Palliative Care in the New Era of Lung Cancer Treatment

Lung cancer remains the most common malignancy and is recognized as having significant impact on quality of life. Advances in lung cancer treatment over the past decade have been significant, with new agents extending life, even in late-stage disease. The purpose of this study was to evaluate palliative care needs and use of supportive care services in a randomly selected sample (N = 99) of patients with lung cancer. Results indicated that despite treatment advances, these patients continue to have significant symptom and quality of life concerns and to receive limited palliative care or supportive care services. Integration of palliative care is needed in the new era of lung cancer treatment.

Care Processes and Quality-of-Life Outcomes Affecting the Gynecologic Cancer Survivorship Experience

PURPOSE

To describe and assess physical and psychosocial concerns and care processes related to cancer and treatment in gynecologic cancer survivors.

PARTICIPANTS & SETTING

44 survivors of gynecologic cancer at City of Hope National Medical Center in southern California were enrolled.

METHODOLOGIC APPROACH

A descriptive mixed-methods approach was used. Data were collected on survivorship care plan implementation, supportive care referrals, and barriers to receiving care. Participants completed questionnaires assessing quality of life, unmet needs, and other outcomes at three, six, and nine months after enrollment. Changes over time were analyzed, and quantitative and qualitative results were compared.

FINDINGS

The most common unmet needs were stress reduction, side effect management, fear of cancer recurrence (FCR), and perception of adequate communication among the care team. Qualitative themes centered around communication, care coordination, FCR, financial distress, and need for information about peer support and healthy lifestyles.

IMPLICATIONS FOR NURSING

Nurses play a key role in coordinating care, assessing symptoms, and addressing psychosocial concerns. Providing education and coaching can reduce stress and facilitate survivors' self-management and self-efficacy.

Family Caregiver Preparedness: Developing an Educational Intervention for Symptom Management

BACKGROUND

Family caregivers provide complex care for patients with cancer, including management of multiple symptoms associated with the disease and its treatment.

OBJECTIVES

The objective of this pilot project was to develop and conduct feasibility testing of a family caregiver educational intervention for symptom management.

METHODS

The intervention was conducted with 23 family caregivers of patients with lung or gynecologic cancer to evaluate feasibility testing and assessment of caregiver preparedness, quality of life, and psychological distress at baseline and three and seven weeks postintervention.

FINDINGS

Family caregivers were very interested in education related to their role in symptom management, with management of constipation, dyspnea, and diarrhea as the highest priorities. The intervention was feasible and valuable in assisting family caregivers in assessing symptoms and making decisions regarding treatment choices.

Implementing quality improvement efforts in spiritual care: outcomes from the interprofessional spiritual care education curriculum

The Interprofessional Spiritual Care Curriculum (ISPEC) was created to train interdisciplinary health care teams to recognize and address the spiritual needs of seriously or chronically ill patients. The curriculum, in a train-the-trainer format, employs didactic presentations, discussions, lab sessions, skill demonstrations, and video clips. In course applications, participants were required to submit goals to achieve and demonstrate institutional support. For the first ISPEC course, in July 2018, 48 clinician-chaplain teams attended. Following the 2½ day course, participants had access to online training modules for 1-year, ISPEC faculty mentoring support, and regular conference calls on goal implementation progress. Participants reported recognizing the importance of providing spiritual care and a new understanding of how collaborating as interprofessional teams enabled them to integrate this care into their home institution settings. In a mixed-methods evaluation survey completed 12 months after the ISPEC course, participants reported on the percentage of their goals completed, number and types of professionals they had educated in spiritual care, and personal confidence regarding spiritual care leadership skills. This data can serve as a model to guide other organizations striving to improve spiritual care, practiced collaboratively by clinicians and chaplains, as an essential aspect of overall QI efforts in palliative care.

Clinical Trials: Understanding Patient Perspectives and Beliefs About Treatment

BACKGROUND

Understanding the experiences of patients with solid tumors who are in phase 1 clinical trials can help nurses to provide optimal care.

OBJECTIVES

The purpose of this article is to describe patient perspectives of participating in a phase 1 trial and understanding their disease status and treatment options. In addition, the authors describe the impact of the disease and clinical trial participation on quality of life.

METHODS

30 patients were interviewed and audio recorded; the interviews were transcribed and content analysis methods were used to identify common themes.

FINDINGS

Patients reported participating in the phase 1 clinical trial because their doctors informed and encouraged them, they had no other treatment options if they wanted to live longer, or they wanted to help future patients with cancer. Most believed that participation would improve or stabilize their illness and quality of life. They believed that, when the clinical trial ended, there would be new treatments. Participants reported that healthcare providers and family members provided support, and that compassion, cultural awareness, spiritual support, and the need for individual attention were important.

A nurse-led intervention for fear of cancer progression in advanced cancer: A pilot feasibility study

PURPOSE

To assess the feasibility, acceptability, and preliminary effects of a nurse-led intervention for managing fear of cancer progression in advanced cancer patients.

METHODS

A single group mixed methods study was conducted in patients with stage III or IV gynecologic or lung cancer (n = 31) with dysfunctional levels of fear of progression or distress. The intervention consisted of seven videoconferencing sessions with skills practice. Feasibility measures included enrollment rate, attendance, attrition, and home practice adherence. Acceptability was based on exit interview responses. Content analysis was used to analyze the qualitative data. Participants completed quantitative questionnaires assessing fear of progression and secondary outcomes at baseline, eight, and 12 weeks. Linear mixed model analysis was used to assess changes in outcome measures.

RESULTS

The average enrollment rate was seven participants/month over 4.5 months. Participants attended a mean of 5.3 of seven sessions. Attrition rate was 30%. The analysis showed improvements over time in fear of progression and exploratory outcomes. Participants reported feeling calmer and more focused. The skills practice helped to manage anxiety and fears. Themes included: Struggling with fears, Refocusing the fears, and Realizing/reaffirming what is important in life. The most beneficial components included the values clarification exercise, detached mindfulness and worry postponement practices.

