Regular use of a verbal pain scale improves the understanding of oncology inpatient pain intensity

Symptoms in Nepali Patients with Incurable Cancers: Implications for Interventions

Aim:

The poor quality and limited extent of palliative care services are of concern across the globe. To identify and measure patients' symptoms in Nepal, using a cell phone questionnaire platform, the investigators conducted and previously reported a cross-sectional study of Nepali adults. The unreported details of pain and other symptoms in these study data are here considered together with possible explanations and implications for interventions to lessen these symptoms.

Methods:

In a “snapshot” cross-sectional study of patients under regular care in three tertiary care Nepalese centers, we questioned 383 patients with incurable cancers using a 15-item cell phone-validated instrument to describe their major current symptoms and their intensities. The distributions of 11 symptom-level scores and the correlations between pain and different symptom scores were determined.

Results:

Thirty-eight percent of the population (142/383) had maximal pain scores which were in the severe range, and 25% (97/383) had such scores where they were evaluated. Patients reported moderate-to-severe tiredness 48% (183/383), depression 45% (172/383), anxiety 56% (217/383), poor appetite 64% (246/383), sleep quantity 64% (246/383), and sleep quality 64% (247/383).

Conclusions:

The significant fractions of patients with severe maximal and at-evaluation pain scores suggest that inadequate recognition and treatment of such symptoms characterized care of these regularly seen patients. The high fractions of patients with mood and sleep disturbances support this reading, suggesting helplessness and hopelessness, all addressable with psychosocial, environmental, and nontoxic, inexpensive pharmacological interventions.

Symptom Levels in Care-Seeking Bangladeshi and Nepalese Adults With Advanced Cancer

Purpose

Three-fourths of patients with advanced cancer are reported to suffer from pain. A primary barrier to provision of adequate symptom treatment is failure to appreciate the intensity of the symptoms patients are experiencing. Because data on Bangladeshi and Nepalese patients’ perceptions of their symptomatic status are limited, we sought such information using a cell phone questionnaire.

Methods

At tertiary care centers in Dhaka and Kathmandu, we recruited 640 and 383 adult patients, respectively, with incurable malignancy presenting for outpatient visits and instructed them for that single visit on one-time completion of a cell phone platform 15-item survey of questions about common cancer-associated symptoms and their magnitudes using Likert scales of 0 to 10. The questions were taken from the Edmonton Symptom Assessment System and the Brief Pain Inventory instruments.

Results

All but two Bangladeshi patients recruited agreed to study participation. Two-thirds of Bangladeshi patients reported usual pain levels ≥ 5, and 50% of Nepalese patients reported usual pain levels ≥ 4 (population differences significant at P < .001).

Conclusion

Bangladeshi and Nepalese adults with advanced cancer are comfortable with cell phone questionnaires about their symptoms and report high levels of pain. Greater attention to the suffering of these patients is warranted.

A randomized trial of weekly symptom telemonitoring in advanced lung cancer

CONTEXT

Lung cancer patients experience multiple, simultaneous symptoms related to their disease and treatment that impair functioning and health-related quality of life (HRQL). Computer technology can reduce barriers to nonsystematic, infrequent symptom assessment and potentially contribute to improved patient care.

OBJECTIVES

To evaluate the efficacy of technology-based symptom monitoring and reporting in reducing symptom burden in patients with advanced lung cancer.

METHODS

This was a prospective, multisite, randomized controlled trial. Two hundred fifty-three patients were enrolled at three sites and randomized to monitoring and reporting (MR) or monitoring alone (MA). Patients completed questionnaires at baseline, 3, 6, 9, and 12 weeks and symptom surveys via interactive voice response weekly for 12 weeks. MR patients' clinically significant symptom scores generated an e-mail alert to the site nurse for management. The primary endpoint was overall symptom burden; secondary endpoints included HRQL, treatment satisfaction, symptom management barriers, and self-efficacy.

RESULTS

This randomized controlled trial failed to demonstrate efficacy of symptom monitoring and reporting in reducing symptom burden compared with monitoring alone in lung cancer. HRQL declined over 12 weeks in both groups (P < 0.006 to P < 0.025); at week 12, treatment satisfaction was higher in MA than MR patients (P < 0.012, P < 0.027). Adherence to weekly calls was good (82%) and patient satisfaction was high.

CONCLUSION

Feasibility of using a technology-based system for systematic symptom monitoring in advanced lung cancer patients was demonstrated. Future research should focus on identifying patients most likely to benefit and other patient, provider, and health system factors likely to contribute to the system's success.

A brief symptom index for advanced lung cancer

BACKGROUND

Advanced lung cancer is often symptomatic; thus the goals of treatment include maintenance of function and palliation of symptoms. Symptom management requires accurate systematic symptom assessment. This study, which focused on lung cancer, is part of a larger study to obtain patient input that, in combination with previously obtained physician and nurse input, was used to develop symptom indexes for 11 advanced cancers.

PARTICIPANTS AND METHODS

Fifty patients with advanced lung cancer were recruited from National Comprehensive Cancer Network (NCCN) member institutions and community support agencies; 10 physician experts were recruited from NCCN institutions. Patients reported symptoms associated with their disease in open-ended format and then completed a checklist of symptoms, rating their 5 most important symptoms. Patient and provider ratings of symptom importance were tabulated to construct the NCCN-Functional Assessment of Cancer Therapy (FACT) Lung Symptom Index-17 (NFLSI-17). Patients also completed the Functional Assessment of Cancer Therapy-Lung (FACT-L), which was used to preliminarily validate the NFLSI-17.

