Patient Navigator Intervention to Improve Palliative Care Outcomes for Hispanic Patients With Serious Noncancer Illness: A Randomized Clinical Trial

Importance

Disparities persist across the trajectory of serious illness, including at the end of life. Patient navigation has been shown to reduce disparities and improve outcomes for underserved populations.

Objective

To determine the effectiveness of a lay patient navigator intervention, Apoyo con Cariño, in improving palliative care outcomes among Hispanic patients.

Design, Setting, and Participants

This was a multicenter randomized clinical trial that took place across academic, nonprofit, safety-net, and community health care systems in urban, rural, and mountain/frontier regions of Colorado from January 2017 to January 2021. Self-identifying Hispanic adults with serious noncancer medical illness and limited prognosis were recruited. Data were collected and analyzed from July 2022 to July 2023.

Interventions

Participants randomized to the intervention group received 5 home visits from a bilingual, bicultural lay patient navigator; participants randomized to control received care as usual. Both groups received culturally tailored educational materials. Investigators/outcome accessors remained blinded to participant assignment.

Main Outcomes and Measures

Change in score from baseline to 3 months on the Functional Assessment of Chronic Illness Therapy (FACIT) General quality of life (QOL) scale (primary outcome), Advance Care Planning (ACP) Engagement Survey, Brief Pain Inventory, Edmonton Symptom Assessment Scale, and FACIT Spiritual Well-Being subscale; at 6 months, advance directive (AD) documentation; and at 46 months or death, hospice utilization and length of stay, as well as aggressiveness of care at end of life.

Results

Of 209 patients enrolled (mean [SD] age, 63.6 [14.3] years; 108 [51.7%] male), 105 patients were randomized to control and 104 patients to the intervention. There were no statistically significant differences in the change in mean (SD) QOL score between the intervention and control groups (5.0 [16.5] vs 4.3 [15.5]; P = .75). Participants in the intervention group, compared with the control group, had statistically significant greater increases in mean (SD) ACP engagement (0.8 [1.3] vs 0.1 [1.4]; P < .001) and were more likely to have a documented AD (62 of 104 [59.6%] vs 28 of 105 [26.9%]; P < .001). There were no statistically significant differences in mean (SD) change in pain intensity score (0-10) between patients in the intervention group compared with control (-0.4 [2.6] vs -0.5 [2.8]; P = .79), nor pain interference (-0.2 [3.7] vs -0.4 [3.7]; P = .71). Patients receiving the intervention were more likely to be referred to hospice compared with patients receiving control (19 of 43 patients [44.2%] vs 7 of 33 patients [21.2%]; P = .04) and less likely to receive aggressive care at end of life (27 of 42 patients [64.3%] vs 28 of 33 patients [84.8%]; P = .046).

Conclusion and Relevance

In this randomized clinical trial, a culturally tailored patient navigator intervention did not improve QOL for patients. However, the intervention did increase ACP engagement, AD documentation, and hospice utilization in Hispanic persons with serious medical illness.

Trial Registration

ClinicalTrials.gov Identifier: NCT03181750.

Reality of Family Caregiving for Hispanics With Alzheimer's Disease and Related Dementias: A Qualitative Analysis

Background: Underserved Hispanic patients often experience unmet palliative care (PC) needs, particularly those with noncancer diagnoses such as Alzheimer's disease and related dementias. Most caregivers for Hispanic patients are family relatives who are less likely to use health care and community resources and experience high caregiver burden. We adapted a culturally tailored patient navigator (PN) intervention to provide support and improve PC outcomes for Hispanics with Alzheimer's disease and related dementias and their family caregivers (FCGs). Objectives: To explore Hispanic FCGs' experiences and perceptions of caregiving for a loved one, and how our PN intervention impacted their needs. Design: Qualitative descriptive. Setting/Subjects: FCG participants (n = 10) from our randomized control trial's intervention group were recruited from academic and safety net hospitals and community-based clinics across urban and rural Colorado in the United States. Measurements: Data obtained from individual, semistructured, 30-minute telephone interviews were recorded, transcribed, translated, and analyzed using NVivo and qualitative thematic analyses. Results: Four major themes emerged: Methods of Support, Cultural Expectations and Varying Family Contributions, Lack of Self-Care, and Awareness. Subthemes highlighted differing definitions of "contributing," role resentment, and interpersonal issues. Varying familial expectations underscore FCG strain when the burden of caregiving is not shared. Participants used various coping strategies as necessary support and gained awareness through education, guidance, and referrals to resources. Conclusions: PNs helped FCGs and patients beyond the intervention's scope. Providing support and awareness to FCGs, and incorporating cultural beliefs, may improve PC access to disparate populations and guide future interventions. Clinical Trial Registration Number NCT03181750.