CONCLUSION

The intervention was acceptable; most feasibility criteria were met. Preliminary data suggest that the intervention reduced fear of progression and improved secondary outcomes. The intervention required a significant time commitment by participants, which may have contributed to increased attrition. To decrease burden, we will shorten the intervention.

Fear of Cancer Progression: Findings From Case Studies and a Nurse-Led Intervention

BACKGROUND

Fear of cancer recurrence or progression (FOP) is a significant concern for cancer survivors. With the advent of new targeted therapies and immunotherapy, many patients with advanced cancer are living longer while dealing with uncertainty and fears related to cancer progression. Although some level of FOP is normal and adaptive, high levels adversely affect quality of life and healthcare costs.

OBJECTIVES

This article describes a nurse-led intervention for managing FOP in two patients with advanced gynecologic cancer. The intervention teaches skills for managing worry, challenging unhelpful beliefs, and modifying unhelpful coping behaviors.

METHODS

Preliminary findings from the two case studies are presented, including a comparison of post-treatment FOP scores to baseline scores.

FINDINGS

The participants reported feeling more focused, less overwhelmed, and more in control of their worries. Both participants achieved statistically reliable improvements in FOP scores.

Integrating Palliative Care for Patients on Clinical Trials: Opportunities for Oncology Nurses

The purpose of this article is to describe the lessons learned in the course of a 5-year research study on a palliative care intervention for persons on a Phase 1 clinical trial. Patients who are participating in Phase 1 trials and the families who care for them may be especially vulnerable and require special attention. The patients are generally experiencing the effects of advanced disease, and they also may soon experience unknown side effects, intense treatment regimens, and the emotional stress of an uncertain future as a result of clinical trial participation. Oncology nurses in all roles including clinical trials/research nurses, clinicians, educators, and advanced practice registered nurses play a critical role in addressing the quality-of-life concerns in this population. Palliative care can provide better symptom control and information on treatment options and facilitate a better understanding of patient/family goals. Attending to these factors can ultimately mean improved survival for the advanced cancer patient, and support for these patients can assist in advancing the field of oncology as these investigational therapies hold the promise for enhancing survival.

Spirituality in cancer patients on phase 1 clinical trials

OBJECTIVES

Patients with cancer who are at a transition to Phase I investigational treatments have been identified as an underserved population with regard to palliative care. This disease transition is often accompanied by spiritual and existential concerns. The study objective was to conduct a secondary analysis of data from a larger study testing a palliative care intervention. This paper reports the findings of this secondary focus on the spiritual needs of this population.

METHODS

Patients (n = 479) were accrued to this study prior to initiating a Phase I clinical trial with data collected at baseline, and 4, 12, and 24 week follow-up.

RESULTS

Qualitative data revealed that the transition to Phase 1 trial participation is a time of balancing hope for extended life with the reality of advancing disease. Quantitative results demonstrated increased spirituality over time in both religious- and non-religious-affiliated patients.

CONCLUSIONS

Patients entering Phase I trials have important spiritual needs as they face treatment decisions, advancing disease, and often mortality. Spiritual care should be provided to seriously ill patients as a component of quality care.

A Support Intervention for Family Caregivers of Advanced Cancer Patients

Family caregivers are the primary providers of care. Education and support are needed to prepare them for the complex physical, psychological, social, and spiritual effects of cancer. This randomized clinical trial tested a palliative care intervention with 240 family caregivers, focusing on family caregivers who reported financial strain from cancer and treatment. A four-part educational program demonstrated improved outcomes in the intervention group in the measures of objective burden, caregiving preparation, and quality of life. The role of advanced practitioners in providing tailored psychoeducation and support to caregivers is important in order to meet the integral needs of patients with cancer as well as to enhance caregiver self-care.

Family Caregivers: A Qualitative Study to Better Understand the Quality-of-Life Concerns and Needs of This Population

BACKGROUND

While providing physical, psychological, and spiritual care to their loved ones with cancer, family caregivers (FCGs) are physically and emotionally vulnerable to the tolls of caregiving. Patients and FCGs experience the uncertainty that comes with illness and treatment, its side effects, the lack of control, the emotional upheaval, the spiritual doubt, and the helplessness of advancing disease.

OBJECTIVES

This study was conducted to better understand the quality-of-life needs of the FCG population, particularly those who encounter financial strain related to patients' cancer and treatment.

METHODS

This qualitative study of FCG concerns was conducted in association with a randomized trial of an FCG support intervention. Twenty FCGs of patients with solid tumor cancers were interviewed in person or via telephone for this study. The FCG version of the City of Hope quality-of-life tool, which consists of four domains of well-being (physical, psychological, social, spiritual), was applied to the content analysis of interviews.

FINDINGS

Care for FCGs is needed across all quality-of-life domains.

Pain and Suffering

OBJECTIVE

To review literature on the relationship of pain, spirituality, and suffering as it relates to the patient with cancer who is experiencing pain.

DATA SOURCES

Peer-reviewed articles, textbooks, internet.

CONCLUSION

Pain and suffering are distinct and yet closely related in patients with cancer. Oncology nurses are important in assessing a patient's pain, including dimensions of spirituality and suffering.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses are the front line of pain management for patients. This includes recognizing existential distress and suffering and responding to suffering.

Translation and Evaluation of a Lung Cancer, Palliative Care Intervention for Community Practice

CONTEXT

A notable gap in the evidence base for palliative care (PC) for cancer is that most trials were conducted in specialized centers with limited translation and further evaluation in "real-world" settings. Health systems are desperate for guidance on effective, scalable models.

OBJECTIVES

The objective of this study was to determine the effects of a nurse-led PC intervention for patients with non-small-cell lung cancer and their family caregivers (FCGs) in a community-based setting.

METHODS

Two-group, sequential, quasi-experimental design with Phase 1 (usual care [UC]) followed by Phase 2 (intervention) was conducted at three Kaiser Permanente Southern California sites. Participants included patients with Stage 2-4 non-small-cell lung cancer and their FCG. Standard measures of quality of life (QOL) included Functional Assessment of Cancer Therapy-Lung, Functional Assessment of Chronic Illness Therapy-Spirituality Subscale, City of Hope Family QOL; other outcomes were distress, health care utilization, caregiver preparedness, and burden.

