Journal of Pain and Symptom Management - Articles in Press

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.