A comparison of patient and proxy symptom assessments in advanced cancer patients

Do Spiritual Well-Being and Pain Intensity Predict Physical or Mental Components of Health-Related Quality-of-Life Scale in Patients With Multiple Myeloma?

BACKGROUND

Multiple myeloma is a complex disease and supportive care is important for improving quality of life. Management of disease treatment symptoms, bone disease, renal dysfunction, infection, anemia, pain, and coagulation disorder are specific issues. Spirituality, or spiritual well-being, is one of the most fundamental and essential concepts for coping with the difficulties and stress caused by cancer.

AIMS

This study explores whether spiritual well-being, pain, and other demographic factors predict the physical and mental components of quality of life in MM subjects.

METHODS

This cross-sectional descriptive study was conducted with 92 multiple myeloma patients registered with the Cancer Warriors Association in Turkey. The data were collected using the Personal Information Form, The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale-12, the Numeric Rating Scale for Pain, and the Short Form-12 Health-Related Quality of Life Scale.

RESULTS

The mean age of the patients was 54.4 ± 10.7 years. It was found that the mean total pain score in the previous week was 3.9 ± 2.6, while the mean total The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale-12 score was 28.1 ± 9.8. Their mean Short Form-12 total physical component score was 39.1 ± 25.4; whereas the Short Form-12 total mental component score was 45.5 ± 24.8. According to this model, 56.7% of the physical component score was explained by vertebroplasty, The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale-12 total score and subscale of peace and the pain intensity experienced in the previous week. According to multiple linear regression analysis, bone-sparing therapy and FACIT-Sp-12-Total and subscale peace significantly predicted the Mental component score (p < .05).

CONCLUSIONS

Cancer pain remains undertreated, and patients with myeloma are no exception. Pain and spiritual well-being scores were significant predictors of physical and mental component scores of quality of life in this group of patients. According to this result, pain-reducing practices should be implemented to improve the quality of life in MM patients and the spiritual needs of the patients should be met.

Heart failure symptom burden in outpatient cardiology: observational cohort study

OBJECTIVES

To assess the self-reported symptom burden in patients with a diagnosis of heart failure attending an outpatient cardiology clinic through the utilisation of validated patient-reported outcome measures.

METHODS

Eligible patients were invited to partake in this observational cohort study. Participant demographics and comorbidities were recorded, followed by participants recording their symptoms using the Integrated Palliative care Outcome Scale (IPOS) and Brief Pain Inventory (BPI) outcome measure tools.

RESULTS

A total of 22 patients were included in the study. The majority were male (n=15). The median age was 74.5 (range 55-94) years. Atrial fibrillation and hypertension were the most common comorbidities (n=10). Dyspnoea, weakness and poor mobility were the most prevalent symptoms, affecting 15 (68%) of the 22 patients. Dyspnoea was reported as being the most troublesome symptom. The BPI was completed by 68% (n=15) of the study participants. Median average pain score was 5/10; median worst pain score in the preceding 24 hours was 6/10 and median pain score at time of BPI completion was 3/10. The impact of pain on daily living during the preceding 24 hours ranged from impacting on all activities (n=7) to not impacting on activities (n=1).

CONCLUSIONS

Patients with heart failure experience a range of symptoms that vary in severity. Introduction of a symptom assessment tool in the cardiology outpatient setting could help identify patients with a high symptom burden and prompt timely referral to specialist palliative care services.

Measuring the reliability of proxy respondents in behavioural assessments: an open question

BACKGROUND

In behavioural assessment, information can be gathered from internally referenced self-reports or from proxy informants.

AIMS

This study aimed to fine-tune a brief but reliable method for evaluating the proxy accuracy in cases where responses obtained from adult and older adults' patient cannot be considered reliable.

METHODS

We generated a set of items reflecting both overt and covert behaviours related to the basic instrumental activities of daily living. The psychometric properties of the content, factorial, and criterium validity of these items were then checked. The Proxy Reliability Questionnaire-ProRe was created. We tested the frequency of "I don't know" responses as a measure of proxy reliability in a sample of healthy older adults and their proxies, and in a second sample of proxy respondents who answered questions about their parents.

RESULTS

As expected, response precision was lower for items characterizing covert behaviours; items about covert compared to overt behaviours generated more "I don't know" answers. Proxies provided less "I don't know" responses when evaluating the parent, they claimed they knew better. Moreover, we tried to validate our approach using response confidence. Encouragingly, these results also showed differences in the expected direction in confidence between overt and covert behaviours.

CONCLUSIONS

The present study encourages clinicians/researchers to how well the proxy the patient know each other, the tendency of proxies to exhibit, for example, response bias when responding to questions about patients' covert behaviours, and more importantly, the reliability of informants in providing a clinical assessment of neurocognitive diseases associated with aging.

Challenges in virtual collection of patient-reported data: a prospective cohort study conducted in COVID-19 era

Prior to the COVID-19 pandemic, patients attending ambulatory clinics at cancer centers in Ontario completed the Edmonton Symptom Assessment Scale (ESAS) at each visit. At our center, completion was via touchpad, with assistance from clinic volunteers. As of March 2020, clinic appointments were conducted virtually when possible and touch pads removed. We anticipated a negative impact on the collection of patient-reported outcomes (PROs) and the recognition of severe symptoms.

METHODS

We performed a prospective cross-sectional cohort study to investigate remote ESAS completion by patients with appointments at a weekly surgical oncology clinic. Patients in the initial study cohort were asked to complete and return the ESAS virtually (V). Given low completion rates, the ensuing cohort was asked to complete a hard-copy (HC) ESAS. For the final cohort, we provided remote, personal mentorship by a member of the care team to support virtual electronic ESAS completion (virtual-mentored (VM) cohort).

RESULTS

Between May and July 2020, a total of 174 patient encounters were included in the study. For the V cohort, 20/46 patients (44%) successfully completed and returned the electronic ESAS, compared to 49/50 (98%) for the HC cohort. For the VM cohort, the overall completion rate was 74% (58/78); however, 12 of these 58 patients did not independently complete a virtual ESAS. Virtual questionnaire completion was not predicted by age, sex, or tumor site, although patients who completed the ESAS were more likely to be in active management rather than surveillance (p = 0.04). Of all completed forms, 42% revealed a depression score of ≥2, and 27% an anxiety score of ≥4.

CONCLUSIONS

We identified significant barriers to the virtual completion of ESAS forms, with a lack of predictive variables. The severe degree of psychological distress reported by ~50% of respondents demonstrates the need for ongoing regular collection/review of these data. Innovative solutions are required to overcome barriers to the virtual collection of PROs.

What matters to patients and clinicians when discussing the impact of cancer medicines on health-related quality of life? Consensus-based mixed methods approach in prostate cancer

OBJECTIVE

To identify what matters to clinicians and patients when discussing cancer medicines' impact on health-related quality of life (HRQoL).