RESULTS

Patients in the intervention cohort had significant improvements in three (physical, emotional, and functional well-being) of the five QOL domains at one month that were sustained through three month compared to UC (P < 0.01). Caregivers in the intervention cohort had improvements in physical (P = 0.04) and spiritual well-being (P = 0.03) and preparedness (P = 0.04) compared to UC. There were no differences in distress or health care utilization between cohorts.

CONCLUSION

Our findings suggest that a research-based PC intervention can be successfully adapted to community settings to achieve similar, if not better, QOL outcomes for patients and FCGs compared to UC. Nonetheless, additional modifications to ensure consistent referrals to PC and streamlining routine assessments and patient/FCG education are needed to sustain and disseminate the PC intervention.

Understanding Family Caregiver Communication to Provide Family-Centered Cancer Care

OBJECTIVES

To describe a family caregiver communication typology and demonstrate identifiable communication challenges among four caregiver types: Manager, Carrier, Partner, and Lone.

DATA SOURCES

Case studies based on interviews with oncology family caregivers.

CONCLUSION

Each caregiver type demonstrates unique communication challenges that can be identified. Recognition of a specific caregiver type will help nurses to adapt their own communication to provide tailored support.

IMPLICATIONS FOR NURSING PRACTICE

Family-centered cancer care requires attention to the communication challenges faced by family caregivers. Understanding the challenges among four family caregiver communication types will enable nurses to better address caregiver burden and family conflict.

Integration of a Palliative Care Intervention into Community Practice for Lung Cancer: A Study Protocol and Lessons Learned with Implementation

BACKGROUND

A notable gap in the evidence base for outpatient palliative care (PC) for cancer is that most trials were conducted in specialized oncology or academic centers with limited translation and further evaluation in "real-world" settings. Health systems are desperate for guidance regarding the most effective and sustainable PC service models.

OBJECTIVE

Describe the study protocol to evaluate the dissemination of a previously tested nurse-led PC intervention (PCI) for patients with lung cancer and their family caregiver in community-based settings, lessons learned in adapting and implementing the PCI, and implications for future dissemination-translational efforts Design: Two-group, prospective sequential, quasi-experimental design with Phase 1 (Usual care) followed by Phase 2 (Intervention) setting/subjects. Three Kaiser Permanente Southern California sites. Patients with stage 2-4 nonsmall cell lung cancer and their caregiver.

MEASUREMENTS

Standard measures of quality of life (QOL; FACT-L, FACIT- SP12, City of Hope Family QOL), symptom burden, distress, and caregiver preparedness and perceived burden.

RESULTS

Adaptations were made to the PCI (comprehensive patient/caregiver assessment, interdisciplinary care planning, and patient/caregiver education) to harmonize with existing workflows, minimize burden to patients, caregivers, and the PC team, and maximize chances of sustainability. Implementation facilitators include external competitive pressures, internal readiness, and adaptability of the PCI. Barriers include the changing lung cancer therapeutic landscape and perceived need for PC support by patients and providers, insufficient staffing, and people-dependent processes.

CONCLUSIONS

Efforts to disseminate and implement previously tested PC models into real-world community practices need to be more realistic and consider the local context.

Interdisciplinary Palliative Care for Patients With Lung Cancer

CONTEXT

Palliative care, including symptom management and attention to quality of life (QOL) concerns, should be addressed throughout the trajectory of a serious illness such as lung cancer.

OBJECTIVES

This study tested the effectiveness of an interdisciplinary palliative care intervention for patients with Stage I-IV non-small cell lung cancer (NSCLC).

METHODS

Patients undergoing treatments for NSCLC were enrolled in a prospective, quasi-experimental study whereby the usual care group was accrued first followed by the intervention group. Patients in the intervention group were presented at interdisciplinary care meetings, and appropriate supportive care referrals were made. They also received four educational sessions. In both groups, QOL, symptoms, and psychological distress were assessed at baseline and 12 weeks using surveys which included the Functional Assessment of Cancer Therapy-Lung and the Lung Cancer Subscale, the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, and the Distress Thermometer.

RESULTS

A total of 491 patients were included in the primary analysis. Patients who received the intervention had significantly better scores for QOL (109.1 vs. 101.4; P < 0.001), symptoms (25.8 vs. 23.9; P < 0.001) spiritual well-being (38.1 vs. 36.2; P = 0.001), and lower psychological distress (2.2 vs. 3.3; P < 0.001) at 12 weeks, after controlling for baseline scores, compared to patients in the usual care group. Patients in the intervention group also had significantly higher numbers of completed advance care directives (44% vs. 9%; P < 0.001), and overall supportive care referrals (61% vs. 28%; P < 0.001). The benefits were seen primarily in the earlier stage patients vs. those with Stage IV disease.

CONCLUSION

Interdisciplinary palliative care in the ambulatory care setting resulted in significant improvements in QOL, symptoms, and distress for NSCLC patients.

Palliative care and spiritual well-being in lung cancer patients and family caregivers

BACKGROUND

Spiritual well-being is an important dimension of quality of life (QOL) and is a core component of quality oncology and palliative care. In this analysis, we aimed to describe spiritual well-being outcomes in a National Cancer Institute (NCI)-supported Program Project that tested the effectiveness of an interdisciplinary palliative care intervention in lung cancer patients and their family caregivers (FCGs).

METHODS

Patients undergoing treatments for NSCLC and their FCGs were enrolled in a prospective, quasi-experimental study. Patients and FCGs in the intervention group were presented at interdisciplinary care meetings and received four educational sessions that included one session focused on spiritual well-being. Spiritual well-being for patients was measured using the FACIT-Sp-12, and FCG spiritual well-being was measured using the COH-QOL-FCG spiritual well-being subscale. Multivariate analysis of covariance was undertaken for subscale and item scores at 12 weeks, controlling for baseline, by religious affiliations (yes or no) and group assignment.

