The Edmonton Symptom Assessment System: Poor performance as screener for major depression in patients with incurable cancer

Emergency palliative cancer care: anxiety and midazolam

BACKGROUND AND OBJECTIVE

Cancer patients treated with palliative intent often report anxiety. Anxiety is associated with dyspnoea, cancer pain, and reduced quality of life. Limited knowledge on variability and treatment effects warranted exploring factors associated with improvement in anxiety for hospitalised palliative cancer patients.

METHODS

This study is a cross-sectional secondary analysis. All patients admitted to an acute palliative care unit for one year were assessed and 164 patients satisfied the study inclusion criteria. The patients reported self-registered symptom intensities using the 11-point numeric rating scale. Demographic variables, patient reports, and medical management were analysed for associations with anxiety.

RESULTS

At admission, 37.8% of the patients reported moderate or severe anxiety, and of these 43.6% used benzodiazepines. The corresponding numbers for benzodiazepine use were 35.1% and 24.4% for patients with mild and no anxiety, respectively. Of all patients, 26.8% reported improved anxiety during their hospital stay. More patients with moderate or severe anxiety at admission reported improved anxiety during hospitalisation (50.0%) compared to the corresponding patients with mild anxiety (22.8%). Patients with moderate or severe anxiety reported less improvement in pain compared to patients with mild anxiety. Improved dyspnoea was the only factor statistically associated with improvement in anxiety, both for patients reporting mild anxiety and moderate and severe anxiety. Thirty-seven-point-1% of patients with moderate or severe anxiety at admission received no benzodiazepine treatment during the hospital stay. Patients receiving midazolam had more anxiety at admission, were younger, and had poorer performance status. Median dose and interquartile range [IQR] of midazolam in these patients were 2 mg/24 h [IQR: 2.0-6.0].

CONCLUSION

Improved dyspnoea was associated with reduced anxiety; however, the use of benzodiazepines was not.

Mental Health Integration and Delivery in the Hospice and Palliative Medicine Setting: A National Survey of Clinicians

CONTEXT

Mental health comorbidities among individuals with serious illness are prevalent and negatively impact outcomes. Mental healthcare is a core domain of palliative care, but little is known about the experiences of palliative care clinicians delivering such care.

OBJECTIVES

This national survey aimed to characterize the frequency with which palliative care providers encounter and manage common psychiatric comorbidities, evaluate the degree of mental health integration in their practice settings, and prioritize strategies to meet the mental health needs of palliative care patients.

METHODS

A e-survey distributed to the American Academy of Hospice and Palliative Medicine membership.

RESULTS

Seven hundred eight palliative care clinicians (predominantly physicians) were included in the analysis. Mood, anxiety, and neurocognitive disorders were frequently encountered comorbidities that many respondents felt comfortable managing. Respondents felt less comfortable with other psychiatric comorbidities. Eighty percent of respondents noted that patients' mental health status impacted their comfort delivering general palliative care at least some of the time. Mental health screening tool use varied and access to specialist referral or to integrated psychiatrists/psychologists was low. Respondents were unsatisfied with mental health training opportunities.

CONCLUSION

Palliative care clinicians play a crucial role in addressing mental health comorbidities, but gaps exist in care. Integrated mental health care models, streamlined referral systems, and increased training opportunities can improve mental healthcare for patients with serious illness.

Operationalizing Depression Screening in Ambulatory Palliative Care: A Quality Improvement Project

BACKGROUND

Depression is common in the palliative care setting and impacts outcomes. Operationalized screening is unusual in palliative care.

LOCAL PROBLEM

Lack of operationalized depression screening at two ambulatory palliative care sites.

METHODS

A fellow-driven quality improvement initiative to implement operationalized depression screening using the patient health questionnaire-2 (PHQ-2). The primary measure was rate of EMR-documented depression screening. Secondary measures were clinician perspectives on the feasibility and acceptability of implementing the PHQ-2.

INTERVENTION

The intervention is a clinic-wide implementation of PHQ-2 screening supported by note templates, brief clinician training, referral resources for clinicians, and opportunities for indirect psychiatric consultation.