METHODS

A framework of HRQoL domain/domain elements was developed, informed by analysis of published patient reported outcome measures (PROMs), applicable to prostate cancer. Using mixed methods (eDelphi, Nominal Group Technique and questionnaire), prostate cancer clinicians and patients attending prostate cancer clinics and support groups were asked which domains/domain elements would be important to them when discussing the impact prostate cancer medicines have on their HRQoL.

RESULTS

Twenty-one clinicians and 71 patients participated from the West of Scotland. Clinicians and patients identified 53/62 domain elements across seven domains as important, of which 32 (60%) were common to both groups. Clinicians placed more importance than patients on Mood & Emotion; in contrast, patients placed importance on a broader range of Symptoms & Side Effects, being informed about their care, and having effective healthcare professional collaboration.

CONCLUSION

This study provides insight into the similarities and differences between what clinicians and patients think is important when discussing the impact of cancer medicines on HRQoL. Future research should involve exploring the potential for consistency of medicines PROMs across different cancer types to support patient-clinician communication and drive improvements in care.

The Level of Distress From Fatigue Reported in the Final Two Months of Life by a Palliative Care Population: An Australian National Prospective, Consecutive Case Series

CONTEXT

Fatigue is the most commonly reported symptom in life-limiting illnesses, although not much is known about the distress it causes patients as they approach death.

OBJECTIVES

To map the trajectory of distress from fatigue reported by an Australian palliative care population in the last 60 days leading up to death.

METHODS

A prospective, longitudinal, consecutive cohort study using national data from the Australian Palliative Care Outcomes Collaboration between July 1, 2013, and December 31, 2018. Patients were included if they had at least one measurement of fatigue on a 0-10 numerical rating scale in the 60 days before death. Descriptive statistics were used to analyse patients by diagnostic cohort and functional status.

RESULTS

A total of 116,604 patients from 203 specialist palliative care services were analyzed, providing 501,104 data points. Distress from fatigue affected up to 80% of patients referred to palliative care, with the majority experiencing moderate or severe distress. Malignant and nonmalignant diagnoses were equally affected, with the neurological cohort showing the greatest variability. The degree of distress correlated with a patient's functional level; it worsened as a patient's function declined until a patient became bedbound when the reporting of distress reduced.

CONCLUSIONS

Distress from fatigue is high in this cohort of patients. Interventions to reduce this distress need to be a research priority.

Edmonton Symptom Assessment Scale Time Duration of Self-Completion Versus Assisted Completion in Patients with Advanced Cancer: A Randomized Comparison

INTRODUCTION

To compare the time duration of self-completion (SC) of the Edmonton Symptom Assessment Scale (ESAS) by patients with advanced cancer (ACPs) versus assisted completion (AC) with a health care professional.

MATERIALS AND METHODS

In this randomized comparison of ACPs seen in initial consultation at the outpatient Supportive Care Center at MD Anderson, ACPs who have never completed the ESAS at MD Anderson were allocated (1:1) to either SC of the ESAS form versus AC by a nurse. Time of completion was measured by the nurse using a stopwatch. Patients completed the Rapid Estimate of Adult Literacy in Medicine (REALM) test prior to administration of the ESAS. In the SC group, the nurse reviewed the responses to verify that the reported ESAS scores were correct.

RESULTS

A total of 126 ACPs were enrolled (69 patients to AC and 57 to SC). Seventy-one patients were female, median age was 60 years, and median REALM score was 65. Median (interquartile range) time (in seconds) of SC was significantly less than AC (73 [42.9-89.1] vs. 109 [79.5-136.7], p < .0001). With nurse review time included, median time of SC increased to 117 seconds, which was not significantly different from AC (p = .28). Lower literacy (REALM) score and shortness of breath were significantly associated with increased completion time (p = .007).

CONCLUSION

Regular use of ESAS will have minimal impact on clinical time, as it can be completed in about 1 minute and provides a concise yet comprehensive and multidimensional perspective of symptoms that affect quality of life of patients with cancer.

IMPLICATIONS FOR PRACTICE

Because the Edmonton Symptom Assessment Scale can be completed in less than 2 minutes, hopefully the routine use of this simple yet comprehensive and multidimensional symptom assessment tool will be used at all medical visits in all patients with cancer so that the timely management of symptoms affecting patients' lives and treatment courses can occur, further enhancing personalized cancer care.

Developing theory-informed knowledge translation strategies to facilitate the use of patient-reported outcome measures in interdisciplinary low back pain clinical practices in Quebec: mixed methods study

Background

There is a growing interest among healthcare providers (HCPs) to use Patient Reported Outcome Measures (PROMs) in clinical care. PROMs can help improve patient-care provider communication and may be used to inform the need for interdisciplinary care for Low Back Pain (LBP). However, PROM implementation to support clinical decision-making is complex and requires knowledge translation (KT) interventions that will overcome barriers to using PROMs in interdisciplinary clinical settings.

Objectives

to 1) identify potential barriers and enablers to using PROMs in primary care LBP clinical practice from the perspective of healthcare team members, and 2) develop a theory-based tailored KT intervention to facilitate the use of PROMs in interdisciplinary clinical practice.

Methods

We invited 25 HCPs working in an interdisciplinary team to complete a self-administered survey designed based on the Theoretical Domain Framework (TDF) to identify the barriers and enablers to using PROM scores in LBP clinical practice. The questionnaire consisted of 30 questions rated on a 5-point Likert scale (quantitative) and included open-ended questions (qualitative). Quantitative and qualitative data were analysed to estimate the frequency of barriers and enablers. Findings were then reviewed by a panel of four KT experts who mapped behaviour change techniques to barriers identified that informed the design of a KT intervention.

Results

Eighteen HCPs responded to the survey. Factors identified as likely to restrict the use of PROM scores included knowledge, skills, social/professional role and identity, goals, decision processes, beliefs about consequences, environmental context and resources, behavioural regulation, and social influence. A multi-component evidence-based KT intervention was proposed by the panel of experts to address these barriers: a training workshop; educational materials; and use of PROM score reports to HCPs that were all delivered by an opinion leader.

Conclusion

The routine use of PROMs in clinical practice may optimize the quality of LBP care and improve patients’ outcomes. The proposed multi-component KT intervention is expected to be an effective strategy to increase HCPs’ ability to integrate PROMs into clinical decision-making and to engage patients in their care.

Real-world treatment patterns in patients with advanced (stage III-IV) ovarian cancer in the USA and Europe

Aim: To analyze real-world data relating to treatment decision-making in stage III-IV ovarian cancer (OC). Materials & methods: Real world data were collected from a survey of physicians and their patients (n = 2413) across Europe and the USA in 2017-2018. Results: 49% had stage IVb disease. 39, 54 and 7% of patients received first-line (1L), second-line, or 7% third-line or later treatment. In the 1L (ongoing or completed), 93% received platinum-containing regimens, 26% bevacizumab-containing regimens and 1% a PARP inhibitor-containing regimen. In 1L maintenance treatment, 81% received bevacizumab, 17% platinum-containing treatments and 6% a PARP inhibitor. Conclusion: The most common 1L treatment for advanced ovarian cancer was platinum-containing chemotherapy. Of those receiving 1L maintenance therapy, 70-99% (across countries) received targeted therapy.

Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes

Background

The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses’ perceptions of patients’ distress and quality of death.

Methods

200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women’s Hospital in Boston. Nurses were interviewed about their perceptions of the patients’ quality of death using validated measures. Patients were divided into 3 groups—no DNR, early DNR, late DNR placement during the patient’s final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient’s comorbidities, length of ICU stay, and procedures were also included in the model.

Results

59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09–0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1–0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12–0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12–0.94]), controlling for non-beneficial procedures.

Conclusions

Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.

The Role of a Symptom Assessment Tool in Shaping Patient-Physician Communication in Palliative Care

CONTEXT

Patients with cancer experience many symptoms that disrupt quality of life, and symptom communication and management can be challenging. The Edmonton Symptom Assessment System (ESAS) was developed to standardize assessment and documentation of symptoms, yet research is needed to understand patients' and caregivers' experiences using the tool and its ability to impact patient-provider aligned care.

OBJECTIVES

The objective of this study was to understand how the ESAS shapes communication between patients and providers by exploring patients' and caregivers' experiences using the ESAS and assessing the level of agreement in symptom assessment between patients and palliative care physicians.

METHODS

This study used a mixed-methods design. Thirty-one semistructured interviews were conducted and audio-recorded with patients (n = 18) and caregivers (n = 13). Data were analyzed following a social constructionist grounded theory approach. Patient and provider ESAS scores were obtained by medical chart review. Intraclass correlation coefficients were used to assess the level of agreement between patient-completed ESAS scores and provider-completed ESAS scores.

RESULTS

Participants reported that the ESAS was a beneficial tool in establishing priorities for symptom control and guiding the appointment with the palliative care physician, despite challenges in completing the ESAS. Filling out the ESAS can also help patients more clearly identify their priorities before meeting with their physician. There was a good to excellent level of agreement between patients and physicians in all symptoms analyzed.

CONCLUSION

The ESAS is beneficial in enhancing symptom communication when used as a guide to identify and understand patients' main concerns.

Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study

Background

People with advanced cancer experience multiple symptoms during their illness trajectory, which can fluctuate in intensity.

Aim

To describe the course of self-reported quality of life, emotional functioning, physical functioning and symptom intensity over time in cancer patients receiving palliative care.

Design

Longitudinal study with monthly assessments, using the EORTC QLQ-C15-PAL. Data were analysed (1) prospectively, from baseline to ≥8-month follow-up; and (2) retrospectively, by taking death as index date and comparing results from three cross-sectional subsamples at different stages of illness (time to death ≥6, 5–3 and 2–0 months). Linear mixed models were calculated.

Setting/participants

A total of 1739 patients (mean age 66, 50% male) from 30 palliative care centers in 12 countries were included.

Results

In prospective analyses, quality of life, functioning and symptoms–except nausea/vomiting–remained generally stable over time. In retrospective analyses, patients 2–0 months before death reported significantly lower quality of life and physical functioning scores than those 5–3 months before death, who in turn scored lower than those ≥6 months before death, suggesting progressive decline. Emotional functioning remained initially unchanged, but decreased in the last months. Pain, fatigue and appetite loss showed a stable increase in intensity towards death. Dyspnea, insomnia and constipation increased from 5–3 to 2–0 months before death. Nausea/vomiting only increased when comparing those ≥6 months before death with those 2–0 months before death.

Conclusion

While the prospective approach showed predominantly stable patterns for quality of life, functioning and symptom severity throughout study duration, retrospective analyses indicated that deterioration was already apparent before the terminal phase and accelerated close to death. Our findings support the importance of early symptom identification and treatment in this population, and highlight the need for further studies to explore what characterizes those with either lower or higher symptom burden at different time points towards death.

Comparing Physician and Nurse Eastern Cooperative Oncology Group Performance Status (ECOG-PS) Ratings as Predictors of Clinical Outcomes in Patients with Cancer

BACKGROUND

The Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scale is commonly used by physicians and nurses in oncology, as it correlates with cancer morbidity, mortality, and complications from chemotherapy and can help direct clinical decisions and prognostication. This retrospective cohort study aimed to identify whether ECOG-PS scores rated by oncologist versus nurses differ in their ability to predict clinical outcomes.

MATERIALS AND METHODS

Over 19 months, 32 oncologists and 41 chemotherapy nurses from a single academic comprehensive cancer center independently scored ECOG-PS (range: 0-5) for a random sample of 311 patients with cancer receiving chemotherapy. Logistic regression models were fit to evaluate the ability of nurse and physician ECOG-PS scores, as well as the nurse-physician ECOG-PS score difference (nurse minus physician), to predict the occurrence of chemotherapy toxicity (CTCAE v4, grade ≥3) and hospitalizations within 1 month from ECOG-PS ratings, as well as 6-month mortality or hospice referrals.

RESULTS

Physician/nurse ECOG-PS agreement was 71% (Cohen's κ = 0.486, p < .0001). Nurse ECOG-PS scores had stronger odds ratio for 6-month mortality or hospice (odds ratio [OR], 3.29, p < .0001) than physician ECOG-PS scores (OR, 2.71, p = .001). Furthermore, ECOG-PS ratings by nurses, but not physicians, correlated with 1-month chemotherapy toxicity (OR, 1.44, p = .021) and 1-month hospitalizations (OR, 1.57, p = .041). Nurse-physician disagreement, but only when physicians gave "healthier" (lower) ratings, was also associated with worse outcomes (chemotherapy toxicity OR = 1.51, p = .045; 1-month hospitalization OR, 1.86, p = .037; 6-month mortality or hospice OR, 2.99, p < .0001).

CONCLUSION

Nurse ECOG-PS ratings seem more predictive of important outcomes than those of physicians, and physician-nurse disagreement in ECOG-PS ratings predicts worse outcomes; scoring by nurses may result in additional clinical benefit.

IMPLICATIONS FOR PRACTICE

Nurse-rated Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scores, compared with those rated by oncologists, better predicted hospitalizations and severe chemotherapy toxicity within 1 month from ECOG-PS assessment, as well as mortality or hospice referrals within 6 months. Physician-nurse disagreement in ECOG-PS scoring was associated with worse hospitalization, chemotherapy toxicity, and mortality and hospice referral rates. Rating performance statuses of patients with cancer by nurses instead or in addition to oncologists can result in additional clinical benefits, such as improved prognostication, as well as better informed clinical decision making regarding whether or not to administer chemotherapy, the need for additional supportive care, and goals of care discussions.