RESULTS

Religiously affiliated patients reported better scores in the Faith subscale and items on finding strength and comfort in faith and spiritual beliefs compared to non-affiliated patients. Non-affiliated patients had better scores for feeling a sense of harmony within oneself. By group, patients who received the intervention had significantly better scores for the Meaning/Peace subscale.

CONCLUSIONS

Our findings support the multidimensionality of spiritual well-being that includes constructs such as meaning and faith for lung cancer patients and FCGs with or without religious affiliations. Palliative care interventions should include content that targets the spiritual needs of both patients and FCGs. Copyright © 2015 John Wiley & Sons, Ltd.

Spiritual Assessment in a Patient With Lung Cancer

CASE STUDY  Mr. G., an 82-year-old retired European man, was diagnosed with stage 4 non-small cell lung cancer (NSCLC) and recently enrolled on a phase II clinical trial. He is married and has two adult children, who are very supportive. He and his wife described themselves as nonpracticing Catholics. He had never smoked, and there was no personal or family history of cancer. Fatigue was the main side effect from the clinical trial drugs, necessitating frequent periods of rest throughout the day and ultimately requiring dose reduction. His left leg was edematous and painful, and he was diagnosed with and treated for deep-vein thrombosis. Over time, these symptoms resolved, and Mr. G. enjoyed a fairly normal quality of life (QOL). He continued to do well for almost a year, but then his cancer progressed and his performance status began to decline. When offered treatment options, he elected to discontinue the clinical trial, take a break, and then initiate single-agent chemotherapy. Mr. G. was enrolled in a palliative care research study that provided patient-tailored education by an advanced practitioner (AP). The education addressed each QOL domain: physical, psychological, social, and spiritual. When the AP connected with Mr. G. during one of his clinic appointments, he appeared very concerned. He shared that he previously had lived in a communist country and now that he was in the United States, he was afraid of losing his insurance and having to stop treatment. The conversation was interrupted as he was called in for his appointment, yet he consented to talk about the matter further by telephone. The AP contacted Mr. G. the next day. He shared a glimpse of his childhood and experience in his homeland to try to explain his current fears. After reassuring him that his insurance would not be withdrawn, the AP asked whether he would be willing to talk about his life before coming to the United States more than 50 years ago. She wanted to assess where he was spiritually as a self-described nonpracticing Catholic. Mr. G. began by stating that he knew he was going to die of his lung cancer. He added that he did not know whether he was afraid of dying or believed in an afterlife, as he felt ambivalent about faith and religion. The AP learned that what gave his life meaning was his family. His "boys" were everything to him, and he did not want to be a burden to them or his wife. The AP listened and then encouraged Mr. G. to tell his whole story. As a child, he had lived in an occupied country in Eastern Europe during World War II. Mr. G. and his family spent over a year in a concentration camp. They slept on straw, their heads were shaved, and they all had lice. Men aged 18 to 40 were shipped to Russia to work in the copper mines, where many died of exhaustion. Most older men were killed, and he watched his grandfather die beside him. Horse-drawn buggies took dead bodies to mass graves, where lime was poured over them. Mr. G. had boils over his entire body from lack of nutrition. Though technically Catholic, Mr. G. did not ask God to save him; he had seen too much to believe that God would be involved. One day, he escaped with two other boys. With the help of a stranger, they crossed at night into Romania. They walked for miles into Hungary, where they found shelter in a convent for several weeks. The Mother Superior collected money so he could take the train to Budapest and arranged for him to stay in a Catholic home. From Budapest, he went to Austria, living in refugee camps until moving into an apartment of his own. Mr. G. attended college in Austria and later moved with his wife to the United States, where they raised two boys and owned a successful business.

Death awareness, feelings of uncertainty, and hope in advanced lung cancer patients: can they coexist?

Patients diagnosed with stage-IV lung cancer are forced to quickly transition from a cancer-free and perhaps healthy life to one of serious illness, uncertainty, and anticipation of a premature death. Health professionals may be too quick to label the patient as being in denial if they hope for healing. Hope may not be lost when reality is accepted. Studies have investigated what it is like to live with awareness of impending death. Using a patient case study this paper discusses the concepts of death awareness, uncertainty, and hope. The aim is to provide a deeper understanding of how these seemingly antithetical emotions can coexist to the benefit of the patient, and to provide clinicians with practical considerations for supporting patients' hope throughout their terminal illness.

Spiritual care for Jewish patients facing a life-threatening illness

Providing biopsychosocial/spiritual care for patients facing a life threatening illness can be complex, and this complexity can be amplified when a patient identifies as Jewish. A common but incorrect assumption is that a person who identifies him or herself as Jewish abides by the tenets of the Jewish religion. However, many Jews consider themselves Jewish in an ethnic or cultural sense rather than connected to a religion or belief in God. This case report presents an ethnic/cultural Jew with a life threatening illness of advanced lung cancer. Despite evidence of spiritual/existential suffering, this patient declined spiritual care. From an analysis of this case and clinical experience, we suggest exploratory questions that clinicians can use in response to common questions or statements made by such patients. This exploration may lead to a chaplain referral and we highlight interventions that chaplains and clinicians may find helpful as they come alongside Jewish patients.

A qualitative analysis of cancer-related fatigue in ambulatory oncology

The purpose of this study was to describe patients' perceptions of the causes, relief, related symptoms, meaning, and suffering secondary to cancer-related fatigue (CRF). In total, 252 patients with breast, lung, colon, and prostate cancers were enrolled in a quasiexperimental study to test the effects of a clinical intervention on reducing barriers to symptom management in ambulatory care. Analysis of data reported in this article was derived from the Piper Fatigue Scale-Revised. Using qualitative research methods and content analysis, written statements related to the impact of CRF were coded using the following themes: patients' perceptions of CRF, causes, relief, related symptoms, meaning, and suffering. Comments were categorized and reviewed for content. Overall, CRF had a significant impact on physical, psychological, social, and spiritual well-being. CRF limited the ability of participants to function, socialize, and participate in enjoyable activities. Emotional issues as a result of CRF were common. The negative impact of CRF on patients' overall well-being alters the meaning and suffering related to the cancer experience. The assessment of personal meaning and suffering related to CRF is an important component of the multidimensional assessment of CRF and will enable nurses to better understand the suffering related to CRF.