RESULTS

Based on combined patient, physician, and nurse input, the NFLSI-17 is composed of 17 priority symptoms, 11 that are disease related, 3 that are treatment related, and 3 that are related to general functional well-being (FWB). Data on 15 of 17 NFLSI-17 symptoms showed good internal consistency (alpha = 0.74) and strong association with the FACT-L total and most subscale scores (r = 0.42-0.92). Both the NFLSI-15 (F(2,47) = 4.46; P = .017) and the NFLSI-disease related subscale (DRS) (F(2,47) = 5.56; P = .007) significantly discriminated patients among performance status groups.

CONCLUSION

The NFLSI-17 reflects the most important patient- and clinician-rated targets of chemotherapy for advanced lung cancer; further validation will follow.

Adherence to medication guideline criteria in cancer pain management

The medication-assessment tool for cancer pain management (MAT-CP) is a novel tool for measuring the quality of drug use in chronic pain management in relation to guideline standards. MAT-CP has recently been revised and validated for use in the U.K. clinical setting. This article presents a measure of the adherence of current practice to specific cancer pain guideline criteria in two palliative care settings. Adult patients with malignant disease experiencing pain and/or receiving analgesics were identified by clinical pharmacists at two hospitals and five hospices in Scotland, United Kingdom. The MAT-CP was applied to data extracted from case notes. Results were quantified in terms of applicability and adherence to guideline criteria and the presence of insufficient data. MAT-CP was applied to 192 cancer patients experiencing pain; 103 (54%) were males and the mean (standard deviation) age was 68.5 (13.0) years. Overall guideline adherence was 75% (confidence interval [CI]: 74%, 77%; n=3460 applicable criteria). Low adherence (<50%) was seen for nine criteria, whereas 21 criteria were considered high-adherence criteria (>75%). Overall adherences for 56 (29%) hospitalized patients and 136 (71%) hospice patients were 65% (CI: 62%, 68%) and 79% (CI: 78%, 81%), respectively. Although good overall guideline adherence was found, there were gaps in both the hospice and hospital palliative care settings in the implementation of certain treatment recommendations, particularly in relation to pain assessment. The application of the tool has highlighted issues for feedback to health care providers and for further study.

Quality of life in chronic illness: children, parents and paediatricians have different, but stable perceptions

AIM

Quality of life assessments can be helpful to estimate the well-being of chronically ill children. The aim of this study was to investigate the differences in perception of health-related quality of life (HRQoL) among children, parents and paediatricians at the time of diagnosis and after initial treatment in four chronic diseases.

METHODS

HRQoL was assessed with the Health Utilities Index mark 3 (HUI3). The HUI3 consists of eight attributes (vision, hearing, speech, ambulation, dexterity, emotion, cognition and pain).

RESULTS

Nineteen paediatricians and 60 patients (aged 10-17 years) and their parents with newly diagnosed acute lymphoblastic leukaemia, juvenile idiopathic arthritis, asthma or with cystic fibrosis admitted for pneumonia participated in the study. Health and well-being perceptions were clearly different among paediatricians, parents and patients, both at diagnosis and after initial treatment. Perception differences were more prominent in the subjective attributes, emotion and pain. The agreement for these attributes was 23% and 5%, respectively. Paediatricians assessed the patients to have less pain than the patients and parents did. The reverse was true for the attribute emotion. At follow-up, the agreement was higher for the attributes ambulation and pain.

CONCLUSION

At the onset of a chronic disease and after initial treatment, paediatricians, parents and children have different perceptions of the child's quality of life, particularly as to the subjective attributes pain and emotion. In view of these differences in perception among patients, their caregivers and paediatricians, this study suggests that whenever possible, multi-respondent assessment of HRQoL should be considered.

Nonmalignant Chronic Pain Evaluation in the Turkish Population as Measured by the McGill Pain Questionnaire

BACKGROUND

The purpose of this study was to explore how Turkish nonmalignant pain patients described their pain and how the language of pain used by Turkish patients compares to the language found in common pain assessment tools.

OBJECTIVE

Pain is influenced by a combination of ethnic, cultural, psychological, and social variants. In the Turkish language, six words are central to pain-like experiences: ağri (pain), aci (suffering), sizi (aching), sanci (colic), istirap (agony), and dert (torture). We assessed discriminant characteristics of the Turkish translation of the McGill Pain Questionnaire (MPQ).

METHODS

Chronic clinical nonmalignant pain patients (n = 319, 35.7% males, 64.3% females) were questioned with the Turkish translation of the MPQ. Pain symptoms were categorized as headache (33.5%), musculoskeletal pain (33.2%), visceral pain (18.8%), and low back pain (14.5%).

RESULTS

The visceral pain group had the highest mean value in the evaluative subscale (2.6 +/- 1.9). Descriptions used for sensory subscale included throbbing, sharp, aching, and tingling, while affective subscale words included tiring, suffocating, sickening, cruel, and wretched. In all pain groups, frequently chosen words for the miscellaneous subscale were nagging and penetrating.

CONCLUSION

Pain descriptors were identified for each type of pain. This is, to our knowledge, the first assessment of the Turkish translation of the MPQ in nonmalignant pain patients.

Twice-daily pain monitoring as standard clinical practice for inpatients at a medical oncology unit: a descriptive study

BACKGROUND

Very limited experiences have explored the use of pain intensity monitoring in everyday clinical practice at a medical oncology inpatient unit.

METHODS

The program 'Pain-Free Hospital,' including a training course for nurses and the recording every 12 h of a visual analog scale (VAS) rating in all the patients admitted to the inpatients' ward independently of their disease stage, was activated in 2002. An audit on the clinical charts of patients admitted for the first time in the first semester of 2003 was carried out in order to ascertain the applicability of the procedure and its congruence with patients' clinical status.