Validity, Reliability, and Diagnostic Accuracy of the Respiratory Distress Observation Scale for Assessment of Dyspnea in Adult Palliative Care Patients

BACKGROUND

The prevalence and severity of dyspnea increase at the end of life. Many of these patients have difficulty in reporting their symptoms. Accurate surrogate measures are needed for appropriate assessment and treatment. The Respiratory Distress Observation Scale (RDOS) is proposed as a possible scale although more external validation is needed. We set out to validate the RDOS in the context of palliative care patients near the end of life.

MEASURES

We prospectively studied 122 palliative care patients in a tertiary hospital in Singapore. Prior RDOS training was done using a standardized instructional video. Dyspnea was assessed by RDOS, Dyspnea Numerical Rating Scale, and Dyspnea Categorical Scale. Pain was assessed by Pain Numerical Rating Scale. We measured RDOS inter-rater reliability, convergent validity, and divergent validity. We used area under receiver operating characteristics curve (AUC) analysis to examine the discriminant properties of RDOS using dyspnea self-report as benchmark.

RESULTS

RDOS had good inter-rater reliability with an intraclass correlation of 0.947 (95% CI 0.919-0.976). It showed moderate-to-strong correlation with Dyspnea Numerical Rating Scale (r = 0.702) and Dyspnea Categorical Scale (r = 0.677) and negligible correlation to Pain Numerical Rating Scale (r = 0.080). It showed good discriminant properties of identifying patients with moderate and severe dyspnea with an AUC of 0.874 (95% CI 0.812-0.936). RDOS ≥ 4 predicted patients with moderate and severe dyspnea with a sensitivity of 76.6%, specificity of 86.2%, positive predictive value of 86.0%, and negative predictive value of 76.9%.

CONCLUSIONS

The RDOS shows promise and clinical utility as an observational dyspnea assessment tool. Further studies in uncommunicative patients are needed to determine clinical usefulness and generalizability of results.

Correlation of affective temperament and psychiatric symptoms in palliative care cancer patients

Background

Psychiatric symptoms are common in terminally ill patients. Studies linking temperamental traits and psychiatric disorders in patients suffering from advanced disease are rare. This study investigated the influence of temperament on depression and anxiety in palliative care cancer patients.

Methods

A total of 53 patients at the palliative care unit (PCU) of the Medical University of Vienna were enrolled in the study. Patients filled out the TEMPS-M and the brief PHQ-9 questionnaires to examine associations between temperament, psychiatric symptoms and sociodemographic parameters.

Results

Pain (67%), anorexia (58%), constipation (42%) and nausea/vomiting (40%) were the most prevalent self-reported symptoms. Self-reported symptoms of depression were less commonly reported (21.8%) than unveiled by the structured assessment by the PHQ-9 questionnaire: 26.4% (n = 14) showed mild symptoms of depression and 64.1% (n = 34) had a major depressive disorder (MDD) according to PHQ-9. The depressive and cyclothymic temperaments showed significant associations with depressive (both: p < 0.001) as well as symptoms of anxiety (p = 0.002; p = 0.036). Furthermore, the anxious temperament was significantly associated with symptoms of depression (p = 0.027).

Conclusions

Mood disorders are common in palliative care patients, as the majority of the patients were suffering from MDD. The depressive, cyclothymic and anxious temperaments were found to be correlated with depressive and anxious symptoms. A sensitization in this field might bring further improvements for the quality of life of palliative care patients and help to appropriately address psychiatric symptoms in palliative care.

Beyond Pain: Nurses' Assessment of Patient Suffering, Dignity, and Dying in the Intensive Care Unit

CONTEXT

Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients' experiences at the end of life in the ICU.

OBJECTIVES

The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity.

METHODS

From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients' experiences. Medical chart abstraction was used to document baseline patient characteristics and care.

RESULTS

The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P < 0.05) associated with suffering, after adjusting for physical pain, including fever/chills, fatigue, and edema. Most patients received vasopressors and mechanical ventilation. Renal replacement therapy was significantly (<0.05) associated with severe suffering (adjusted odds ratio [AOR] 2.53) and loss of dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12).

CONCLUSION

Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU.

Symptom Intensity of Hospice Patients: A Longitudinal Analysis of Concordance Between Patients' and Nurses' Outcomes

CONTEXT

Nearing death, hospice patients are increasingly unable or unwilling to self-report their symptom intensity and rely on nurses' assessments.

OBJECTIVES

We hypothesized that concordance between patients' and nurses' assessments of symptom intensity improves over time.

METHOD

A prospective longitudinal study was conducted from January 2012 to June 2015 using dyads of patient- and nurse-reported outcome measures, collected in daily hospice practice in the first three weeks after admission. Main outcomes were symptom intensity and well-being, measured using the Utrecht Symptom Diary (USD) and USD-Professional. Absolute concordance was the proportion of dyads with no difference in scores between USD and USD-Professional per week after admission. For agreement beyond chance, the squared weighted Kappa for symptom intensity and the one-way agreement intraclass correlation coefficient for well-being were used.

RESULTS

The most prevalent symptoms, fatigue, dry mouth, and anorexia also had the highest intensity scores assessed by patients and nurses. Symptom intensity was underestimated more frequently than overestimated by the nurses. The absolute concordance was fair to good (35%-69%). Agreement beyond chance was low to fair (0.146-0.539) and the intraclass correlation for well-being was low (0.25-0.28). Absolute concordance and agreement beyond chance did not improve over time.

CONCLUSION

Concordance between patients' and nurses' assessment of symptom prevalence is good, and both patients and nurses reveal identical symptoms as most and least prevalent and intense. However, nurses tend to underestimate symptom intensity. Concordance between patients and nurses symptom intensity scores is poor and does not improve over time.

Safety and Effectiveness of Palliative Drug Treatment in the Last Days of Life-A Systematic Literature Review

CONTEXT

Dying patients commonly experience potentially distressing symptoms. Palliative care guidelines recommend opioids, anticholinergics, antipsychotics, and benzodiazepines for symptom relief.

OBJECTIVES

The objective of this study was to systematically review the effectiveness and safety of palliative drug treatment in the last days of life of adult patients, focusing on the management of pain, dyspnea, anxiety, restlessness, and death rattle.

METHODS

A systematic search of the literature was published before December 2016 in PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Cochrane, ClinicalTrials.gov, and SveMed+. Studies on safety or effectiveness of drug therapy in dying adults with at least one outcome on symptom control, adverse effects, or survival were included. Data for included studies were extracted. Study quality was assessed using the Effective Public Health Practice Quality assessment tool for quantitative studies.