Quality of life and barriers to symptom management in colon cancer

PURPOSE OF THE RESEARCH

Pain and fatigue are recognized as critical symptoms that impact QOL for patients with colon cancer. Barriers to optimum pain and fatigue relief include patient-related beliefs and attitudes about the treatment of cancer-related symptoms. The overall objective of this paper was to describe quality of life (QOL) and barriers to pain and fatigue management in patients with colon cancer.

METHODS AND SAMPLE

This longitudinal, descriptive study included was conducted in the ambulatory clinic of one NCI-designated comprehensive cancer center. A cohort of 56 patients with colon cancer and a pain and/or fatigue of ≥4 (moderate to severe) was recruited. Subjects completed questionnaires to assess subjective ratings of overall QOL, fatigue, barriers to pain and fatigue, and pain and fatigue knowledge.

KEY RESULTS

The majority of subjects (58%) reported having moderate to severe (4-6) fatigue at the time of accrual. Overall QOL score was moderate (M = 5.20, SD = 1.43), and the social well-being subscale had the lowest score (M = 4.57, SD = 1.82). Patient barriers to pain and fatigue existed in attitudes and beliefs regarding addiction, tolerance, and that fatigue is an inevitable part of cancer and its treatments. Patient knowledge of pain and fatigue was high (77%-88% correct), but lack of knowledge persisted in areas such as addiction to pain medications and utilizing physical activity to manage fatigue.

CONCLUSIONS

Several patient-related attitudes and beliefs may hinder optimum relief of symptoms such as pain and fatigue. Social well-being may be a major determinant of overall QOL for patients with colon cancer.

Effectiveness of a clinical intervention to eliminate barriers to pain and fatigue management in oncology

BACKGROUND

Pain and fatigue are recognized as critical symptoms that impact quality of life (QOL) in cancer, particularly in palliative care settings. Barriers to pain and fatigue relief have been classified into three categories: patient, professional, and system barriers. The overall objective of this study was to test the effects of a clinical intervention on reducing barriers to pain and fatigue management in oncology.

METHODS

This longitudinal, three-group, quasi-experimental study was conducted in three phases: phase 1 (usual care), phase 2 (intervention), and phase 3 (dissemination). A sample of 280 patients with breast, lung, colon, or prostate cancers, stage III and IV disease (80%), and a pain and/or fatigue of 4 or more (moderate to severe) were recruited. The intervention group received four educational sessions on pain/fatigue assessment and management, whereas the control group received usual care. Pain and fatigue barriers and patient knowledge were measured at baseline, 1 month, and 3 months post-accrual for all phases. A 3 × 2 repeated measures statistical design was utilized to derive a priori tests of immediate effects (baseline to 1 month) and sustained effects (baseline or 1 month to 3 months) for each major outcome variable, subscale, and/or scale score.

RESULTS

There were significant immediate and sustained effects of the intervention on pain and fatigue barriers as well as knowledge. Measurable improvements in QOL were found in physical and psychological well-being only.

CONCLUSION

A clinical intervention was effective in reducing patient barriers to pain and fatigue management, increasing patient knowledge regarding pain and fatigue, and is feasible and acceptable to patients.

Evaluation of the FICA Tool for Spiritual Assessment

CONTEXT

The National Consensus Project for Quality Palliative Care includes spiritual care as one of the eight clinical practice domains. There are very few standardized spirituality history tools.

OBJECTIVES

The purpose of this pilot study was to test the feasibility for the Faith, Importance and Influence, Community, and Address (FICA) Spiritual History Tool in clinical settings. Correlates between the FICA qualitative data and quality of life (QOL) quantitative data also were examined to provide additional insight into spiritual concerns.

METHODS

The framework of the FICA tool includes Faith or belief, Importance of spirituality, individual's spiritual Community, and interventions to Address spiritual needs. Patients with solid tumors were recruited from ambulatory clinics of a comprehensive cancer center. Items assessing aspects of spirituality within the Functional Assessment of Cancer Therapy QOL tools were used, and all patients were assessed using the FICA. The sample (n=76) had a mean age of 57, and almost half were of diverse religions.

RESULTS

Most patients rated faith or belief as very important in their lives (mean 8.4; 0-10 scale). FICA quantitative ratings and qualitative comments were closely correlated with items from the QOL tools assessing aspects of spirituality.

CONCLUSION

Findings suggest that the FICA tool is a feasible tool for clinical assessment of spirituality. Addressing spiritual needs and concerns in clinical settings is critical in enhancing QOL. Additional use and evaluation by clinicians of the FICA Spiritual Assessment Tool in usual practice settings are needed.

Reducing patient barriers to pain and fatigue management

CONTEXT

Pain and fatigue are recognized as critical symptoms that impact the quality of life of cancer patients. The barriers to pain and fatigue relief have been classified into three categories: patient, professional, and system barriers.

OBJECTIVES

The overall objective of this trial as to test the effects of the "Passport to Comfort" intervention on reducing barriers to pain and fatigue management for ambulatory care cancer patients.

METHODS

This quasi-experimental, comparative study uses a Phase 1 control group of usual care followed sequentially by a Phase 2 intervention group in which educational and system-change efforts were directed toward improved pain and fatigue management. A sample of 187 cancer patients with breast, lung, colon, or prostate cancers, and a pain and/or fatigue rating of 4 or more (moderate to severe), were recruited. Patients in the intervention group received four educational sessions on pain/fatigue assessment and management, whereas patients in the control group received usual care. Pain and fatigue barriers and patient knowledge were measured at baseline, one month, and three months post-accrual.

RESULTS

Patients in the intervention group experienced significant improvements in pain and fatigue measures immediately postintervention, and these improvements were sustained over time.