RESULTS

The VAS rating was reported in 211 out of 223 (94.6%) clinical charts. At entry, 60 out of 211 (28.4%) patients presented VAS>or=1, 21 (35%) of whom were not taking any analgesics. The mean VAS score>or=1 was 3.4. No statistically significant difference emerged in the distribution of VAS rating as regards disease extension, presence or absence of bone metastases and performance status.

CONCLUSIONS

The systematic monitoring of VAS by nurses at a medical oncology inpatients' ward is feasible with a good patient compliance. The reliability of the procedure in terms of guiding the analgesic treatment has yet to be demonstrated.

Diagnosis, management, and evaluation of chemotherapy-induced peripheral neuropathy

Peripheral neuropathy induced by cancer chemotherapy represents a large unmet need for patients due to the absence of treatment that can prevent or mitigate this common clinical problem. Chemotherapy-induced peripheral neuropathy (CIPN) diagnosis and management is further compounded by the lack of reliable and standardized means to diagnose and monitor patients who are at risk for, or who are symptomatic from, this complication of treatment. The pathogenesis and pathophysiology of CIPN are not fully elucidated, but there is increasing evidence of damage or interference with tubulin function. The diagnosis of CIPN may present a diagnostic dilemma due to the large number of potential toxic etiologies and conditions, which may mimic some of the clinical features; the diagnosis must be approached with care in such patients. The incidence and severity of CIPN is commonly under-reported by physicians as compared with patients. The development of new and reliable methods for the assessment of CIPN as well as safe and effective treatments to prevent this complication of treatment would represent important medical advancements for cancer patients.

Schmerzerfassung bei invasiven diagnostischen Prozeduren

BACKGROUND AND OBJECTIVE

Pain measurement during diagnostic procedures is an accepted prerequisite for appropriate therapy. In this study, the agreement between rankings of pain intensity on a numerical and a verbal rating scale was analyzed.

METHODS

Patients attending a haematological outpatient clinic who underwent bone marrow puncture were requested to assess pain intensity perceived during the procedure on a elen-point numerical and a six-point verbal rating scale.

RESULTS

Analysis of patients' pain ratings in 263 bone marrow punctures showed a very good correlation between numerical and verbal rating scale (Spearman correlation coefficient 0,86). By means of a transfer instruction categories of the verbal rating scale were assigned to figures of the numerical rating scale (0 - no pain, 1 or 2 - mild p., 3, 4 or 5 moderate p., 6 or 7 severe p., 8, 9 or 10 - very severe and worst possible pain). The resulting transfer table showed a good agreement with a weighted kappa of 0.72 (95% confidence interval: 0.66-0.79).

CONCLUSION

Both scales can be employed efficiently for pain assessment during diagnostic procedures. Verbal categories can be assigned to numerical values and vice versa numerical values to verbal categories. However, in view of the inter-individual variations it appears appropriate to re-assure pain perception with each patient in order to avoid over- or undertreatment.

A difference in perception of quality of life in chronically ill children was found between parents and pediatricians

BACKGROUND AND OBJECTIVES

Quality of life measurements can help to estimate the well-being of chronically ill patients, and disclose discrepancies in perception between physicians and patients that might otherwise interfere with the effectiveness of treatment. The objective was to investigate the differences in perception of quality of life between parents of chronically ill children and pediatricians.

METHODS

A cross-sectional study was conducted in four tertiary pediatric care centers in The Netherlands. The Health Utilities Index mark 3 (HUI3) was used by 37 pediatricians and 279 parents of patients (children aged 1 to 17 years) with cystic fibrosis admitted either in daycare or for a pneumonia, or patients with newly diagnosed acute lymphoblastic leukemia, juvenile idiopathic arthritis, or asthma.

RESULTS

Differences in perception of quality of life between parents and pediatricians appeared to be dependent of the disease. In patients with acute lymphoblastic leukemia (OR 7.4; [95% CI 2.88-18.97], juvenile idiopathic arthritis (4.7; [95% CI 2.00-11.22]), and asthma (2.3; [95% CI 1.13-4.69]) a difference in perception was more likely to occur than in patients with cystic fibrosis admitted in daycare.

CONCLUSION

At the onset of a chronic disease, the parents of pediatric patients may be misunderstood by health care professionals, especially in subjective attributes. Assessment of quality of life may contribute to better understanding between pediatricians and parents, and thus may even enhance compliance and treatment effects.

Quality of life in chronic illness: perceptions of parents and paediatricians

AIMS

To investigate the differences in perception of quality of life between parents of chronically ill children and paediatricians at diagnosis and follow up. Quality of life was assessed using the (HUI3).

METHODS

Longitudinal study (July 1999-January 2002) of 37 paediatricians and 181 parents of patients (children aged 1-17 years) with cystic fibrosis admitted for a pneumonia or patients with newly diagnosed acute lymphatic leukaemia, juvenile idiopathic arthritis, or asthma. Main outcome measure was percentage agreement on the attributes of the HUI3 between parents and paediatricians.

RESULTS

Differences in perception of health and wellbeing between paediatricians and parents of children with a chronic disease were found, not only at diagnosis but also after a period of follow up. Differences were particularly clear in the subjective attributes emotion (range of agreement 28-68%) and pain/discomfort (range of agreement 11-33%). In all patient groups, at baseline and follow up, the paediatrician assessed the patient to have less pain/discomfort in comparison to the parents. Despite a prolonged patient- paediatrician relationship, differences at follow up did not decrease compared to baseline.

