intervention. Participants were 400 inpatient veterans admitted with a physician-estimated risk of one-year mortality more than 25%; 260 (65%) had cancer as the primary diagnosis. Patients who believed that they had a life-limiting illness (89% of sample) reported that their provider had communicated this to them more frequently than those who did not share that belief (78% vs. 22%, P<0.001). Over half (53%) of the participants reported discussing their care preferences with their providers and 66% reported such discussions with their family; 35% had a living will. In multivariate analysis, greater functional impairment was associated with patients having discussed their care preferences with providers (P<0.05), whereas patient understanding of prognosis (P<0.05), better quality of life (P<0.01), and not being African American (P<0.05) were associated with patients having discussed their care preferences with family; higher education (P<0.001), and not being African American (P<0.01) were associated with having a living will. Patients with poor understanding of prognosis are less likely to discuss care preferences with family members, suggesting the importance of provider communication with patients regarding prognosis. Because functional decline may prompt physicians to discuss prognosis with patients, patients with relatively preserved function may particularly need such communication.

Proceedings of the 12th World Congress of Pain: An Informative Compilation - Corrected Proof

Judith A. Paice — 2010-02-12

The 12th World Congress on Pain, the biennial meeting of the International Association for the Study of Pain (IASP), was held in Glasgow in August 2008. This was an extraordinary meeting that addressed the most timely topics, delivered by esteemed clinicians, scientists, and others interested in pain. This book superbly translates the plenary sessions delivered by these experts into an interesting compilation that will be appreciated by all, regardless of whether they attended the meeting or not. In particular, this book provides an excellent primer for those wishing to update their knowledge of a broad array of pain-related topics, from the basic sciences to psychology to methodology issues in pain research and quality improvement.

A Singular Source of Contemporary Information on Pain Management - Corrected Proof

Gregg Figg, John C. Rowlingson — 2010-02-12

The fourth edition of Raj's Practical Management of Pain continues to upgrade and expand what is widely regarded as a definitive standard for textbooks in the field of pain management. As the specialty itself rapidly changes, it becomes more difficult to consolidate the plethora of evolving knowledge into an easily accessible reference. Yet, this new textbook seems to have met that challenge. Intended initially in 1986 by Raj to be “a resource for a pain trainee who had one year to learn everything about pain management,” the scope of this new text has been broadened by the inclusion of input from a multidisciplinary group of distinguished experts. The stated goal of this edition is to serve “pain clinicians looking for application in their daily practice, pain researchers seeking adequate background on relevant topics, fellows reviewing for the pain boards, and residents who want a complete discussion of the breadth of the field.” This text achieves these lofty goals in admirable fashion.

Fundamental Facets of Pediatric Hospice Care - Corrected Proof

Chris Feudtner — 2010-02-12

If one of the surest signs of a maturing discipline within medicine is the growth in the number of textbooks devoted to the topic, then pediatric palliative and hospice care is blossoming. Among several fine textbooks that are either already available or in the works, in the vanguard stands Hospice Care for Children, which was first published in 1993 and now appears in a revised and updated third edition.

Management of Treatment-Related Intermittent Partial Small Bowel Obstruction: The Use of Octreotide - Corrected Proof

Jeff Myers, Anoo Tamber, Macey Farhadian — 2010-02-12

We submit to you the following case and brief discussion intended to outline a possible role for the independent use of octreotide in the setting of cancer treatment-related intermittent bowel obstruction. In addition, and of great significance in the setting of cancer survivorship, we identify an innovative aspect to the symbiotic partnership between the fields of palliative care and oncology.

Every Patient Tells a Story - Corrected Proof

Martin Chasen — 2010-02-08

In today's health care system, enormous attention is given to the biomedical model of approaching the health aspects of the patients. The correct diagnosis is the key to prescribing the correct treatment, which aims to alleviate the patient's suffering. Targeted questioning, which leads to categorization of symptoms into specific syndromes provides the bulk of knowledge, which then allows for further clinical examination to verify our clinical suspicions.