CONCLUSION

The "Passport to Comfort" intervention was effective in reducing patient barriers to pain and fatigue management as well as in increasing patient knowledge regarding pain and fatigue. This intervention demonstrates innovation by translating the evidence-based guidelines for pain and fatigue as developed by the National Comprehensive Cancer Network into practice.

Cancer-related fatigue: role of oncology nurses in translating National Comprehensive Cancer Network assessment guidelines into practice

This article reviews the National Comprehensive Cancer Network's (NCCN's) guidelines for cancer-related fatigue (CRF) assessment and discusses many of the common barriers that hinder the translation of the CRF guidelines into practice settings. Current assessment and measurement scales validated in patients with cancer are highlighted, and case studies reflect the vital roles that oncology nurses can play in managing patients with CRF. Oncology nurses must remember to assess the "gang of 7" (i.e., anemia, pain, sleep difficulties, nutrition issues, deconditioning or changes in activity patterns, emotional distress [depression or anxiety], and presence of comorbidities) that may affect workup, treatment, and supportive care referrals. Teaching patients about the importance of viewing CRF as the "sixth vital sign" can emphasize this symptom's importance and significance. Oncology nurses also can recognize the many patient-, provider- and system-related barriers that exist and work with others in a systematic and collaborative fashion within the system to decrease these barriers and begin to incorporate a simple intensity scale for CRF assessment and screening, documentation, and ongoing monitoring. By using available resources, oncology nurses can play significant roles in the translation of the NCCN's evidence-based practice guidelines for CRF in their practice settings.

Implementing the Fatigue Guidelines at one NCCN member institution: process and outcomes

Fatigue, despite being the most common and distressing symptom in cancer, is often unrelieved because of numerous patient, provider, and system barriers. The overall purpose of this 5-year prospective clinical trial is to translate the NCCN Cancer-Related Fatigue Clinical Practice Guidelines in Oncology and NCCN Adult Cancer Pain Clinical Practice Guidelines in Oncology into practice and develop a translational interventional model that can be replicated across settings. This article focuses on one NCCN member institution's experience related to the first phase of the NCCN Cancer-Related Fatigue Guidelines implementation, describing usual care compared with evidence-based guidelines. Phase 1 of this 3-phased clinical trial compared the usual care of fatigue with that administered according to the NCCN guidelines. Eligibility criteria included age 18 years or older; English-speaking; diagnosed with breast, lung, colon, or prostate cancer; and fatigue and/or pain ratings of 4 or more on a 0 to 10 screening scale. Research nurses screened all available subjects in a cancer center medical oncology clinic to identify those meeting these criteria. Instruments included the Piper Fatigue Scale, a Fatigue Barriers Scale, a Fatigue Knowledge Scale, and a Fatigue Chart Audit Tool. Descriptive and inferential statistics were used in data analysis. At baseline, 45 patients had fatigue only (> or = 4) and 24 had both fatigue and pain (> or = 4). This combined sample (N = 69) was predominantly Caucasian (65%), female (63%), an average of 60 years old, diagnosed with stage 3 or 4 breast cancer, and undergoing treatment (82%). The most common barriers noted were patients' belief that physicians would introduce the subject of fatigue if it was important (patient barrier); lack of fatigue documentation (professional barrier); and lack of supportive care referrals (system barrier). Findings showed several patient, professional, and system barriers that distinguish usual care from that recommended by the NCCN Cancer-Related Fatigue Guidelines. Phase 2, the intervention model, is designed to decrease these barriers and improve patient outcomes over time, and is in progress.

Barriers to pain assessment and management in cancer survivorship

INTRODUCTION

Healthcare providers frequently lack the knowledge and skills to provide optimal pain management for cancer survivors. Scientific evidence and clinical guidelines are lacking in the management of chronic, persistent pain in survivors. The purpose of this article is to describe pain-related issues of cancer survivors using case presentations of selected patients enrolled in a randomized trial to eliminate barriers to pain management.

MATERIALS AND METHODS

Case presentations were selected from a National Cancer Institute-funded study that utilizes patient and professional educational content derived from the clinical guidelines of the National Comprehensive Cancer Network. Case presentation criteria included a pain rating of >or=6 and diagnosis of Stage I, II, or III of the following cancers: breast, colon, lung, or prostate cancer. Cases are presented based on the study's framework of patient, professional, and system-related barriers to optimal pain relief.

RESULTS

Across all three case presentations, barriers such as fear of side effects from pain medications, fear of addiction, lack of professional knowledge of the basic principles of pain management, and lack of timely access to pain medications due to reimbursement issues are prevalent in cancer survivorship.

CONCLUSIONS

Chronic pain syndromes related to cancer treatments are common in cancer survivors. Patient, professional, and system-related barriers that are seen during active treatment continue to hinder optimal pain relief during survivorship.

IMPLICATIONS FOR CANCER SURVIVORS

Healthcare providers must acknowledge the impact of chronic, persistent pain on the quality of cancer survivorship. Clinical as well as scientific efforts to increase knowledge in chronic pain management will improve the symptom management of cancer survivors.

Overcoming barriers to cancer pain management: an institutional change model

The Agency for Health Care Policy and Research Pain Guidelines of 1994 recognized pain as a critical symptom that impacts quality of life (QOL). The barriers to optimum pain relief were classified into three categories: patient, professional, and system barriers. A prospective, longitudinal clinical trial is underway to test the effects of the "Passport to Comfort" innovative intervention on pain and fatigue management. This article reports on preintervention findings related to barriers to pain management. Cancer patients with a diagnosis of breast, lung, colon, or prostate cancer who reported a pain rating of >/=4 were accrued. Subjects completed questionnaires to assess subjective ratings of overall QOL, barriers to pain management, and pain knowledge at baseline and at one- and three-month evaluations. A chart audit was conducted at one month to document objective data related to pain management. The majority of subjects had moderate (4-6 on a 0-10 numeric rating scale) pain at the time of accrual. Patient barriers to pain management existed in attitudes and knowledge regarding addiction, tolerance, and not being able to control pain. Subjects who were currently receiving chemotherapy were reluctant to communicate their pain with health care professionals. Professional and system barriers were focused around screening, documentation, reassessment, and follow-up of pain. Lack of referrals to supportive care services for patients was also noted. Several well-described patient, professional, and system barriers continue to hinder efforts to provide optimal pain relief. Phase II of this initiative will attempt to eliminate these barriers using the "Passport" intervention to manage cancer pain.