RESULTS

Of the 5940 unique titles identified, 12 studies met the inclusion criteria. Five studies assessed anticholinergics for death rattle, providing no evidence that scopolamine hydrobromide and atropine were superior to placebo. Five studies examined drugs for dyspnea, anxiety, or terminal restlessness, providing some evidence supporting the use of morphine and midazolam. Two studies examined opioids for pain, providing some support for morphine, diamorphine, and fentanyl. Eight studies included safety outcomes, revealing no important differences in adverse effects between the interventions and no evidence for midazolam shortening survival.

CONCLUSION

There is a lack of evidence concerning the effectiveness and safety of palliative drug treatment in dying patients, and the reviewed evidence provides limited guidance for clinicians to assist in a distinct and significant phase of life.

Reducing Symptom Distress in Patients With Advanced Cancer Using an e-Alert System for Caregivers: Pooled Analysis of Two Randomized Clinical Trials

Background

Symptom distress in patients toward the end of life can change rapidly. Family caregivers have the potential to help patients manage those symptoms, as well as their own stress, if they are equipped with the proper resources. Electronic health (eHealth) systems may be able to provide those resources. Very sick patients may not be able to use such systems themselves to report their symptoms but family caregivers could.

Objective

The aim of this paper was to assess the effects on cancer patient symptom distress of an eHealth system that alerts clinicians to significant changes in the patient’s symptoms, as reported by a family caregiver.

Methods

A pooled analysis from two randomized clinical trials (NCT00214162 and NCT00365963) compared outcomes at 12 months for two unblinded groups: a control group (Comprehensive Health Enhancement Support System [CHESS]-Only) that gave caregivers access to CHESS, an online support system, and an experimental group (CHESS+CR [Clinician Report]), which also had CHESS but with a CR that automatically alerted clinicians if symptoms exceeded a predetermined threshold of severity. Participants were dyads (n=235) of patients with advanced lung, breast, or prostate cancer and their respective family caregivers from 5 oncology clinics in the United States of America. The proportion of improved patient threshold symptoms was compared between groups using area-under-the-curve analysis and binomial proportion tests. The proportion of threshold symptoms out of all reported symptoms was also examined.

Results

When severe caregiver-reported symptoms were shared with clinicians, the symptoms were more likely to be subsequently reported as improved than when the symptoms were not shared with clinicians (P<.001). Fewer symptom reports were completed in the group of caregivers whose reports went to clinicians than in the CHESS-Only group (P<.001), perhaps because caregivers, knowing their reports might be sent to a doctor, feared they might be bothering the clinician.

Conclusions

This study suggests that an eHealth system designed for caregivers that alerts clinicians to worrisome changes in patient health status may lead to reduced patient distress.

Trial Registration

Clinicaltrials.gov NCT00214162; https://clinicaltrials.gov/ct2/show/NCT00214162 (Archived by WebCite at http://www.webcitation.org/6nmgdGfuD) and Clinicaltrials.gov NCT00365963; https://clinicaltrials.gov/ct2/show/NCT00365963 (Archived by WebCite at http://www.webcitation.org/6nmh0U8VP)

Added Value from Secondary Use of Person Generated Health Data in Consumer Health Informatics

Introduction: Various health-related data, subsequently called Person Generated Health Data (PGHD), is being collected by patients or presumably healthy individuals as well as about them as much as they become available as measurable properties in their work, home, and other environments. Despite that such data was originally just collected and used for dedicated predefined purposes, more recently it is regarded as untapped resources that call for secondary use. Method: Since the secondary use of PGHD is still at its early evolving stage, we have chosen, in this paper, to produce an outline of best practices, as opposed to a systematic review. To this end, we identified key directions of secondary use and invited protagonists of each of these directions to present their takes on the primary and secondary use of PGHD in their sub-fields. We then put secondary use in a wider perspective of overarching themes such as privacy, interpretability, interoperability, utility, and ethics. Results: We present the primary and secondary use of PGHD in four focus areas: (1) making sense of PGHD in augmented Shared Care Plans for care coordination across multiple conditions; (2) making sense of PGHD from patient-held sensors to inform cancer care; (3) fitting situational use of PGHD to evaluate personal informatics tools in adaptive concurrent trials; (4) making sense of environment risk exposure data in an integrated context with clinical and omics-data for biomedical research. Discussion: Fast technological progress in all the four focus areas calls for a societal debate and decision-making process on a multitude of challenges: how emerging or foreseeable results transform privacy; how new data modalities can be interpreted in light of clinical data and vice versa; how the sheer mass and partially abstract mathematical properties of the achieved insights can be interpreted to a broad public and can consequently facilitate the development of patient-centered services; and how the remaining risks and uncertainties can be evaluated against new benefits. This paper is an initial summary of the status quo of the challenges and proposals that address these issues. The opportunities and barriers identified can serve as action items individuals can bring to their organizations when facing challenges to add value from the secondary use of patient-generated health data.

Family estimates of risk for neurocognitive late effects following pediatric cancer: From diagnosis through the first three years of survivorship

BACKGROUND

Families often express a need for additional information about neurocognitive late effects (NCLE) after a pediatric cancer diagnosis. Therefore, we examined: (i) differences in parent, child, and oncologist estimates of risk for NCLE; (ii) whether the estimates of parents and/or children change over time; and (iii) whether estimates are different for children treated with central nervous system (CNS) directed therapies.

PROCEDURE

Mothers, fathers, and children (initial age: 5-17, self-report: >10) from 258 families reported their perceived likelihood of the child developing "thinking/learning problems" on a visual analog scale (0-100%) at 2 months (T1), 1 year (T2), and 3 years (T3) following cancer diagnosis/relapse. Oncologists estimated the likelihood of NCLE at T1. Children were separated into groups based on CNS-directed treatment (n = 137; neurosurgery, intrathecal chemotherapy, and/or craniospinal radiation) or no CNS treatment.

RESULTS

Mother, father, and child estimates of risk for NCLE were similar to oncologists and to one another around diagnosis (T1). Although there were no significant mean differences, a considerable subset of family members either underestimated their child's risk for NCLE (>40%) or overestimated the risk for NCLE (20%) in comparison to oncologists. At T2 and T3, the estimates of mothers were significantly higher than children. Linear growth curves indicated that mothers' estimates for children with CNS-directed treatment significantly increased throughout the first 3 years of survivorship.

CONCLUSIONS

Considering that accurate understanding of NCLE is essential to seeking appropriate assessment and intervention, healthcare providers should focus on implementing family-based education early in treatment and throughout survivorship care.

Lack of Patient-Clinician Concordance in Cancer Patients: Its Relation With Patient Variables

CONTEXT

Patients with cancer are bothered by its diagnosis, treatment, and associated uncertainty. Lack of concordance (LOC) of patients' reporting of their symptoms and quality of life (QOL) with that of their clinicians has been observed in cancer care. However, information regarding the reporting of patients' bother due to aspects of cancer experience and their clinicians' assessment is lacking.