CONCLUSION

At the onset of a chronic disease, but also after a period of follow up, quality of life of paediatric patients may be misunderstood by healthcare professionals, especially in the subjective attributes. Systematic assessment of quality of life may contribute to better understanding between physicians and parents.

Improving the quality of life of patients with prostate carcinoma

BACKGROUND

Treatments for clinically localized prostate carcinoma are accompanied by sexual, urinary, and bowel dysfunction and other sequelae that can result in significant distress and reduced well being. Methods capable of improving quality of life are needed that can be integrated into clinical practice. To address this need, a nurse-driven, cancer care intervention was developed and tested.

METHODS

Within 6 weeks after completing treatment, 99 patients, along with their partners, were enrolled into a prospective, controlled trial and were randomized to receive the cancer care intervention or to receive standard care. Participants in the intervention arm met once each month for 6 months with an oncology nurse intervenor, who helped patients identify their quality-of-life needs using an interactive computer program. The intervener then provided education and support tailored to participants' needs. Primary outcome variables included 1) disease-specific quality of life, including sexual, urinary, and bowel outcomes and cancer worry; 2) depression; 3) dyadic adjustment; and 4) general quality of life. Outcomes data were collected prior to randomization and again at 4 months, 7 months, and 12 months posttreatment.

RESULTS

Patients in the intervention arm experienced long-term improvements in quality-of-life outcomes related to sexual functioning and cancer worry compared with patients who received standard care. Baseline depression moderated the impact of the intervention on several other quality-of-life outcomes.

CONCLUSIONS

The findings of the current study indicated that a computer-assisted, nurse-driven intervention was capable of providing durable improvements in the quality of life of men who underwent treatment for clinically localized prostate carcinoma.

Patients' values and clinical substituted judgments: The case of localized prostate cancer

The authors examined agreement between patients' utilities and importance rankings and clinicians' judgments of these assessments using a multiattribute model representing 6 aspects of health states potentially associated with localized prostate cancer. Patients were interviewed individually shortly after diagnosis and at a follow-up visit to obtain time-tradeoff utilities for 4 health states, including current health, and importance ranks of the 6 attributes. Their clinicians independently provided views of what utilities and importance ranks would be in the patient's best interest. Using patient-clinician pairs as the unit of analysis, the authors discovered that only about 50% of the correlations across 4 health states were high enough (.80) to be acceptable for clinical use for substituted judgment. Their conclusion: Clinicians should recognize that their judgments of the utility of health states associated with localized prostate cancer may not correspond closely with those of the patient.

Impact of radiation oncology practice on pain: A cross-sectional survey

PURPOSE

A cross-sectional study was performed to evaluate the prevalence of pain in our radiotherapy (RT) department. The impact of RT practice on pain and pain management were analyzed.

METHODS AND MATERIALS

Of 126 patients, 93 (73.8%) completed the questionnaire proposed in this survey. It was designed to assess the proportion of patients experiencing pain in the department, the impact of RT practice on pain, and patients' estimate of the quality of management of their pain by the medical staff. Pain intensity and patient satisfaction were assessed using an 11-point numeric rating scale.

RESULTS

Of the 93 patients, 66 experienced pain during RT, 13 of whom were totally relieved by analgesic treatment. The mean pain intensity was 3.9 (SD 2.3). A total of 26 patients had a numeric rating >/=4, indicating that their pain was not sufficiently treated. The objective length of waiting time for a session, transportation, and mobilization for session positioning worsened the pain of a substantial proportion of patients. A total of 56% of patients had a favorable opinion about pain management in our department. A high percentage (72.2%) of patients found that the time spent by the medical staff for pain management was inadequate, and 54.5% believed that the psychological support they received was insufficient. Personnel in the RT department remained the primary source of information regarding pain control. However, 17.5% of patients did not report their pain or talked about it to non-health care professionals.

CONCLUSION

The prevalence of pain was high in the department. The specific practice of RT worsened pain and nearly one-half of patients were not satisfied with its management. The necessity for medical staff to be more available was highlighted by patients.

Pain intensity assessment by bedside nurses and palliative care consultants: a retrospective study

OBJECTIVE

To evaluate the specificity, sensitivity, and accuracy of pain intensity assessments (0-10) conducted by registered nurses (RN) and clinical nurse assistants (CAN) as compared to those conducted by the palliative care consultant (PCC).

PATIENTS AND METHODS

We performed a retrospective review of charts of patients who had received palliative care consult between April 2002 and August 2002. Data on patient demographic, date of palliative care consult, and date and intensity of pain assessment were collected. A numerical rating scale from 0 (no pain) to 10 (worst pain) was used to assess pain intensity. The data were included for analysis if the pain intensity assessment was performed during the same shift by all three care providers (RN, CNA, and PCC).

RESULTS

Forty-one charts were found to include a complete pain assessment performed by the RN, CNA, and PCC. The agreement of pain intensity between the PCC and both the RN and CNA was poor. For a diagnosis of moderate-to-severe pain, the RN's intensity assessment had a specificity of 90% but a sensitivity of 45%, and the CNA's intensity assessment had a specificity of 100% but a sensitivity of only 30%. The Spearman correlation coefficient between the intensity assessments performed by the PCC and the RN was 0.56 (p=0.00) and between those by the PCC and the CNA 0.22 (p=0.15).

CONCLUSION

Lack of agreement between pain intensity assessments performed by the PCC and bedside nurse suggests possible inconsistencies in the way the assessments were performed. Better education on how to perform standard pain intensity assessment is needed.

Agreement between prostate cancer patients and their clinicians about utilities and attribute importance

PURPOSE

To examine the agreement between prostate cancer patients' utilities for selected health states and their rankings of the importance of six attributes of the health states and the clinicians' judgements of what would be in the patients' best interests.