The oncology nurse's role in the informed consent process

Cancer clinical trials are a necessary component of the effort to improve cancer prevention, diagnosis, and treatment. Essential to this process is the informed consent of the individuals who participate in these research studies. The purpose of this article is to describe patient, provider, and informed consent process issues with presentations of data reported in the current literature. The role of nursing in the facilitation of informed consent is discussed.

"Research to Practice": A Practical Program to Enhance the Use of Evidence-Based Practice at the Unit Level

PURPOSE/OBJECTIVES

To assist clinical nurses in translating research into clinical practice.

DATA SOURCES

City of Hope Quality-of-Life (QOL) Model to guide presentations and discussion, research utilization theories, and evidence-based practice literature.

DATA SYNTHESIS

Based on percentage of individual participant involvement, the four domains of QOL, and a knowledge survey.

OUTCOMES

Attendance, discussion, QOL domain ranking, satisfaction, and pre- and postknowledge scores. Attendance averaged 13 individuals; average discussion participation was 54%. The psychological QOL domain was most important (58%), and discussion averaged a score of 3 (1 = slow to 5 = lively). A one-point increase (scale 1-5) measured a change in knowledge.

CONCLUSIONS

The challenge for nursing assessment is to fully address patient issues in the psychological domain.

IMPLICATIONS FOR NURSING

A practical program can be formulated to bring evidence-based practice to the clinical setting.

Management of Pain and Nausea in Outpatient Surgery

The cost associated with surgical procedures has been dramatically decreased by the ability to perform these procedures on an outpatient basis. Pain and nausea, two common symptoms after anesthesia and surgical procedures, are among the greatest concerns for patients and their family members. As a result of the distress and sequelae associated with these symptoms, clinicians have attempted to determine the optimal intraoperative and postoperative symptom management for patients. The purpose of this quality improvement project was to describe the incidence of these symptoms and their management in patients who underwent planned outpatient surgical procedures in a cancer center. A sample of 39 patients were accrued at a comprehensive cancer center over a 3-month period. Data were collected at three specific time points (i.e., preoperatively, at 24 hours and at 7 days postoperatively). Postoperative pain and nausea were generally well managed, but improvement was needed in preoperative patient teaching, including the topics of drug and nondrug interventions. The methods used in this project have potential application for the measurement of other clinical outcomes after outpatient surgical procedures.

Family caregiving in cancer pain management

The experience of cancer pain is known to greatly affect family caregivers as well as patients. There are many demands placed on caregivers of cancer patients with pain at home as a result of the shifting of care from the acute setting to the home. These complex demands significantly affect caregiver quality of life. The purpose of this study was to describe the experience of pain management from the perspective of family caregivers of patients with cancer amidst the current healthcare environment. This quasi-experimental study involved 231 family caregivers of patients with cancer pain receiving home care. Family caregivers were assessed in conjunction with a pain education program that provided patient and. family education regarding pain assessment, drug and nondrug interventions. Assessment measures used were the Quality of Life (QOL)-Family Caregiver Tool, Knowledge and Attitudes about Pain (K&A) Tool, and Caregiver Finances Tool. Study findings reveal disruption to family caregiver quality of life in the areas of physical, psychological, social, and spiritual well-being. There is also a continued need for education regarding cancer pain management. Comparison between patients and family caregivers demonstrates that pain impacts both the patient experiencing it and their caregivers.

Concerns of family caregivers of patients with cancer facing palliative surgery for advanced malignancies

PURPOSE/OBJECTIVES

To describe the concerns of family caregivers of patients undergoing palliative surgeries for advanced malignancies.

DESIGN

Descriptive study with repeated measures.

SETTING

A National Cancer Institute-designated Comprehensive Cancer Center in the western United States.

SAMPLE

Family caregivers (N = 45) of patients with cancer.

METHODS

Family caregivers were assessed prior to planned palliative surgery and at two weeks and six weeks postsurgery. Quantitative assessment of caregiver quality of life (QOL) occurred at each interval. A subset of nine caregivers also participated in a structured interview presurgery and at two weeks postsurgery.

MAIN RESEARCH VARIABLES

Caregiver concerns, QOL, decision making.

FINDINGS

Family caregivers have important QOL concerns and needs for support before and after surgery for advanced disease. Psychological issues were most pronounced, and common concerns included uncertainty, fears regarding the future, and loss. Family caregivers have concerns about surgical risks and care after surgery and voiced recognition of the declining status of patients.

CONCLUSIONS

Surgery is an important component of palliative care and profoundly impacts family caregivers of patients with cancer. The needs of family caregivers are multiple and complex, requiring ongoing assessment to provide interventions that help them cope and ultimately improve their QOL. This important topic requires further research and clinical attention.

IMPLICATIONS FOR NURSING

Findings suggest that family caregivers experience their own trajectory during the course of their loved ones' cancer, with surgery being a part of the course. This includes their profound emotions that may swing like a pendulum from one minute to the next. Nurses need to assess family caregivers in addition to patients to provide support and resources that will help increase caregivers' QOL.

Online exclusive: patient and surgeon decision making regarding surgery for advanced cancer

PURPOSE/OBJECTIVES

To describe a program of research related to outcomes of palliative surgery and focus on one phase of this research involving decision making by patients and surgeons considering surgery for advanced disease.

DESIGN

Descriptive.

SAMPLE

10 patients undergoing surgery and 3 oncology surgeons.

METHODS

Qualitative interviews were conducted with patients and their surgeons pre- and postoperatively. Transcripts were content analyzed to identify major themes in patient and surgeon interviews based on study questions.

MAIN RESEARCH VARIABLES

Decision making, palliative surgery, quality of life.

FINDINGS

The study findings highlight the issues of greatest concern to patients and surgeons considering palliative surgery. This phase was an important component of the overall program of palliative surgery research.