RESULTS

Operationalized depression screening rates increased from 2% to 38%. All clinicians felt incorporation of depression screening was useful and feasible.

CONCLUSIONS

Operationalized depression screening is feasible in ambulatory palliative care workflow, though optimization through having screening be completed prior to clinician visit might improve uptake.

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.

Exploring the Safety, Effectiveness, and Cost-Effectiveness of a Chinese Patent Medicine (Fufang E'jiao Syrup) for Alleviating Cancer-Related Fatigue: A Protocol for a Randomized, Double-Blinded, Placebo-Controlled, Multicenter Trial

Objective:

To provide higher level evidence on the benefits of a Chinese patent medicine (CPM) (Fufang E’jiao Syrup, FFEJS) for alleviating cancer-related fatigue (CRF), this article describes a protocol for a randomized controlled trial.

Methods/design:

We designed a double-blind, placebo-controlled stratified permuted block randomization clinical trial on CRF among 3 types of cancer in China. Participants will be equally allocated to FFEJS group or placebo group according to the randomization sequence and the hospitals they were enrolled at. Each patient will receive 20 ml of either the study formula FFEJS or a placebo formula, 3 times a day for 6 weeks. The follow-up period will be another 4 weeks for safety evaluation. The primary outcome is the difference in improvement of fatigue as measured with the Revised Piper Fatigue Scale-Chinese Version (RPFS-CV). Secondary outcomes include change in fatigue (measured by routine blood panel and hormones in peripheral blood) and QoL (measured by Edmonton symptom assessment scale and Functional Assessment of Cancer Therapy). Patient safety will be measured by liver, renal or cardiac damage, and the risk of FFEJS having a tumor promotion and progression effect will be monitored throughout this study. Cost-effectiveness will also be evaluated mainly by incremental cost per each quality-adjusted life year gained.

Discussion:

This article describes the study design of a CPM for CRF in patients with advanced cancer through exploring the effectiveness, safety, and cost-effectiveness of FFEJS.

Trial registration:

ClinicalTrials.gov, NCT04147312. Registered on 1 Sep 2019.

The palliative care needs of lung transplant candidates

BACKGROUND

Little is known about the palliative care needs of patients awaiting lung transplantation. The aim of this study was to describe these needs in patients undergoing evaluation for or awaiting lung transplantation.

METHODS

Cross-sectional survey using an adapted version of the Needs at the End-of-life Screening Tool (NEST-13) at a US-based transplant program.

RESULTS

Among the 111 participants, 83.5% were White, 60.0% were female, and almost three-quarters had either restrictive or obstructive lung disease. The greatest palliative care needs included difficulty being physically active (mean: 7.9/10; SD: 2.6; median: 9.0), physical symptoms (mean: 7.4/10; SD: 2.6; median: 8.0), missing work due to illness (mean: 6.2/10; SD: 4.0; median: 8.0), and concerns that life might end (mean: 5.1/10; SD: 3.6; median: 5.0). Participants reported that religious/spiritual beliefs contribute to their sense of purpose (mean: 4.1/10; SD: 3.9) but had few unmet needs in this area (mean: 0.9/10; median: 0.0). Only 6.4% reported seeing a palliative care specialist, and 48.2% were unsure what a palliative care specialist is.

CONCLUSION

There are substantial palliative care needs among lung transplant candidates, particularly physical symptoms and end-of-life concerns. These findings support integrating palliative care and end-of-life discussions in the management of lung transplant candidates.