METHOD

Patients with newly diagnosed localized prostate cancer individually completed a time trade-off utility assessment shortly after being diagnosed. The health states evaluated were constructed from a multi-attribute utility model that incorporated six aspects of living with the disease and outcomes of treatment. Each patient assessed his current health state and three hypothetical states that might occur in the future, and provided rankings of the importance of the six attributes. The clinicians caring for each patient independently provided their views of what utilities and importance rankings would be in the patient's best interest.

RESULTS

The across-participant correlations between patients' and clinicians' utilities were very low and not statistically significant. Across-participant correlations between patient and clinician importance rankings for the six attributes were also low. Across-health state and across-attribute correlations between utilities or importance rankings were highly variable across patient-clinician pairs.

CONCLUSION

In the clinical settings studied, there is not a strong relationship between valuations of current and possible future health states by patients with newly diagnosed prostate cancer and their clinicians. Implications of these results for substituted judgement, when clinicians advise their patients or recommend a treatment strategy, are discussed.

Interventions to overcome clinician- and patient-related barriers to pain management

Barriers to optimal cancer pain management exist among clinicians and patients, and within the healthcare system. This article focuses on clinician- and patient-related barriers and the interventions that have been tested to overcome them. Although individual studies have shown promise in improving patient outcomes, overall the studies do not provide clear answers to guide practice. Further research is required to determine what components of educational interventions are necessary to facilitate optimal cancer pain management.

The psychometric properties of Chinese pain intensity verbal rating scale

BACKGROUND

This study investigates the validity and reliability of the Chinese pain intensity verbal rating scale (C-PIVRS).

METHODS

This is a correlational comparative study. Fifty Chinese adults were recruited by convenience. A pain source generator (precision pain source, PPS-3) was used to produce four levels of mechanical pain stimuli (350, 550, 750 and 950 g). The pain stimuli were applied to subjects' interphalangeal joints in random sequences to stimulate sensation of pain. The subjects then rated their pain intensity using both the C-PIVRS and the visual analog scale (VAS) for each stimulus. The pain scores obtained from the C-PIVRS were compared with the VAS for satisfactory level of reliability and validity. Test and re-test were applied to verify consistency between the two pain scales.

RESULTS

The test/re-test correlation coefficients between the two pain scales were r = 0.92 (P < 0.001) and r = 0.91 (P < 0.001), respectively. This showed a good positive correlation. The intra-class correlation (ICC) ranged from 0.78 to 0.90, which indicated good reliability. In the factor analysis, a single factor emerged in each analysis. The first eigen values of each matrix were 3.42, 3.24, 3.17 and 3.29 for each level of pain stimulation. This indicated that both pain scales were assessing the same pain dimension.

CONCLUSIONS

The two pain scales have a comparable level of reliability and validity for assessing pain intensity in Chinese adults.

The Hawthorne effect in the assessment of pain by house staff

Internal medicine residents are one component of the healthcare delivery team in the hospital setting. Their ability to assess and treat pain should be considered in quality improvement efforts. We surveyed our residents, using a 0 to 10 scale to determine how well they assessed their patients' level of pain. We then asked half of these residents to write down their patients' pain score as a fifth vital sign in the medical record. We repeated the house staff survey three weeks later. The residents improved their assessment as a whole, with the nonintervention group faring better on the follow-up surveys. We believe that the residents' improvement can be attributed to the Hawthorne effect, in which a group that is singled out for special study or consideration has its performance positively affected. The residents' ability to accurately rate patients with moderate and severe pain is still an area for further development. Improvements in our palliative care curriculum have been implemented to enhance our residents' education and performance in this area.

Usability of a computerized PAINReportIt in the general public with pain and people with cancer pain

We examined usability (completion time, acceptability, and completeness of information) of a computerized format for pain assessment, PAINReportIt. PAINReportIt is the first interactive software extension of the 1970 McGill Pain Questionnaire. Two hundred thirteen patients experiencing pain were recruited for this descriptive, comparative study. Subjects used a Microsoft Windows 95/98 personal computer with a touch-screen to complete 1) PAINReportIt, 2) demographic, and 3) acceptability questions. Qualitative and quantitative data from the study support PAINReportIt as a feasible method for patients to self-report their pain. Patients completed the tool in less than 18 minutes on average, answered all sections, and scored it high regarding acceptability. Improved directions and practice screens would likely improve patients' independence in completing PAINReportIt, which would free clinicians to focus direct communication on more complex pain issues.

Information exchange in oncology outpatient clinics: source, valence and uncertainty

A large literature of doctor-patient communication exists, yet little is known about how symptom information is communicated in cancer care. This qualitative study explores the exchange of symptom and clinical information between cancer patients and oncologists in outpatient clinics of a regional teaching hospital. Verbatim transcripts of consultations between 14 doctors and 43 post-treatment follow-up patients from eight consultants' clinics were subjected to analytic induction and microinteractional analysis techniques. Findings from these analyses indicate that information about patients was accorded varying relevance by doctors depending upon its source, valence and certainty. Doctors' requests for information was contingent upon certainty of clinical information. Symptom information was elicited from patients only when clinical information with high certainty was unavailable. If negative patient information was volunteered, it was not addressed when positive clinical information was present and cancer treatment was not indicated. It appears that information in outpatient oncology consultations is organised according to a hierarchy and is used to make treatment decisions and not primarily for symptom management.