OBJECTIVES

The objective was to describe cancer patients' bother due to aspects of their disease experience and explore the concordance (LOC) or a lack thereof between patients' and clinicians' reporting of patients' bother and factors associated with it.

METHODS

Data from a prospective study of cancer patients' symptoms were analyzed. LOC was defined as any discrepancy between patient-clinician pairs in reporting patients' bother due to disease, cancer treatment, comorbidity, and side effects of symptom management. The relation of LOC to patients' QOL and distress was also explored.

RESULTS

Of the 2597 patients analyzed, a perfect concordance was observed in 37%-42%. Clinicians underestimated the severity of bother in 62%-76% of discordant cases. LOC was significantly associated with patient-reported distress and poor QOL. Referral for symptom management was associated with the clinician's rating of patients' bother, and LOC was associated with likelihood of poor compliance with recommendations for symptom management.

CONCLUSION

Majority of clinicians tended to underestimate cancer patients' bother, and this was associated with poor QOL of cancer patients and their distress. Future studies should examine the LOC and its correlates to confirm the results of this study.

Screening using the fifth vital sign in the electronic medical recording system

Purpose

To investigate the usefulness of screening for patient symptoms as the fifth vital sign using an electronic medical recording system.

Patients and methods

In the electronic medical recording system, all admitted patients received routine nurse-based assessment of discomfort (defined as any physical symptom) at every vital sign check regarding item 2 of the Support Team Assessment Schedule Japanese version (STAS-J). All cancer patients admitted to oncology units were screened at 1-week intervals. Screening-positive was defined when patients had a STAS-J score of 2 or more at least two times in a week. For all screening-positive patients, the palliative care team reviewed each patient's medical records, and provided written recommendations as needed. The primary outcomes were the proportion of screening-positive patient, and the proportion of patients deemed to need additional palliative treatment in the screening-positive patients.

Results

Of 2427 patients screened, 223 (9.1%; 95% confidence interval, 8-10%) met the screening-positive criterion. A total of 12 (5.4%; 95% confidence interval, 3-9%) of them were deemed to need additional palliative care, including six patients referred to the PCT within 1 week. In the remaining 211 screening-positive patients, 100 had received adequate palliative care, 68 had already been referred to the palliative care team and 43 had self-limiting transient discomfort.

Conclusion

This screening system was feasible but the majority of screening-positive patients did not require additional palliative care interventions.

A descriptive cross-sectional study of pain in patients with neuroendocrine tumors

OBJECTIVE

Neuroendocrine tumors (NET) are rare cancer forms, which are often disseminated at diagnosis. In cancer patients, pain is a feared symptom and reported in 30% of patients during treatment and in 70-90% with advanced disease. However, the extent and the severity of pain in patients with NET have never been investigated.

MATERIAL AND METHODS

We conducted a cross-sectional survey of 207 NET patients in the period March 2014 to March 2015 at our tertiary NET Center. We used a questionnaire to investigate the prevalence, severity and character of pain along with demographic, clinical and pathological data from medical records.

RESULTS

One hundred and 37 patients had undergone surgery (66%) of which 95 patients (69%) were considered cured and 112 patients had residual disease after surgery or comorbidity at diagnosis that contradicted surgery. Eighty-five patients (41%) reported any pain within the past week; the median pain intensity (numerical rating scale 0-10) was 5.0. Forty-seven (23%) of all included patients reported pain within the past week that developed in relation to NET or its treatment and 51% of these had pain descriptors consistent with neuropathic pain. The median level of plasma chromogranin A in patients with pain was significantly higher compared to patients without pain (p < .05).

CONCLUSIONS

A considerable proportion of our NET patients suffered from pain with moderate intensity and did not receive adequate pain treatment. Screening for pain should therefore be performed during NET follow-up visits and specific pain treatment should be considered.

Breathlessness and presentation to the emergency department: a survey and clinical record review

BACKGROUND

Breathlessness is a frequently occurring symptom of cardiorespiratory conditions and is a common cause of emergency department presentation. The aim of this study was to estimate the prevalence of acute-on-chronic breathlessness as a cause for presentation to the major emergencies area of the emergency department.

METHODS

A prospective patient self-report survey and clinical record review of consecutive attendees to the major emergencies area of the emergency department in a single tertiary hospital between 12/5/14 and 29/5/14 was conducted. Eligible patients were clinically stable and had mental capacity to provide data.

RESULTS

There were 2,041 presentations during the study period, of whom 1,345 (66%) were eligible. There was a 90% survey response rate (1,212/1,345); 424/1,212 (35%) self-reported breathlessness most days over the past month of whom 245 gave breathlessness as a reason for this presentation. Therefore, the prevalence of acute-on-chronic breathlessness as a reason to present to the major emergencies area was 20.2% (245/1,212, 95% CI 17.9% to 22.5%). During this period there were 4,692 major and minor presentations; breathlessness was therefore a cause of at least 5.2% (245/4,692, 95% CI 4.6 to 5.9%) of all emergency department presentations.

CONCLUSIONS

This study found that one in five ambulance presentations to the ED were due to acute-on-chronic breathlessness. Most patients had non-malignant underlying conditions, had experienced considerable breathlessness for an extended period, had discussed breathlessness with their GP and presented out of daytime hours. Others were often involved in their decision to present. This represents clinically significant burden for patients, their family carers and the emergency health services.

Association Between Symptom Burden and Time to Hospitalization, Nursing Home Placement, and Death Among the Chronically Ill Urban Homebound

CONTEXT

Homebound adults experience significant symptom burden.

OBJECTIVES

To examine demographic and clinical characteristics associated with high symptom burden in the homebound, and to examine associations between symptom burden and time to hospitalization, nursing home placement, and death.

METHODS

Three hundred eighteen patients newly enrolled in the Mount Sinai Visiting Doctors Program, an urban home-based primary care program, were studied. Patient sociodemographic characteristics, symptom burden (measured via the Edmonton Symptom Assessment Scale), and incidents of hospitalization, nursing home placement, and death were collected via medical chart review. Multivariate Cox proportional hazards models were used to analyze the effect of high symptom burden on time to first hospitalization, nursing home placement, and death.

RESULTS

Of the study sample, 45% had severe symptom burden (i.e., Edmonton Symptom Assessment Scale score >6 on at least one symptom). Patients with severe symptom burden were younger (82.0 vs. 85.5 years, P < 0.01), had more comorbid conditions (3.2 vs. 2.5 Charlson score, P < 0.01), higher prevalence of depression (43.4% vs. 12.0%, P < 0.01), lower prevalence of dementia (34.3% vs. 60.6%, P < 0.01), and used fewer hours of home health services (73.6 vs. 94.4 hours/wk, P < 0.01). Severe symptom burden was associated with a shorter time to first hospitalization (hazard ratio = 1.51, 95% CI 1.06-2.15) in adjusted models but had no association with time to nursing home placement or death.