CONCLUSIONS

Comprehensive care for patients with advanced cancer seeks to achieve a balance of providing aggressive care, ensuring optimum symptom management, and maintaining a focus on comfort. Further study of palliative surgery as an aspect of interdisciplinary care is warranted.

IMPLICATIONS FOR NURSING

Patients undergoing surgery for advanced disease require expert nursing care to address quality-of-life concerns. Further research is needed in this area.

The surgical treatment of cancer

BACKGROUND

Costs associated with the provision of medical care continue to escalate. Therefore, providers must evaluate the cost-effectiveness and benefit to individual healthcare practices. The authors evaluated the immediate and short-term resource utilization needs of patients undergoing surgical intervention with curative or palliative intent.

METHODS

Three hundred two patients undergoing surgery with therapeutic intent were observed from the time of admission for intervention until the time of death or until 6 months from the time of the surgical procedure. Surgeons preoperatively identified each case as either curative or palliative in intent. Demographic information, as well as the nature of all interactions with the cancer center, was recorded.

RESULTS

Surgeons identified 58 (19%) procedures as palliative and 244 (81%) as curative in intent. Demographic characteristics between the two groups were similar, although recurrent or metastatic disease was more often present in palliative rather than curative patients (P = 0.0078) and palliative intent patients were more likely to have received previous therapy. During the 6-month period, 4690 encounters occurred with the cancer center. The mean number of encounters per patient in each group was similar, although curative intent patients were more likely to have visits with therapeutic intent including chemotherapy administration (P = 0.01), radiation (P = 0.003), or repeat surgical procedures (P = 0.006). In contrast, palliative patients were more likely to be admitted for management of symptoms (P = 0.0001) and had fewer hospital-free days than did curative patients (P = 0.0069).

CONCLUSIONS

The average number of encounters for patients undergoing treatment of disease was not significantly different, suggesting that patients undergoing surgery with palliative intent do not require a greater amount of resources than curative intent patients. The nature of the interactions, however, was different, suggesting that resource needs are different and may need to be anticipated in the assessment of how better quality outcomes can be achieved in the palliative surgery setting.

A prospective evaluation of palliative outcomes for surgery of advanced malignancies

BACKGROUND

We prospectively evaluated the effectiveness of major surgery in treating symptoms of advanced malignancies.

METHODS

Fifty-nine patients were evaluated for major symptoms of intent to treat and were followed up until death or last clinical evaluation. Surgeons identified planned operations before surgery as either curative or palliative and estimated patient survival time. An independent observer assessed symptom relief. A palliative surgery outcome score was determined for each symptomatic patient.

RESULTS

Surgeons identified 22 operations (37%) as palliative intent and 37 (63%) as curative intent. The median overall survival time was 14.9 months and did not differ between curative and palliative operations. Surgical morbidity was high but did not differ between palliative (41%) and curative (44%) operations. Thirty-three patients (56%) were symptomatic before surgery, and major symptom resolution was achieved after surgery in 26 (79%) of 33. Good to excellent palliation, defined as a palliative surgery outcome score >70, was achieved in 64% of symptomatic patients.

CONCLUSIONS

Most symptomatic patients with advanced malignancies undergoing major operations attained good to excellent symptom relief. Outcome measurements other than survival are feasible and can better define the role of surgery in multimodality palliative care. A new outcome measure to evaluate major palliative operations is proposed.

Community implementation of home care palliative care education

PURPOSE

The purpose of this National Cancer Institute-funded training project was to improve end-of-life care agencies through implementation of a palliative care curriculum. The Home Care Outreach for Palliative Care Education (HOPE) program was designed to improve the knowledge and skills of home healthcare professionals who provide care to the terminally ill and their families at home.

DESCRIPTION OF PROGRAM

A five-module palliative care education curriculum was designed and implemented in five home care agencies in the Los Angeles area. One hundred twenty-five nurses and 28 home health aides participated. The methods of data collection included two written surveys conducted before and after intervention, chart audit tool and a case study analysis form.

RESULTS

The precourse data revealed deficiencies in home-care agency staff knowledge in and clinical aspects of end-of-life care. Regarding agency nurses' knowledge on end-of-life issues, the overall percentage scores from preeducation to posteducation rose from 84.6% to 89.0% (P =.0001). Participants rated the education program as extremely valuable for the home care agency staff.

CLINICAL IMPLICATIONS

As home care will likely continue to be a primary setting for end-of-life healthcare, improvement of palliative care education in home health agencies is needed. The HOPE project provided insight and experience in the education of nonhospice home care staff in end-of-life care. Participant responses and evaluations indicated that end-of-life care education can improve the quality of care provided by home health agencies. Finally, this education program may result in a heightened awareness of hospice care and, although not objectively quantified, perhaps an increase in referrals to hospice.

Use of routine and breakthrough analgesia in home care

PURPOSE/OBJECTIVES

To describe current use of routine analgesics in home care and the treatment of breakthrough pain.

DESIGN

Descriptive, companion study.

SETTING

Homecare agencies in southern California.

SAMPLE

Convenience sample of 369 patients with cancer participating in a pain-education study.

METHODS

Data regarding breakthrough pain were derived from the homecare medical records and patient interviews.

MAIN RESEARCH VARIABLES

Analgesic medications prescribed and used for treatment of routine and breakthrough cancer pain.

FINDINGS

Results demonstrate discrepancy between recommended pain management in clinical practice guidelines and the actual practice of pain management at home. Deficiencies were found in medications prescribed as well as in actual use by patients.

CONCLUSIONS

Optimum relief of cancer pain is contingent on adequate treatment of routine and breakthrough pain, including greater use of recommended analgesics in adequate doses and clinical care consistent with clinical practice guidelines.

IMPLICATIONS FOR NURSING PRACTICE

Breakthrough pain is a common problem affecting the quality of life of patients with cancer. Improved management of breakthrough pain is contingent on accurate pain assessment, optimum use of analgesics, and patient education. Nurses should address the important topic of breakthrough pain as new analgesic drugs and methods of delivery become available.