Palliative care and pain management

Benefits of Spiritual and Religious Support in the Pain Management of Cancer Patients: A Literature Scoping Review

Pain is one of the main symptoms of cancer and the most difficult to control due to its complexity as it can involve physical, psychological, social, and spiritual aspects. We proposed to summarize the scientific knowledge already published related to the influence of spirituality on pain therapy in cancer patients. Articles were searched in PubMed, SciELO, SciFinder, PsycInfo, and ScienceDirect databases using the following descriptors: "Spirituality," "Religion," "Religion," "Chronic Pain," "Pain Management" and "Cancer." A total of 68 articles were included and discussed. Most articles dealt with the influence of spirituality in palliative care, focussed on patient quality, and highlighted the importance of integrative oncology. Although few studies associated spirituality with chronic pain, most articles reported that spirituality could confer greater pain control.

Strengths, Gaps, and Opportunities: Results of a Statewide Community Needs Assessment of Pediatric Palliative Care and Hospice Resources

CONTEXT

Pediatric palliative care (PPC) can improve quality of life of children with life-threatening conditions and their families. However, PPC resources vary by state and within a state, and PPC resources and personnel are often inequitably distributed toward urban areas with major hospital systems. A community needs assessment (CNA) that evaluates the current status of PPC and pediatric hospice care can help identify gaps and opportunities to improve PPC access.

OBJECTIVES

A CNA was performed in the state of Georgia to explore the scope and gaps of PPC and hospice services and plan for what is needed to grow PPC and hospice services.

METHODS

The CNA used a mixed-methods approach, including a community profile, literature search, windshield survey, key informant interviews, and a quantitative online survey. The methodology is outlined in a companion article, entitled "A methodological approach to conducting a statewide community needs assessment of pediatric palliative care and hospice resources."

RESULTS

Four key themes were identified from synthesis of primary and secondary data collection: defining and providing PPC, the environment for PPC in Georgia, coordination and collaboration, and the future of PPC in Georgia. Recommendations to improve PPC services in Georgia were categorized by feasibility and importance. High feasibility and high importance recommendations included expanding PPC education for both providers and patients and creating a formal network or coalition of PPC providers and allies who can work collaboratively at multiple care levels across Georgia in expanding PPC services.

CONCLUSION

In Georgia, this assessment provides the foundation for next steps in coordinated efforts between hospital-based clinicians, state hospice and palliative care organizations, and state policy makers to ultimately expand PPC care available to children and families.

A Methodologic Approach to Conducting a Statewide Community Needs Assessment of Pediatric Palliative Care and Hospice Resources

CONTEXT

Prior studies have indicated that pediatric palliative care (PPC) resources vary across states and within regions in a state. Evaluating the current status of PPC and pediatric hospice care through a community needs assessment (CNA) can help address the gaps that exist to improve and increase access to PPC for children in need.

OBJECTIVES

Using the state of Georgia as an example, the process, methods, lessons learned, and limitations in conducting a statewide PPC CNA are described.

METHODS

A mixed-method descriptive design with multiple stages incorporating different methodological approaches was used. These included literature review, community profile, survey and interview questionnaire development, windshield survey, identifying and interviewing key informants, and quantitative survey of the state's hospice organizations. Key themes (providing PPC, PPC environment, collaboration, and future of PPC) and subthemes emerged, which were then triangulated across all existing data collection techniques to provide recommendations of varying feasibility and importance.

RESULTS

Described in a subsequent article (Johnson K.A. et al.).

CONCLUSION

This approach can be used by other state organizations, coalitions, governments, or national organizations looking to perform a CNA of palliative care, hospice resources, or could be applied to other geographical settings or types of care.

Curculigo recurvata W.T.Aiton exhibits anti-nociceptive and anti-diarrheal effects in Albino mice and an in silico model

BACKGROUND

Curculigo recurvata (C. recurvata) is an enthnomedicinally important herb reported to have significant medicinal values. The present study aimed to explore the in vivo and in silico anti-nociceptive and anti-diarrheal effects of a C. recurvate rhizome methanol extract (Me-RCR).

METHODS

The analgesic effects of Me-RCR were assessed using acetic acid-induced writhing and the formalin-induced flicking test. The drugs were administered intraperitoneally (IP) at doses of 200 and 400 mg/kg body weight (bw). Anti-diarrheal activity was evaluated by assessing intestinal motility, hypersecretion, and fecal score in mice at oral doses of 200 and 400 mg/kg·bw. Computer facilitated analyses for anti-nociceptive and anti-diarrheal activities of three isolated compounds from C. recurvata were undertaken to identify the best-fit phytoconstituents.