Screening Performance of Edmonton Symptom Assessment System in Kidney Transplant Recipients

An average prevalence of 35% for psychiatric comorbidity has been reported in kidney transplant recipients (KTRs) and an even higher prevalence of other psychosocial syndromes, as defined by the Diagnostic Criteria for Psychosomatic Research (DCPR), has also been found in this population. Consequently, an easy, simple, rapid psychiatric tool is needed to measure physical and psychological symptoms of distress in KTRs. Recently, the Edmonton Symptom Assessment System (ESAS), a pragmatic patient-centred symptom assessment tool, was validated in a single cohort of KTRs. The aims of this study were: to test the screening performances of ESAS for the International Classification of Diseases-10th Revision (ICD-10) psychiatric diagnoses in KTRs; to investigate the optimal cut-off points for ESAS physical, psychological and global subscales in detecting ICD-10 psychiatric diagnoses; and to compare ESAS scores among KTR with ICD-10 diagnosis and DCPR diagnosis. 134 KTRs were evaluated and administered the MINI International Neuropsychiatric Interview 6.0 and the DCPR Interview. The ESAS and Canadian Problem Checklist (CPC) were given as self-report instruments to be filled in and were used to examine the severity of physical and psychological symptoms and daily-life problems. The physical distress sub-score (ESAS-PHYS), psychological distress sub-score (ESAS-PSY) and global distress score (ESAS-TOT) were obtained by summing up scores of six physical symptoms, four psychological symptoms and all single ESAS symptoms, respectively. Routine biochemistry, immunosuppressive agents, socio-demographic and clinical data were collected. Receiving Operating Characteristic (ROC) analysis was used to examine the ability of the ESAS emotional distress (DT) item, ESAS-TOT, ESAS-PSY and ESAS-PHYS, to detect psychiatric cases defined by using MINI6.0. The area under the ROC curve for ESAS-TOT, ESAS-PHYS, ESAS-PSY and DT item were 0.85, 0.73, 0.89, and 0.77, respectively. The DT item, ESAS-TOT and ESAS-PSY optimal cut-off points were ≥4 (sensitivity 0.74, specificity 0.73), ≥20 (sensitivity 0.85, specificity 0.74) and ≥12 (sensitivity 0.85, specificity 0.80), respectively. No valid ESAS-PHYS cut-off was found (sensitivity <0.7, specificity <0.7). Thirty-nine (84.8%) KTRs with ICD-10 diagnosis did exceed both ESAS-TOT and ESAS-PSY cut-offs. Higher scores on the ESAS symptoms (except shortness of breath and lack of appetite) and on the CPC problems were found for ICD-10 cases and DCRP cases than for ICD-10 no-cases and DCPR no-cases. This study shows that ESAS had an optimal screening performance (84.8%) to identify ICD-10 psychiatric diagnosis, evaluated with MINI; furthermore, ESAS-TOT and ESAS-PSY cut-off points could provide a guide for clinical symptom management in KTRs.

A modified Edmonton Symptom Assessment Scale for symptom clusters in radiation oncology patients

Patient‐reported outcomes regarding symptom burden may provide valuable information in addition to physician assessment. Systematic collection of patient‐reported outcomes may be an important metric to identify unmet needs and improve quality of patient care. To understand common symptoms of patients seen in radiation oncology clinic, we examined the prospectively collected modified Edmonton Symptom Assessment Scale (ESAS‐r) data to explore symptom clusters. Our clinic established use of a modified Edmonton Symptom Assessment Scale in August 2015. All outpatients presenting for radiation oncology services completed the form at each clinic visit. Symptom clusters are defined by two or more symptoms that are interrelated and occur simultaneously with a high degree of predictability. A sample of 916 de‐identified surveys was assessed statistically using principal component analysis (PCA) with varimax rotation to determine independent clustering between the symptoms queried. We found four major clusters of symptoms: Tiredness (tired, drowsiness; PC1), Loss of Appetite (nausea, lack of appetite; PC2), Low Well‐Being (overall & spiritual well‐being; PC3), and Depression (depression, anxiety; PC4). These accounted for 46%, 9.2%, 7.6%, and 7% of total variance, respectively. Internal consistency using Cronbach's alpha was 0.87, 0.7, 0.82, and 0.87, respectively. The most frequent write‐in item was itchiness, present in 24% of the 148 patients responding. Assessment of patients seen in a large radiation oncology clinic revealed several symptom clusters. {Tiredness and drowsiness} represents a major symptom cluster. Itchiness may be underrecognized.