Anxiety and Depression in Metastatic Cancer: A Critical Review of Negative Impacts on Advance Care Planning and End-of-Life Decision Making With Practical Recommendations

PURPOSE

Providers treating adults with advanced cancer increasingly seek to engage patients and surrogates in advance care planning (ACP) and end-of-life (EOL) decision making; however, anxiety and depression may interfere with engagement. The intersection of these two key phenomena is examined among patients with metastatic cancer and their surrogates: the need to prepare for and engage in ACP and EOL decision making and the high prevalence of anxiety and depression.

METHODS

Using a critical review framework, we examine the specific ways that anxiety and depression are likely to affect both ACP and EOL decision making.

RESULTS

The review indicates that depression is associated with reduced compliance with treatment recommendations, and high anxiety may result in avoidance of difficult discussions involved in ACP and EOL decision making. Depression and anxiety are associated with increased decisional regret in the context of cancer treatment decision making, as well as a preference for passive (not active) decision making in an intensive care unit setting. Anxiety about death in patients with advanced cancer is associated with lower rates of completion of an advance directive or discussion of EOL wishes with the oncologist. Patients with advanced cancer and elevated anxiety report higher discordance between wanted versus received life-sustaining treatments, less trust in their physicians, and less comprehension of the information communicated by their physicians.

CONCLUSION

Anxiety and depression are commonly elevated among adults with advanced cancer and health care surrogates, and can result in less engagement and satisfaction with ACP, cancer treatment, and EOL decisions. We offer practical strategies and sample scripts for oncology care providers to use to reduce the effects of anxiety and depression in these contexts.

Identifying Nursing Home Residents with Unmet Palliative Care Needs: A Systematic Review of Screening Tool Measurement Properties

OBJECTIVES

Despite common use of palliative care screening tools in other settings, the performance of these tools in the nursing home has not been well established; therefore, the purpose of this review is to (1) identify palliative care screening tools validated for nursing home residents and (2) critically appraise, compare, and summarize the quality of measurement properties.

DESIGN

Systematic review of measurement properties consistent with Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

SETTINGS AND PARTICIPANTS

Embase (Ovid), MEDLINE (PubMed), CINAHL (EBSCO), and PsycINFO (Ovid) were searched from inception to May 2022. Studies that (1) reported the development or evaluation of a palliative care screening tool and (2) sampled older adults living in a nursing home were included.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias.

RESULTS

We identified only 1 palliative care screening tool meeting COSMIN criteria, the NECesidades Paliativas (NEC-PAL, equivalent to palliative needs in English), but evidence for use with nursing home residents was of low quality. The NEC-PAL lacked robust testing of measurement properties such as reliability, sensitivity, and specificity in the nursing home setting. Construct validity through hypothesis testing was adequate but only reported in 1 study. Consequently, there is insufficient evidence to guide practice. Broadening the criteria further, this review reports on 3 additional palliative care screening tools identified during the search and screening process but which were excluded during full-text review for various reasons.

CONCLUSION AND IMPLICATIONS

Given the unique care environment of nursing homes, we recommend future studies to validate available tools and develop new instruments specifically designed for nursing home use. In the meantime, we recommend that clinicians consider the evidence presented here and choose a screening instrument that best meets their needs.

A randomized controlled trial of a multi-modal palliative care intervention to promote advance care planning and psychological well-being among adults with advanced cancer: study protocol

Background

Up to half of adults with advanced cancer report anxiety or depression symptoms, which can cause avoidance of future planning. We present a study protocol for an innovative, remotely-delivered, acceptance-based, multi-modal palliative care intervention that addresses advance care planning (ACP) and unmet psychological needs commonly experienced by adults with metastatic cancer.

Methods

A two-armed, prospective randomized controlled trial (RCT) randomizes 240 adults with Stage IV (and select Stage III) solid tumor cancer who report moderate to high anxiety or depression symptoms to either the multi-modal intervention or usual care. The intervention comprises five weekly two-hour group sessions (plus a booster session one month later) delivered via video conferencing, with online self-paced modules and check-ins completed between the group sessions. Intervention content is based on Acceptance and Commitment Therapy (ACT), an acceptance, mindfulness, and values-based model. Participants are recruited from a network of community cancer care clinics, with group sessions led by the network’s oncology clinical social workers. Participants are assessed at baseline, mid-intervention, post-intervention, and 2-month follow-up. The primary outcome is ACP completion; secondary outcomes include anxiety and depression symptoms, fear of dying, and sense of life meaning. Relationships between anxiety/depression symptoms and ACP will be evaluated cross-sectionally and longitudinally and theory-based putative mediators will be examined.