RESULTS

The Me-RCR showed significant (P < .05) peripheral anti-nociception at the highest dose. The extract inhibited both early and late phases of nociception in the formalin-induced writhing test. In the castor oil-induced diarrhoea model, the extract significantly (P < .05) prolonged the onset time of diarrhoea, inhibited percentage of diarrhoea, and decreased both the volume and weight of intestinal contents. Rates of intestinal fluid accumulation inhibition were (33.61 ± 1.00)% and (46.44 ± 0.89)% at Me-RCR doses of 200 and 400 mg/kg·bw, respectively. Moreover, a significant (P < .05) reduction in gastrointestinal motility was observed. An absorption, distribution, metabolism, excretion and/or toxicity (ADME/T) test showed that the selected compounds yielded promising results, satisfying Lipinski's rule of five for predicting drug-like potential. Notably, of the three phytoconstituents curculigine and isocurculigine possessed the highest affinity for the COX-1 and COX-2. Isocurculigine was also identified as the most effective anti-diarrheal compound in the computer-facilitated model.

CONCLUSION

An extract of the plant C. recurvata showed potential analgesic and anti-diarrheal activity due to the presence of one or more active secondary metabolite(s).

Antinociceptive and Anxiolytic and Sedative Effects of Methanol Extract of Anisomeles indica: An Experimental Assessment in Mice and Computer Aided Models

Anisomeles indica (L.) kuntze is widely used in folk medicine against various disorders including allergy, sores, inflammation, and fever. This research investigated the antinociceptive, anxiolytic and sedative effects of A. indica methanol extract. The antinociceptive activity was assessed with the acetic acid-induced writhing test and formalin-induced flicking test while sedative effects with open field and hole cross tests and anxiolytic effects with elevated plus maze (EPM) and thiopental-induced sleeping time tests were assayed. Computer aided (pass prediction, docking) analyses were undertaken to find out the best-fit phytoconstituent of total 14 isolated compounds of this plant for aforesaid effects. Acetic acid treated mice taking different concentrations of extract (50, 100, and 200 mg/kg, intraperitoneal) displayed reduced the writhing number. In the formalin-induced test, extract minimized the paw licking time of mice during the first phase and the second phase significantly. The open field and hole-cross tests were noticed with a dose-dependent reduction of locomotor activity. The EPM test demonstrated an increase of time spent percentage in open arms. Methanol extract potentiated the effect of thiopental-induced hypnosis in lesser extent comparing with Diazepam. The results may account for the use of A. indica as an alternative treatment of antinociception and neuropharmacological abnormalities with further intensive studies. The compound, 3,4-dihydroxybenzoic acid was found to be most effective in computer aided models.

Early pain detection and management after esophageal metal stent placement in incurable cancer patients: A prospective observational cohort study

BACKGROUND AND STUDY AIMS

Studies of esophageal self-expandable metal stents (SEMS) mainly focus on efficacy and recurrent dysphagia. Retrosternal pain has been described in up to 14 % of these patients, however, prospective daily pain assessment has not yet been performed. We conducted a prospective study to evaluate the occurrence and management of pain after esophageal SEMS deployment.

PATIENTS AND METHODS

A total of 65 patients who underwent SEMS placement for incurable malignant esophageal stenosis were included. Patients used a diary to record intensity of pain twice daily for 2 weeks, according to the Numeric Rating Scale (NRS). A pain score ≥ 4 was used to determine whether patients experienced significant pain. If pain occurred, acetaminophen was used and, in cases of ongoing pain, an opiate was prescribed. Dose, duration, and kind of analgesic were noted.

RESULTS

The rate of significant pain increased from 0 % at baseline to 60 % on Day 1 (P < 0.001), followed by 37 % and 25 % on Days 7 and 14, respectively. The rate of analgesics use increased from 20 % at baseline to 78 % on Day 1 (P < 0.001), followed by 72 % and 62 % on Days 7 and 14, respectively. The use of opiates increased from 14 % at baseline to 42 % on Day 1 (P < 0.001). No variables associated with SEMS related pain were found.

CONCLUSIONS

Two-thirds of patients experience significant pain after esophageal SEMS insertion and analgesics, including opiates, are frequently required. Patients need to be informed and preventive prescription of analgesia should be considered in order to improve quality of life.

The importance of measuring customer satisfaction in palliative care

In the last decades, palliative care has been more and more focused on the evaluation of patients' and families' satisfaction with care. However, the evaluation of customer satisfaction in palliative care presents a number of issues such as the presence of both patients and their families, the frail condition of the patients and the complexity of their needs, and the lack of standard quality indicators and appropriate measurement tools. In this manuscript, we critically review existing evidence and literature on the evaluation of satisfaction in the palliative care context. Moreover, we provide - as a practical example - the preliminary results of our experience in this setting with the development of a dedicated tool for the measurement of satisfaction.