Symptom assessment in cancer patients

Patients with cancer suffer from a multitude of symptoms. Effective treatment strategies are available for a number of the common symptoms. A major reason for inadequate symptom relief is lack of effective symptom assessment. Accurate assessment of symptoms is necessary before any treatment can be undertaken. Although there are many complexities involved in the assessment of symptoms, simple, effective tools are available for identification and scoring of symptoms in clinical practice. This review describes recent advances in the study of symptom assessment in cancer patients. Several common symptoms are presented individually, followed by an overview of efforts addressing the assessment of multiple symptoms. Also, new tools in the evaluation of symptoms, including computer-based questionnaires, are discussed.

Testing an instrument measuring Greek nurses' knowledge and attitudes regarding pain

This pretest-post-test study was conducted to test the construct validity, test-retest reliability, and internal consistency of the Nurses' Knowledge and Attitudes Survey Regarding Pain with Greek nurses. Forty-six registered nurses were randomly assigned to an expert or nonexpert group. The expert group viewed 4 translated educational videotapes about pain management. The nonexpert group received no pain education. All of the nurses completed a pretest and a post-test using a Greek translation of the Nurses' Knowledge and Attitudes Survey Regarding Pain, with a time delay of 8 to 12 days between testing. The expert nurses learned significantly more than the nonexpert nurses from pretest to post-test, M = 9.0 and M = 1.5 items, respectively. Expert and nonexpert nurses correctly answered 51.5% and 43.3% of the pretest and 74.6% and 47.2% of the post-test questions, respectively. Test-retest reliability for the 28 nonexpert nurses was r = 0.68, P < .001. Cronbach's alpha for the entire sample was 0.88 (n = 30) at the post-test. These results contribute to the validity and reliability of the Greek version of the Nurses' Knowledge and Attitudes Survey Regarding Pain and provide the basis for phase II of the study, which will use the Nurses' Knowledge and Attitudes Survey Regarding Pain to examine the state of pain management in an anticancer facility in Greece.

From hospital to home care: a randomized controlled trial of a Pain Education Programme for cancer patients with chronic pain

AIM OF THE STUDY

To investigate the role of district nurses in the care of cancer patients with chronic pain at home, as well as the effects of a Pain Education Programme for patients and their district nurses. The Pain Education Programme consisted of a tailored multi-method approach in which they were educated about pain, instructed how to report pain, and how to contact health care providers.

BACKGROUND

No educational programs for patients in pain have been studied in outpatients nor integrated with the home care provided.

DESIGN AND METHODS

One hundred and four patients and their 115 district nurses were enrolled in a prospective, longitudinal, randomized controlled study. The primary outcome of interest was type of care provided by district nurses, satisfaction with the pain treatment, and agreement in estimating patients' pain intensity.

RESULTS

Results showed that continuity of care was poor as only 36% of the district nurses were informed about patients' pain by hospital nurses. Pain was rarely the reason for referring the patient to district nursing after discharge. Although pain control was not a main reason for district nurses to visit a patient, pain was a subject for discussion in 76% of visits. Besides discussing the pain problem with patients, district nurses provided only a few pain-relieving interventions. District nurses randomized to the intervention group significantly better estimated patients' pain intensity, and were more satisfied about patients' pain treatment, but no differences were found in their assessment of patients' pain relief.

CONCLUSIONS

These findings suggest a significant but moderate effect of the Pain Education Programme, with district nurses only playing a minor role in the treatment of cancer pain.

Spouse ratings of quality of life in patients with metastatic prostate cancer of lower socioeconomic status: an assessment of feasibility, reliability, and validity

OBJECTIVES

To examine the reliability and validity of spousal assessments by evaluating the collateral quality-of-life (QOL) ratings of patients of lower socioeconomic status with metastatic prostate cancer because collateral ratings provide supplemental information when advanced cancer limits patient self-report.

METHODS

Patients with Stage D2 prostate cancer (n = 36) of lower socioeconomic status completed validated QOL instruments (Functional Assessment of Cancer Therapy-General [FACT-G], European Organization for Research and Treatment of Cancer-Quality of Life-30, and Quality of Life Index). Spouses completed a modified FACT-G, and physicians rated performance status using Karnofsky's scale.

RESULTS

The internal consistency reliability was moderate to high for patient ratings on all FACT-G subscales and for spousal ratings on the modified FACT-G physical, functional, and emotional subscales. The spouses' ratings of the patients on the social and doctor relationship subscales were below the accepted criterion for a measure's use in group comparisons. The comparisons of the mean values of the FACT-G revealed agreement between patients and spouses, except that the spouses rated the patients as having poorer emotional function than did the patients. The intraclass correlations were moderate to high for the functional and emotional subscales and were low, but significant, for the physical and social subscales. The patient and spouse FACT-G ratings correlated with the patient ratings and physician ratings across the instruments for the functional and physical domains (r = 0.48 to 0.77, for patients; r = 0.31 to 0.70, for spouses), with less consistent relationships for the social and emotional domains.

CONCLUSIONS

The collateral QOL assessments from spouses are potentially useful in assessing the functional status in patients of lower socioeconomic status with metastatic prostate cancer. For subjective domains, such as the social domain, direct patient assessments are needed.

Feasibility of quantitative pain assessment in outpatient oncology practice

PURPOSE

Although physicians view failure to assess pain systematically as the most important barrier to outpatient cancer pain management, little is known about pain assessment in this setting. We sought to determine whether pain is routinely assessed and whether routine quantitative pain assessment is feasible in a busy outpatient oncology practice.

PATIENTS AND METHODS

We conducted a pre- and postintervention chart review of 520 randomly selected medical and radiation oncology patient visits at a community hospital-based private outpatient practice. The intervention consisted of training health assistants (HAs) to measure and document patient pain scores by using a visual analog scale. The main outcome measures included HA documentation of patient pain scores, quantitative and qualitative mention of pain in the physician note, and analgesic treatment before and after the intervention.