Discussion

Among adults with advanced cancer in community oncology settings, this RCT will provide evidence regarding the efficacy of the group ACT intervention on ACP and psychosocial outcomes as well as examine the relationship between ACP and anxiety/ depression symptoms. This trial aims to advance palliative care science and inform clinical practice.

Trial Registration

Clinicaltrials.gov NCT04773639 on February 26, 2021.

Developing the Graduate Nurse Residency: An Oral History With Dr. Colleen Goode and Dr. Mary Krugman

Health care organizations face the challenge of needing newly licensed nurses to fill positions and facilitate competent care for patients. Wide variation in graduate nurse orientation programs, a growing complexity of care, and high graduate nurse turnover rates led to the development of nurse residency programs. The historical perspectives of two nursing pioneers involved in the development of a national model for nurse residency programs provide context to the importance of creating a vision, providing leadership, and applying an evidence-based rationale to structure a series of learning and work experiences designed to support graduate nurses as they transition into their first professional nursing position. [J Contin Educ Nurs. 2022;53(4):171-177.].

Transitioning to Remote Recruitment and Intervention: A Tale of Two Palliative Care Research Studies Enrolling Underserved Populations During COVID-19

CONTEXT

During the COVID-19 pandemic, community-based research studies experienced prolonged shutdowns unless able to pivot to remote study procedures.

OBJECTIVES

To describe the revision of two National Institutes of Health funded community-based palliative-focused clinical trials serving underserved populations to accommodate remote subject enrollment and examine its impact.

METHODS

Transitioning to remote processes required multiple protocol and procedural changes including: altering informed consent processes; reducing the number of surveys administered; adding internet access as an inclusion criterion. To understand technological challenges, a screening tool was developed for one study to identify potentially eligible subjects' technology abilities and accessibility.

RESULTS

Subjects' limited access to the internet and internet-enabled devices and discomfort with technology led to changes in recruitment patterns. Lack of familiarity with technology increased the amount of time it took research team members and subjects to connect remotely. Patients with significant cognitive and/or sensory deficits were at higher risk of experiencing fatigue during remote study visits leading to streamlining of data collection. A researcher-developed technology screening tool found that potential subjects were not comfortable with videoconferencing through Zoom expressing a preference for phone visits. Reduced travel time made scheduling remote study visits more efficient.

CONCLUSION

Future community- and home-based palliative care trials must consider the best way to utilize remote recruitment, enrollment, and data collection processes to increase efficiency and reduce costs. Researchers should consider technology accessibility and train staff to ensure the greatest possible opportunity to recruit underserved populations who have traditionally been underrepresented in research studies.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

A scoping review of nurse-led advance care planning

BACKGROUND

Advance care planning (ACP) supports persons at any age or health status to determine their values, goals, and preferences regarding future medical care. The American Nurses Association endorses nurses to facilitate ACP to promote patient- and family-centered care.

PURPOSE

This project reviewed and synthesized literature on nurse-led ACP training models.

METHODS

A scoping review used the Arksey and O'Malley Framework to identify: (a) ACP training model type, (b) nurse-led ACP recipients, (c) ACP in special populations, (d) ACP outcomes.

FINDINGS

Of 33 articles reviewed, 19 included 11 established models; however, the primary finding was lack of a clearly identified evidence-based nurse-led ACP training model.

DISCUSSION

Nurses are integral team members, well positioned to be a bridge of communication between patients and care providers. This is a call to action for nurse leaders, researchers, educators to collaborate to identify and implement an evidence-based, effective nurse-led ACP training model.

International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

A Psychometric Evaluation of the Casey-Fink Graduate Nurse Experience Survey

OBJECTIVE

The purpose of this study was to evaluate the psychometric properties of the Casey-Fink Graduate Nurse Experience Survey (CFGNES).

BACKGROUND

Transitioning from the student role to professional nurse is challenging and stressful. Accurate measurement of role transition is important because of concerns regarding retention.

METHODS

A secondary analysis of 71 919 graduate nurse responses to the CFGNES, collected 6 months into the Vizient/AACN residency program, was conducted. Psychometric testing included exploratory and confirmatory factor analysis. Internal consistency reliability was measured using Cronbach's α.