Palliative Vitamin C Application in Patients with Radiotherapy-Resistant Bone Metastases: A Retrospective Study

The aim of this study was to observe effects of ascorbic acid application on pain, performance status, and survival time in cancer patients. A retrospective cohort of 39 patients with bone metastases treated with radiotherapy was identified. All patients were radiotherapy-resistant. Fifteen patients who received chemotherapy, and 15 patients who received an infusion of 2.5 g ascorbic acid were included in the study. Nine control patients were treated with neither chemotherapy nor vitamin C. Eastern Cooperative Oncology Group Performance Status Scale and Visual Analog Scale were used to determine performance status and pain assessments. Survival time and rate in patients were defined. Statistical analyses were performed to compare the results of groups. Performance status was increased in 4 patients of vitamin C group and 1 patient of chemotherapy group, whereas performance status in control group was decreased. A median reduction of 50% in pain was observed among the patients in the vitamin C group. Median survival time was 10 mo in patients receiving ascorbic acid, whereas the chemotherapy and control groups had a median survival of 2 mo. Intravenous vitamin C application seems to reduce pain in patients in comparison to other patients who did not receive it. Patient performance status and survival rate were increased using vitamin C.

Anesthetic management during labor and delivery of a multiparous patient terminally ill with metastatic breast cancer

Multiple ethical issues arise when caring for a terminally ill patient who is also pregnant. We present the management of labor and delivery of a 35-year-old multiparous patient with stage 4 metastatic breast cancer. The ethical challenges in treating a mother and fetus when a terminal illness complicates pregnancy is also included.

Interdisciplinary hospice team processes and multidimensional pain: a qualitative study

Hospice teams may address multidimensional pain through the synergistic interaction of team members from various professional disciplines during regularly scheduled team meetings. However, the occurrence of that critical exchange has not been adequately described or documented. The purpose of this qualitative study was to explore two processes in team pain palliation: communication and collaboration. Data were gathered through individual interviews and a 1-year observation of team members from two hospices (physicians, nurses, aides, chaplains, social workers). Utilizing constant comparison, 14 final thematic categories were discovered. Use of biopsychosocial/spiritual terms by all team members meant that the team had the common language needed to communicate about multidimensional pain. Interviews and observation revealed a gap in translating multidisciplinary communication in team meetings into collaborative acts for pain treatment. In addition, structural influences inhibited creativity in pain palliation. There was no mutual understanding of the purpose for team meetings, no recognition of the need to reflect on team process, or common definition of leadership. Social work roles in hospice should include leadership that moves teams toward interdisciplinary care for multidimensional pain.

Do elderly patients with metastatic cancer have worse quality of life scores?

PURPOSE

The purpose of this study is to compare self-reported quality of life (QOL) scores in old and young patients with metastatic cancer using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C15-PAL questionnaire.

MATERIALS AND METHODS

Patients receiving palliative radiotherapy (RT) for bone metastases and brain metastases completed the QLQ-C15-PAL questionnaire prior to treatment. Using multiple linear regression analysis, a parametric test, the QLQ-C15-PAL scores were compared using 65 and 70 years as cutoff ages.

RESULTS

A total of 340 patients were referred for palliative RT for bone metastases (n = 190) or brain metastases (n = 150). Physical functioning and appetite were worse in the older group using either 65 or 70 years as the cutoff age. Age-related differences in the QLQ-C15-PAL scores varied as a function of age cutoff used and location of metastatic site irradiated.

CONCLUSION

Based on the (EORTC) QLQ-C15-PAL, elderly advanced cancer patients have a different QOL profile. Similar observations have been reported with the (EORTC) QLQ-C30 questionnaire.

Palliative and end-of-life care in psychogeriatric patients

A rapidly growing number of elderly persons and their families are burdened by one or more terminal illnesses in the later years of their life. How best to support their quality of life is a major challenge for healthcare teams. Palliative and end-of-life (PEOL) care is well positioned to respond to this challenge. While the evidence of PEOL is just beginning, much of the suffering can be relieved by what is already known. PEOL care for the elderly needs to go beyond the focus on the patient and should rest on a broad understanding of the nature of suffering that includes family and professional caregivers in that experience of suffering. The dissemination of PEOL care principles should be a public health priority. This article aims to improve understanding of appropriate PEOL care in the elderly and discuss future perspectives.