RESULTS

After the intervention, HA documentation of pain scores increased from 1% to 75.6% (P < .0001). Physician documentation increased from 0% to 4.8% for quantitative documentation (P < .01), and from 60.0% to 68.3% for qualitative documentation (not significant). Of all the patients, 23.1% reported significant pain. Subgroups with greater pain included patients actively receiving radiation treatments and patients with lung cancer. Of patients with significant pain, 28.2% had no mention of pain in the physician note and 47.9% had no documented analgesic treatment.

CONCLUSION

Quantitative pain assessment was virtually absent before our intervention but easily implemented and sustained in a busy outpatient oncology practice. Pain score collection identified a high prevalence of pain, patient subgroups at risk for pain, and a significant proportion of patients with pain that was neither evaluated nor treated by their oncologists.

A pain monitoring program for nurses: effects on communication, assessment and documentation of patients' pain

Nurses need to be informed about the patient's pain to be able to take appropriate measures to alleviate pain. However, communication, assessment, and documentation of pain by nurses is often a problemfor hospitalized patients. In this study we aimed to overcome the main barriers by developing, implementing, and evaluating a Pain Monitoring Program (PMP) for nurses. The PMP consists of two components: educating nurses about pain, pain assessment and pain management; and implementing daily pain assessment by means of a numeric rating scale. We describe the effects of the PMP on communication about pain between nurses and patients and between physicians and patients, agreement between patients 'pain intensity and nurses estimations of patients'pain intensity, and documentation about pain in the nursing records. Factors that might influence communication, assessment, and documentation are also discussed. The effects of the PMP were measured in a quasi-experimental design with a nonequivalent control group. In total, 703 patients participated: 358 patients in the control group and 345 in the intervention group. Results of the control group showed that communication about pain between nurses and patients, agreement between patients' and nurses pain ratings, and documentation about pain in nursing records, remain inadequate. Patients'pain intensity and age were related to communication, assessment, and documentation. Communication and documentation is better in patients with moderate to severe pain than in patients with mild pain, and assessment is better in patients with mild pain. Older patients communicate less with nurses and physicians about pain, and nurses document less about pain in nursing recordsfor older patients compared with younger patients. The PMPproved to be effective in improving nurses'assessment of patients 'pain and documentation about pain in nursing records. Patients' pain intensity and care setting were related to the efficacy of the PMP Communication about pain between patients and nurses, and between patients and physicians did not improve as a result of the PAIP Based on this study it can be concluded that in using a simple method such as the numeric rating scale, together with an education program, attention is focused in a systematic way on patients'pain complaints and creates a common language between patients and nurses. Because the PMP proved effective in a heterogenous population in multiple care settings, it is recommended to implement the PMP in nursing practice.

Nurses' personal opinions about patients' pain and their effect on recorded assessments and titration of opioid doses

In many clinical settings, nurses have a vital role in pain assessment and titration of opioid doses. Surveys of nurses have revealed knowledge deficits in these areas that are thought to contribute to under-treatment of pain. The present study surveys nurses' decisions about assessment and treatment of pain in 2 patient situations and confirms that nurses continue to undertreat severe pain. As shown in previous studies, nurses may be more influenced by the patient's behavior than the patient's self-report of pain, especially in relation to decisions about opioid titration. Nurses are less likely to increase a previously safe but ineffective dose of opioid for a smiling patient than a grimacing patient. Survey results reveal a tendency for nurses' personal opinions about the patients' pain, rather than their recorded assessments, to influence choice of opioid dose and to contribute to undertreatment of pain.

The 'right kind' of pain: talking about symptoms in outpatient oncology consultations

Despite improvements in cancer management over the past 25 years, unrelieved symptoms continue to be reported. Little is known about how patients' problems and concerns are communicated to professionals during oncology treatment. This qualitative study investigates the process of communication between cancer patients and oncologists during consultations in outpatient clinics of a regional teaching hospital. Data were collected by nonparticipant observation and audiotaping consultations. Analyses were by qualitative content analysis and conversation analysis. An objectives, strategies and tactics model was applied to organize the findings. Seventy-four consultations between cancer patients and 15 doctors were observed and audiotaped. Pain talk is defined and identified as a substantial topic, occurring in 39 out of 74 consultations. Doctor-initiated questions are the predominant discourse feature and are prominent not only in initiating discussions but also in directing further talk (e.g. over three-quarters of doctor-initiated questions are in a closed form which focus narrowly on limited physical aspects of patients' pain). This limited information exchange is used alongside other communication tactics to identify the 'right kind' of pain that may benefit from cancer therapy and to truncate talk of problems perceived to be outside of this specialist remit. Although individualized, holistic care is the expressed philosophy of the clinic, our data show that doctors tightly control the agenda to focus narrowly on pain which was amenable to radiotherapy, chemotherapy, surgery or hormone manipulation. Inadequate exploration of patients' pain is likely to be detrimental to symptom control.