CONCLUSION

The homebound with severe symptom burden represents a unique cohort of patients who are at increased risk of hospitalization. Tailored symptom management via home-based primary and palliative care programs may prevent unnecessary health care utilization in this population.

Pain Assessment--Can it be Done with a Computerised System? A Systematic Review and Meta-Analysis

Background: Mobile and web technologies are becoming increasingly used to support the treatment of chronic pain conditions. However, the subjectivity of pain perception makes its management and evaluation very difficult. Pain treatment requires a multi-dimensional approach (e.g., sensory, affective, cognitive) whence the evidence of technology effects across dimensions is lacking. This study aims to describe computerised monitoring systems and to suggest a methodology, based on statistical analysis, to evaluate their effects on pain assessment. Methods: We conducted a review of the English-language literature about computerised systems related to chronic pain complaints that included data collected via mobile devices or Internet, published since 2000 in three relevant bibliographical databases such as BioMed Central, PubMed Central and ScienceDirect. The extracted data include: objective and duration of the study, age and condition of the participants, and type of collected information (e.g., questionnaires, scales). Results: Sixty-two studies were included, encompassing 13,338 participants. A total of 50 (81%) studies related to mobile systems, and 12 (19%) related to web-based systems. Technology and pen-and-paper approaches presented equivalent outcomes related with pain intensity. Conclusions: The adoption of technology was revealed as accurate and feasible as pen-and-paper methods. The proposed assessment model based on data fusion combined with a qualitative assessment method was revealed to be suitable. Data integration raises several concerns and challenges to the design, development and application of monitoring systems applied to pain.

Effect of palliative care nurse champions on the quality of dying in the hospital according to bereaved relatives: A controlled before-and-after study

BACKGROUND

To improve the quality of end-of-life care, hospitals increasingly appoint palliative care nurse champions.

AIM

We investigated the effect of nurse champions on the quality of life during the last 3 days of life and the quality of dying as experienced by bereaved relatives.

DESIGN

A controlled before-and-after study (June 2009-July 2012). Halfway, in each of seven intervention wards, two nurse champions were appointed; 11 wards served as control wards. The quality of life during the last 3 days of life, quality of dying and multiple dimensions of quality of dying were compared before and after the introduction of nurse champions.

SETTING

In a university hospital, each death at non-intensive care units was followed up by an invitation to relatives (10-13 weeks later) to answer a questionnaire.

RESULTS

For the two periods, data were collected on 86 and 84 patients in intervention wards and on 108 and 118 patients in control wards (overall response: 52%). In the intervention wards, no differences were found in the quality of life during the last 3 days of life and the quality of dying scores: in both periods, median score for the quality of life during the last 3 days of life was 3.0 and for the quality of dying 7.0. No differences were found in multiple quality of dying dimensions. In control wards, the median quality of dying score was 7.0 pre-intervention and 6.0 post-intervention (p = 0.04). Other scores were comparable with those in intervention wards.

CONCLUSION

Performing a complex intervention study in palliative care proved to be feasible. This study showed no differences in the experiences of bereaved relatives after introduction of nurse champions. The complexity of palliative care in the hospital might require more intensive and longer training of nurse champions.

Psyche at the end of life: Psychiatric symptoms are prevalent in patients admitted to a palliative care unit

OBJECTIVE

Our aim was to evaluate the frequency and treatment of psychiatric symptoms in patients at palliative care units (PCUs).

METHOD

Patients admitted to one of five participating PCUs in Austria were included. The short version of the Patient Health Questionnaire (PHQ-D) was used to evaluate their mental health status. Pain intensity was rated on a numeric rating scale (NRS) from 0 to 10 by patients and physicians. Patients with a previously diagnosed psychiatric disorder were compared to those without or with newly diagnosed psychiatric symptoms, based on PHQ-D results. Pain and psychopharmacological medication were assessed. Opioid doses were converted into oral morphine equivalents (OMEs).

RESULTS

Some 68 patients were included. Previously undetected psychiatric symptoms were identified in 38% (26 of 68), preexisting psychiatric comorbidities were evident in 25% (17), and no psychiatric symptoms were observed in 37% (25). Patients with a preexisting psychiatric comorbidity received antidepressants and benzodiazepines significantly more often than patients without or with previously undetected psychiatric symptoms (p < 0.001). Patient and physician median NRS ratings of pain intensity correlated significantly (p = 0.001). Median NRS rating showed no significant difference between patients with preexisting, previously undetected, or without psychiatric symptoms. OMEs did not differ significantly between preexisting, without, or previously undetected psychiatric symptoms. Patients with undetected and preexisting psychiatric comorbidities had a greater impairment in their activities of daily living than patients without psychiatric symptoms (p = 0.003).

SIGNIFICANCE OF RESULTS

Undetected psychiatric comorbidities are common in patients receiving palliative care. Screening for psychiatric symptoms should be integrated into standard palliative care to optimize treatment and reduce the psychosocial burden of the disease.

Healthcare providers' accuracy in assessing patients' pain: A systematic review

OBJECTIVE

Healthcare providers satisfy an important role in providing appropriate care in the prevention and management of acute and chronic pain, highlighting the importance of providers' abilities to accurately assess patients' pain. We systematically reviewed the literature on healthcare providers' pain assessment accuracy.

METHODS

A systematic literature search was conducted in PubMed and PsycINFO to identify studies addressing providers' pain assessment accuracy, or studies that compared patients' self-report of pain with providers' assessment of pain.

RESULTS

60 studies met the inclusion criteria. Healthcare providers had moderate to good pain assessment accuracy. Physicians and nurses showed similar pain assessment accuracy. Differences in pain assessment accuracy were found according to providers' clinical experience, the timing of the pain assessment, vulnerable patient populations and patients' pain intensity.

CONCLUSION

Education and training aimed at improving providers with poor pain assessment accuracy is discussed especially in relation to those with limited clinical experience (<4 years) or a great deal of clinical experience (>10 years) and those providing care for vulnerable patient populations.

PRACTICE IMPLICATIONS

More research on characteristics that influence providers' pain assessment accuracy and trainings to improve pain assessment accuracy in medical and continuing education may improve pain treatment for patients.

The psychometric properties of cancer multisymptom assessment instruments: a clinical review

PURPOSE

Various instruments are used to assess both individual and multiple cancer symptoms. We evaluated the psychometric properties of cancer multisymptom assessment instruments.

METHODS

An Ovid MEDLINE search was done. All searches were limited to adults and in English. All instruments published from 2005 to 2014 (and with at least one validity test) were included. We excluded those who only reported content validity. Instruments were categorized by the three major types of symptom measurement scales employed as follows: visual analogue (VAS), verbal rating (VRS), and numerical rating (NRS) scales. They were then examined in two areas: (1) psychometric thoroughness (number of tests) and (2) psychometric strength of evidence (validity, reliability, generalizability). We also assigned an empirical global psychometric quality score (which combined the concepts of thoroughness and strength of evidence) to rank the instruments.