Prognostication Remains More an Art Than a Science - Corrected Proof

Larry D. Cripe — 2010-02-08

Prognosis in Advanced Cancer is a multiauthored volume, edited by Drs. Paul Glare and Nicholas Christakis, divided into three sections. The first section, “The Science of Prognostication” consists of eight chapters that serve as part critique of the current prognostic activities of physicians and part primer to improve prognostication. The goal of the first section is a renaissance in the science of prognostication. The second and third sections are entitled “Prognostication in Specific Cancers” and “Prognosis in Palliative Care” and consist of 12 and 14 chapters, respectively. The apparent purpose of these chapters is to provide a brief summary of selected information about survival based on the specific type of cancer or a sentinel finding, such as spinal cord compression or hypercalcemia. The goals of the latter two sections are to provide information that may be useful in prognostication in specific situations. The overall goal of the book is “…to help physicians and other clinicians to improve their skills of prognostication near the end of life in patient [sic] with cancer…” And therein lies the potential relevance of this volume to the readership of this journal. However, I believe that the relevance of this volume is seriously diminished by several shortcomings. Thus, having completed my review of the book, I suspect I will neither consult it again nor recommend it to colleagues or students.

A Sourcebook for Pain-Related Research - Corrected Proof

Frederick Burgess — 2010-02-05

Although pain is the primary reason most patients will seek the assistance of a physician, the concept of pain as a sensation and as a disease remains confused in the minds of most patients and clinicians. Pain as a distinct disease state, maldynia, has been difficult to define and study. The uniquely subjective nature of pain, the highly variable individual response to pain, and the associated physical and emotional impact of pain on patients' lives creates a formidable challenge for the health care provider. As noted by the authors in Chapter 1, patients with pain have begun to exert greater autonomy in controlling and directing their care, in contrast to other more conventional disease-centered models, reflecting in part the difficulties encountered in measuring such a personal experience. This frequently leaves the health care provider in an uncomfortable and pressured position of trying to balance the risks and benefits of various treatment options without a clear set of objectively measurable parameters to guide therapy. As in other disease models, health care providers continue to seek reliable outcome measures to ensure that optimal care is being provided. Unfortunately, this has led to the propagation of a myriad of pain-related outcome measures, which are often population and diagnosis specific, with individual strengths and weaknesses, depending on the targeted physical, functional, or psychological measure. As a clinician and researcher, it is often difficult to sort out which tools are most appropriate for a given circumstance.

Factors Associated with Congruence Between Preferred and Actual Place of Death - Corrected Proof

Christina L. Bell, Emese Somogyi-Zalud, Kamal H. Masaki — 2010-01-29

Abstract: Congruence between preferred and actual place of death may be an essential component in terminal care. Most patients prefer a home death, but many patients do not die in their preferred location. Specialized (physician, hospice, and palliative) home care visits may increase home deaths, but factors associated with congruence have not been systematically reviewed. This study sought to review the extent of congruence reported in the literature and examine factors that may influence congruence. In July 2009, a comprehensive literature search was performed using MEDLINE, PsychInfo, CINAHL, and Web of Science. Reference lists, related articles, and the past five years of six palliative care journals were also searched. Overall congruence rates (percentage of met preferences for all locations of death) were calculated for each study using reported data to allow cross-study comparison. Eighteen articles described 30%–91% congruence. Eight specialized home care studies reported 59%–91% congruence. A physician-led home care program reported 91% congruence. Of the 10 studies without specialized home care for all patients, seven reported 56%–71% congruence and most reported unique care programs. Of the remaining three studies without specialized home care for all patients, two reported 43%–46% congruence among hospital inpatients, and one elicited patient preference “if everything were possible,” with 30% congruence. Physician support, hospice enrollment, and family support improved congruence in multiple studies. Research in this important area must consider potential sources of bias, the method of eliciting patient preference, and the absence of a single ideal place of death.

Prevalence, Severity, and Correlates of Sleep-Wake Disturbances in Long-Term Breast Cancer Survivors - Corrected Proof