Integrating palliative care in public health: the Colombian experience following an international pain policy fellowship

Access to palliative care is insufficient in many countries around the world. In an effort to improve access to palliative care services and treatments, a public health approach as suggested by the World Health Organization was implemented in Colombia to improve opioid availability, increase awareness and competences about palliative care for healthcare workers, and to include palliative care as a component of care in legislation. As a result, opioid availability has improved, a mandatory palliative care course for medical undergraduate students has been implemented and a palliative care law is being discussed in the Senate. This article describes the strategy, main achievements and suggestions for implementing similar initiatives in developing countries.

Palliative care for adults across the cancer trajectory: from diagnosis to end of life

OBJECTIVES

To provide an overview of palliative care across the cancer trajectory from diagnosis through treatment, the chronic phase, and end of life.

DATA SOURCES

Journal articles, research reports, state of the science papers, and clinical practice experience and guidelines.

CONCLUSION

Symptoms occur throughout the cancer trajectory but are more common during active treatment and at the end of life. Symptom assessment facilitates optimal management of symptoms, promotion of comfort, and improvement in quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Clinicians have a responsibility to anticipate and assess symptoms throughout the illness trajectory. Identification of symptoms should prompt a plan of care that is based on evidence-based guidelines and best practices.

Using the values-based history to fine-tune advance care planning for oncology patients

There is no standardized approach to the discussion of advanced care planning. One approach to discussing advanced care planning involves the use of a values history. The values history focuses on questions related to overall health, personal relationships, and independence, as well as symptoms. The values history facilitates communication with the patient and allows the patient to express their view. This approach to patient communication is less threatening to patients and does not force the patient into thinking that they need the right answer. Values-based directives are less intrusive on a doctor's skill in making appropriate clinical decisions. They ask questions that require no technical skill and are easily done by other members of the health-care team. Values histories are useful in a wide range of situations where the doctor needs to understand the patient as a person. Compared to traditional, medicalized advance directives, values histories are less subject to the objections of not being clearly established at the time of their writing, or applicable in the circumstances that subsequently arise as in this case. They can help to validate preferences about treatment and also indicate appropriate courses of action that were not, or could not, be covered by traditional advance directives alone. This article illustrates the use of a values-based history in a patient with advanced head and neck cancer.

French general practitioners vary in their attitudes toward treating terminally ill patients

The purpose of this study is to analyze French general practitioners' attitudes toward prescribing opiate painkillers for dying patients and compare them with their attitudes toward making frequent home visits. One hundred and fifteen general practitioners indicated the acceptability of prescribing opiates in 48 scenarios of terminal cancer patients with different levels of age, gender, stated pain, request for painkillers, and signs of depression; 103 of them also indicated the acceptability of making frequent home visits in the same 48 scenarios. The responses were analyzed using analysis of variance and cluster analysis. For prescribing opiates, four clusters of physicians were found: 13 prescribed primarily in response to stated pain; 43 to request for painkillers; 43 to the combination of pain, request, and depression; and 16 in virtually all cases. Using the same clusters to analyze visiting gave results that were very consistent with those for prescribing. We conclude that French general practitioners have differing and consistent styles in prescribing painkillers and making home visits to dying cancer patients.

End-of-life issues in the acute and critically ill patient

The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.

Review Article: Goals of Care Toward the End of Life: A Structured Literature Review

Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967—2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.

Palliative care provision for patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major cause of disability, morbidity and mortality in old age. Patients with advanced stage COPD are most likely to be admitted three to four times per year with acute exacerbations of COPD (AECOPD) which are costly to manage. The adverse events of AECOPD are associated with poor quality of life, severe physical disability, loneliness, and depression and anxiety symptoms. Currently there is a lack of palliative care provision for patients with advanced stage COPD compared with cancer patients despite having poor prognosis, intolerable dyspnoea, lower levels of self efficacy, greater disability, poor quality of life and higher levels of anxiety and depression. These symptoms affect patients' quality of life and can be a source of concern for family and carers as most patients are likely to be housebound and may be in need of continuous support and care. Evidence of palliative care provision for cancer patients indicate that it improves quality of life and reduces health care costs. The reasons why COPD patients do not receive palliative care are complex. This partly may relate to prognostic accuracy of patients' survival which poses a challenge for healthcare professionals, including general practitioners for patients with advanced stage COPD, as they are less likely to engage in end-of-life care planning in contrast with terminal disease like cancer. Furthermore there is a lack of resources which constraints for the wider availability of the palliative care programmes in the health care system. Potential barriers may include unwillingness of patients to discuss advance care planning and end-of-life care with their general practitioners, lack of time, increased workload, and fear of uncertainty of the information to provide about the prognosis of the disease and also lack of appropriate tools to guide general practitioners when to refer patients for palliative care. COPD is a chronic incurable disease; those in an advanced stage of the disease pursuing intensive medical treatment may also benefit from the simultaneous holistic care approach of palliative care services, medical services and social services to improve quality of end of life care.