Pain in adult recipients of blood or marrow transplant

Severe pain is a problem for most bone marrow transplant (BMT) recipients. The purpose of this descriptive study was to describe the pain experience of adults undergoing autologous BMT, allogeneic BMT, or peripheral blood stem cell transplant. The sample consisted of 20 adults, 21 to 54 years of age. Using investigator-developed structured interview guides, investigators interviewed each participant four times: on the day of transplant, then at 3-weekly intervals. Investigators used a content analysis approach when analyzing data. During the first interview, 18 participants said that they were told to expect mouth sores during BMT, yet only six said that they actually expected to experience mouth sores during BMT. During successive interviews, 13 reported mouth sores. Eight other pain sites were reported. Participants reported that their tolerance of mild, moderate, and severe pain decreased over 2 weeks, and they named a wide variety of factors that caused or relieved pain. Ten said that they used nonpharmacologic techniques to feel more comfortable. Seven said that their BMT pain was worse or more difficult than they had expected. Overall pain ratings ranged from 0 to 8 on a 0 to 10 scale, M = 4.5. Five said the side effects of analgesics bothered them more than their pain. Most of them said a pain-rating scale was useful. Three weeks post-BMT, seven said they still experienced pain. Implications for clinical practice, research, and education are discussed.

Evaluating the quality of life of cancer patients: assessments by patients, significant others, physicians and nurses

This study examined the usefulness of caregiver ratings of cancer patients' quality of life (QOL), an issue of relevance to both adequate patient care and to the possible use of proxy QOL raters in clinical studies. We compared QOL ratings of 90 cancer patients receiving inpatient chemotherapy with those provided by their significant others (most often the spouse), physicians and nurses. During patients' scheduled appointment for receiving chemotherapy on a clinical ward, all raters completed independently the Dartmouth COOP Functional Health Assessment charts/WONCA, an instrument developed by a cooperative group of primary care physicians to briefly assess a core set of seven QOL domains (physical fitness, feelings, daily and social activities, overall health, pain and quality of life) by single items with five response options. With few exceptions, mean scores of the proxy raters were equivalent or similar to those of the patients. Most patient-proxy correlations varied between 0.40 and 0.60, indicating a moderate level of agreement at the individual level. Of all comparisons made, 41% were in exact agreement and 43% agreed within one response category, leaving 17% more profound patient-proxy discrepancies. Disagreement was not dependent on the type of proxy rater, or on raters' background characteristics, but was influenced by the QOL dimension under consideration and the clinical status of the patient. Better patient-proxy agreement was observed for more concrete questions (daily activities, pain) and for patients with either a very good (ECOG 0) or poor (ECOG 3) performance status. The results indicate that both significant others and health care providers can be useful sources of information about cancer patients' QOL.

Recent developments in palliative cancer care

In recent years major developments have taken place in palliative cancer care. Cancer specialists should be familiar with a number of these developments since they can improve symptom control in advanced cancer patients. Some of these developments are discussed in this article, with particular emphasis on the multidimensional assessment of symptom complexes and neurotoxicity of opioids.

Oral analogue scale as an outcome measure after displaced intra-articular calcaneal fractures

Functional outcome measures of displaced intra-articular calcaneal fractures have been documented using general health surveys (SF36) and disease-specific health surveys (Visual Analogue Scale). A simple oral analogue scale (OAS) was collected on 115 patients with 124 displaced intra-articular calcaneal fractures at 2 years or more after fractures. There was a high correlation (r = 0.72, P < 0.0001) between the verbal OAS and the written Visual Analogue Scale. We believe that the OAS may assist in follow-up outcome assessment and management in this difficult trauma patient population. Outcomes may be accomplished verbally rather than in written form.

Measurement issues in the comprehensive assessment of cancer pain

OBJECTIVES

To examine issues related to the assessment of pain, symptoms and functional status in patients with cancer and the timing of assessment and appropriate tools to collect this information.

DATA SOURCES

Review articles, research studies book chapters, and government guidelines pertaining to measurement issues in the assessment of cancer pain.

CONCLUSIONS

Each component of the measurement process (ie, choice of an instrument to measure pain, timing and frequency of measurement measurement of symptoms accompanying pain or its treatment, and measurement of functional status) is important in developing an accurate and comprehensive assessment of cancer pain. This comprehensive assessment is a prerequisite to effective pain management.

IMPLICATIONS FOR NURSING PRACTICE

For pain to be evaluated and treated effectively, regular consistent assessment of pain by the clinician is imperative. This comprehensive assessment allows the clinician to choose modalities most likely to work for the individual patient.

Management of painful paraneoplastic syndromes

The majority of patients with advanced malignant disease experience pain, so pain is commonly present in patients with paraneoplastic syndromes. It is rare, however, that the pain itself is a paraneoplastic manifestation of cancer. Usually, the pain in this context is associated with a paraneoplastic syndrome but is not a direct result of that syndrome. Three syndromes in which pain is part of the syndrome and a paraneoplastic manifestation of malignant disease--neuropathy, ganglionitis, and monolitis--have been described in the literature. These syndromes and their management are discussed in this article.

Bedside charting of pain levels in hospitalized patients with cancer: a randomized controlled trial

Despite advances in the technology of cancer pain assessment and control, cancer pain often remains undertreated even in hospital settings. To determine whether a graphical display of cancer patients' pain levels might improve their treatment, the investigators conducted a randomized controlled trial. Patients assigned to the intervention group (N = 40) had periodic pain assessments by study staff, who graphically recorded their reported pain-intensity levels on bedside wall charts. Control group patients (N = 38) had periodic pain assessments by study staff but did not have this information displayed. The results failed to show a significant beneficial effect of the intervention on pain control, sleep, cancer-related symptoms, or analgesic dosing, but confidence intervals were broad. More research is needed to improve the quality of care for inpatients with cancer-related pain.

Symptom assessment

Medical intervention aims to eliminate disease, to mitigate disease effect, and maximize quality of life. Throughout the course of illness, accurate symptom assessment is imperative if these goals are to be achieved. Symptom scales may facilitate this process in the clinical setting. Many valid scales are available for research, and investigators must be familiar with a methodology that can quantify the impact of therapies on symptoms, symptom distress, and overall QOL.