2010-01-18

Abstract: Context: Current evidence shows that sleep-wake disturbances are a persistent problem linked to poor quality of life in women surviving breast cancer. Information regarding correlates of sleep-wake disturbances in long-term survivors is sparse.Objectives: The objective of this study was to refine knowledge regarding prevalence, severity, and correlates of sleep-wake disturbances in long-term breast cancer survivors (BCS) compared with age-matched women without breast cancer (WWC).Methods: The cross-sectional convenience sample included 246 BCS and 246 WWC who completed a quality-of-life study and were matched within ±5 years of age.Results: BCS were a mean of 5.6 years beyond completion of cancer treatment (range = 5.6–10.0 years). Based on Pittsburgh Sleep Quality Index (PSQI) scores, BCS had significantly more prevalent sleep-wake disturbances (65%) compared with WWC (55%) (P < 0.05). BCS also had significantly higher PSQI global scores indicating poorer sleep quality compared with WWC (P < 0.05). Significant correlates of prevalence of poor sleep for BCS included hot flashes, poor physical functioning, depressive symptoms, and distress, and for WWC, these included hot flashes, poor physical functioning, and depressive symptoms. Significant correlates (P < 0.05) of severity of poor sleep for BCS included presence of noncancer comorbidities, hot flashes, depressive symptoms, and residual effects of cancer treatment. For WWC, these included hot flashes, poor physical functioning, depressive symptoms, and impact of a life event.Conclusion: Knowledge of prevalence, severity, and correlates of sleep-wake disturbances provides useful information to health care providers during clinical evaluations for treatment of sleep-wake disturbances in BCS.

Lack of Benefit From Paracetamol (Acetaminophen) for Palliative Cancer Patients Requiring High-Dose Strong Opioids: A Randomized, Double-Blind, Placebo-Controlled, Crossover Trial - Corrected Proof

Fiona J. Israel, Greg Parker, Margaret Charles, Liz Reymond — 2010-01-18

Abstract: Context: The adjunctive use of paracetamol (acetaminophen) with strong opioids has become entrenched practice in palliative care pain management, despite little evidence to support its use.Objective: The study aim was to investigate potential analgesic benefits of 4g of paracetamol daily for palliative cancer patients requiring high-dose opioids.Methods: Thirty-one patients, using at least 200mg of oral morphine equivalent daily, were recruited to a prospective, double-blinded, randomized, crossover trial. Patients received usual medications plus 4g of paracetamol or placebo for five days each in random order. Primary outcome, effect on pain, was assessed using daily diaries, including numerical rating scale (NRS) from zero (no pain) to 10 (unbearable) and recording numbers of breakthrough analgesics. Secondary outcomes—nausea, vomiting, cognitive impairment, constipation, and overall well-being—were assessed using the NRS. Data from the last four days of each treatment were analyzed. Patients also indicated in which part of the study their pain was better controlled.Results: Twenty-two patients, requiring a median dose of 255mg of oral morphine equivalent daily, completed the trial. There were no significant order or treatment-by-order interaction effects for any variable; paired t-tests were conducted to investigate change in mean levels on outcome variables with placebo vs. paracetamol. For none of the variables was there a statistically significant difference when assessed with placebo compared with paracetamol. No change approached clinically significant levels, with a mean difference in rated pain of 0.16, and mean difference of 0.42 for a number of breakthrough medications. Fifteen patients were undecided whether paracetamol improved pain.Conclusions: These data do not support the common practice of adding regular paracetamol daily as an adjunct to high-dose opioids for pain control in cancer patients receiving palliative care.

Families' Perceptions of Veterans' Distress Due to Post-Traumatic Stress Disorder-Related Symptoms at the End of Life - Corrected Proof

2010-01-18

Abstract: Objectives: To define the frequency of post-traumatic stress disorder (PTSD)-related symptoms among veterans who are near the end of life and to describe the impact that these symptoms have on patients and their families.Methods: Patients had received inpatient or outpatient care from a participating VA facility in the last month of life, and one family member per patient was selected using predefined eligibility criteria. Family members then completed a telephone survey, The Family Assessment of Treatment at End-of-life, which assessed their perceptions of the quality of the care that the patients and they themselves received during the patients' last month of life.Results: Seventeen percent of patients (89 out of 524) were reported to have had PTSD-related symptoms in the last month of life. PTSD-related symptoms caused discomfort less often than pain did (mean frequency score: 1.79 vs. 1.93; Wilcoxon sign rank test, P<0.001) but more often than dyspnea did (mean severity score: 1.79 vs. 1.73; Wilcoxon sign rank test, P<0.001). Family members of patients with PTSD-related symptoms reported less satisfaction overall with the care the patient received (mean score: 48 vs. 62; rank sum test, P<0.001). Patients who received a palliative care consult (n=49) had lower ratings of discomfort attributed to PTSD-related symptoms (mean: 1.55 vs. 2.07; rank sum test, P=0.007).Conclusion: PTSD-related symptoms may be common and severe among veterans near the end of life and may have a negative effect on families' perceptions of the quality of care that the veteran received.