RESULTS

We analyzed 57 instruments (17 original, 40 modifications). They varied in types of scales used, symptom dimensions measured, and time frames evaluated. Of the 57, 10 used VAS, 28 VRS, and 19 NRS. The Edmonton Symptom Assessment System (ESAS), ESAS-Spanish, Hospital Anxiety and Depression Scale (HADS), Profile of Mood States (POMS), Symptom Distress Scale (SDS), M.D. Anderson Symptom Inventory (MDASI)-Russian, and MDASI-Taiwanese were the most comprehensively tested for validity and reliability. The ESAS, ESAS-Spanish, ASDS-2, Memorial Symptom Assessment Scale (MSAS)-SF, POMS, SDS, MDASI (and some translations), and MDASI-Heart Failure all showed good validity and reliability.

CONCLUSIONS

The MDASI appeared to be the best overall from a psychometric perspective. This was followed by the ESAS, ESAS-Spanish, POMS, SDS, and some MDASI translations. VRS-based instruments were most common. There was a wide range of psychometric rigor in validation. Consequently, meta-analysis was not possible. Most cancer multisymptom assessment instruments need further extensive validation to establish the excellent reliability and validity required for clinical utility and meaningful research.

A satisfaction survey on cancer pain management using a self-reporting pain assessment tool

BACKGROUND

Pain is one of the most common and distressing symptoms in patients with cancer, with a high prevalence of 90%. Appropriate pain assessment is very important in managing cancer pain.

OBJECTIVE

The aims of this study were to (1) evaluate patient satisfaction with pain control therapy using a self-reporting pain assessment tool, (2) explore the usefulness of a self-reporting assessment tool for patients and physicians, and (3) evaluate patient perception of pain management and opioid analgesics.

METHODS

We enrolled a total of 587 South Korean adult cancer patients hospitalized for five days or more. Pain assessment using a self-reporting pain assessment tool was performed by patients themselves from Day 1 to Day 5. The average pain intensity on a numeric rating scale (NRS) and the frequency of breakthrough pain between Day 1 and Day 5 were recorded with a self-reporting pain assessment tool. We evaluated patient satisfaction with pain control and the usefulness of a self-reporting pain assessment tool for patients and physicians on Day 5.

RESULTS

Among the 587 enrolled patients, 551, excluding 36 patients who violated inclusion criteria, were analyzed. The pain satisfaction rate was 79.5%, and only 6.2% of assessed patients had a negative pain management index (PMI). However, symmetry analysis for pain intensity between patient and physician showed low agreement (kappa=0.21). The patients with dissatisfaction for cancer pain control expressed negative attitudes toward using opioid analgesics and misconceptions regarding pain management. The satisfaction for using a self-reporting pain assessment tool was 79.2% in patients and 86.4% in physicians, respectively.

CONCLUSION

The use of a self-reporting pain assessment tool as a communication instrument provides an effective foundation for evaluating pain intensity in cancer pain management. A more individualized approach to patient education about pain management may improve patient outcome.

Assessing Health-Related Quality of Life in the Greek Home Health Care Setting

The study’s aim was to evaluate the agreement between patients’ and nurses’ ratings of patients’ health-related quality of life (HRQoL) and to identify factors that affect their level of agreement. A total of 150 home health care cancer patients from Greece and all nurses ( N = 5) who worked in the home health care units completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30 (EORTC QLQ-C30). Intraclass correlation coefficients varied between .45 and .87, indicating a moderate to excellent agreement. Median absolute difference on QLQ-C30 scores ranged from 0.00 to 16.66 points on the 0 to 100 scale. Cohen’s d varied between −0.15 and 0.59. Nurses’ higher educational level was associated with greater agreement ( p = .05). Nurses assessed lower the QoL of patients who were completely disabled than the patients themselves did ( p = .005). Our findings suggest that Greek home health care nurses estimate patients’ QoL in a reliable and valid way.

Comparison between patient-reported and clinician-observed symptoms in oncology

BACKGROUND

Symptom assessment is critical to understand the effectiveness of cancer treatment. Traditionally, clinicians have provided the information about cancer patients' symptoms. However, current research has shown that there are discrepancies on symptom assessment results reported by patients themselves and clinicians.

OBJECTIVE

The objective of this study was to present an integrative review on studies comparing patient-reported symptoms and clinician-observed symptoms in patients with a diagnosis of cancer.

METHODS

This was a review of published articles from PubMed, CINAHL, and the Cochrane Database, using the key words symptom or toxicity, and patient-reported, patient-rated, patient-assessed or patient-evaluated, which were combined with cancer, oncology, neoplasm, or tumor.

RESULTS

Clinicians have the propensity to underestimate the incidence, severity, or distress of symptoms experienced by cancer patients. These discrepancies appear to be consistently demonstrated over time and become even more apparent when symptoms are more severe and distressing to patients. In addition, patients report both symptom frequency and severity earlier than clinicians do; patients' symptom assessments are more predictable for daily health status, whereas clinicians' symptom measurements are more related to clinical outcomes.

CONCLUSIONS

Healthcare professionals must appreciate that there can be discordance between what they perceive and what patients experience and report. Further research needs to address methodological limitations and weaknesses of existing literature.

IMPLICATIONS FOR PRACTICE

Symptoms reported by patients themselves provide the necessary and different insight into cancer and its treatment, compared with those observed by clinicians. The use of patient-reported symptoms should be incorporated into routine clinical practice and not just research studies.

Impact of tracheostomy placement on anxiety in mechanically ventilated adult ICU patients

OBJECTIVE

To determine if self-reported anxiety levels decreased after tracheostomy placement in a sample of mechanically ventilated intensive care unit patients.

BACKGROUND

There is limited research regarding the impact of a tracheostomy on patients' anxiety. Elevated anxiety delays healing and contributes to long-term mental health complications.

METHODS

This was a secondary analysis of data from a large clinical trial conducted in urban Minnesota. Fifty-one of 116 patients received a tracheostomy. Anxiety scores were obtained daily using the Visual Analog Scale-Anxiety. Mixed model analysis was used to compare anxiety ratings pre- and post-tracheostomy.

RESULTS

There was no significant decrease in anxiety following tracheostomy after controlling for time and gender (all p > .16). Age was the only variable to impact anxiety levels: anxiety scores increased as age increased (p = .02).

CONCLUSIONS

Prospective studies are needed to more accurately assess the impact of tracheostomy placement on patient anxiety and salient outcomes.

Palliative care in the ICU: relief of pain, dyspnea, and thirst--a report from the IPAL-ICU Advisory Board

PURPOSE

Pain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU (IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management.

METHODS

We conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst.

RESULTS

Evidence-based methods to assess pain are the enlarged 0-10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0-10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs.

CONCLUSIONS

Relief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.