RESULTS

Analysis revealed a consistent 5-factor solution. Factors were labeled job satisfaction, support, organize/prioritize care, role confidence, and professional socialization. Results demonstrated the CFGNES is a reliable and valid instrument for measuring perceptions of role transition.

CONCLUSIONS

This study was needed to inform survey item revisions. The CFGNES continues to be valuable in providing voice to the needs of graduate nurses and evidence for improving nurse residency program outcomes.

Global Survey of the Roles, Satisfaction, and Barriers of Home Health Care Nurses on the Provision of Palliative Care

Background: The World Health Assembly urges members to build palliative care (PC) capacity as an ethical imperative. Nurses provide PC services in a variety of settings, including the home and may be the only health care professional able to access some disparate populations. Identifying current nursing services, resources, and satisfaction and barriers to nursing practice are essential to build global PC capacity. Objective: To globally examine home health care nurses' practice, satisfaction, and barriers, regarding existing palliative home care provision. Design: Needs assessment survey. Setting/Subjects: Five hundred thirty-two home health care nurses in 29 countries. Measurements: A needs assessment, developed through literature review and cognitive interviewing. Results: Nurses from developing countries performed more duties compared with those from high-income countries, suggesting a lack of resources in developing countries. Significant barriers to providing home care exist: personnel shortages, lack of funding and policies, poor access to end-of-life or hospice services, and decreased community awareness of services provided. Respondents identified lack of time, funding, and coverages as primary educational barriers. In-person local meetings and online courses were suggested as strategies to promote learning. Conclusions: It is imperative that home health care nurses have adequate resources to build PC capacity globally, which is so desperately needed. Nurses must be up to date on current evidence and practice within an evidence-based PC framework. Health care policy to increase necessary resources and the development of a multifaceted intervention to facilitate education about PC is indicated to build global capacity.

Community-Based Conversations about Advance Care Planning for Underserved Populations Using Lay Patient Navigators

Background: Widespread community engagement in advance care planning (ACP) is needed to overcome barriers to ACP implementation. Objective: Develop, implement, and evaluate a model for community-based ACP in rural populations with low English language fluency and health care access using lay patient navigators. Design: A statewide initiative to improve ACP setting/subjects-trained in a group session approach, bilingual patient navigators facilitated 1-hour English and Spanish ACP sessions discussing concerns about choosing a surrogate decision maker and completing an advance directive (AD). Participants received bilingual informational materials, including Frequently Asked Questions, an AD in English or Spanish, and Goal Setting worksheet. Measurement: Participants completed a program evaluation and 4-item ACP Engagement Survey (ACP-4) postsession. Results: For 18 months, 74 ACP sessions engaged 1034 participants in urban, rural, and frontier areas of the state; 39% were ethnically diverse, 69% female. A nurse or physician co-facilitated 49% of sessions. Forty-seven percent of participants completed an ACP-4 with 29% planning to name a decision maker in the next 6 months and 21% in the next 30 days; 31% were ready to complete an AD in the next 6 months and 22% in the next 30 days. Evaluations showed 98% were satisfied with sessions. Thematic analysis of interviews with facilitators highlighted barriers to delivering an ACP community-based initiative, strategies used to build community buy-in and engagement, and ways success was measured. Conclusion: Patient navigators effectively engaged underserved and ethnically diverse rural populations in community-based settings. This model can be adapted to improve ACP in other underserved populations.

Interprofessional Master of Science in Palliative Care: On Becoming a Palliative Care Community Specialist

Background: Palliative care (PC) is a limited resource in health care systems. Many providers develop a PC interest later in their careers when it is difficult to relocate and compete for a limited number of training positions. In communities without an academic tertiary medical center, interprofessional PC community specialists are poised to deliver high-quality accessible PC to patients/families with needs beyond what can be addressed by primary care providers. Objective: An interprofessional 36-credit Master of Science in Palliative Care (MSPC) provides evidence-based education to nurses, pharmacists, physicians, physician assistants, social workers, spiritual care providers, psychologists, counselors, and other allied health professionals. Design: The predominantly online curriculum, designed and taught by an interprofessional faculty, focuses on interdisciplinary teamwork, communication skills, and practical application of biomedical and psycho-sociocultural-spiritual-ethics content. The pedagogy is narrative based, emulating in-person clinical experiences, with patient cases progressing throughout the curriculum. We have enrolled four student cohorts. Measurements: Student self-assessments pre-mid-post program. Results: Students highly rate curriculum with demonstrated application of knowledge in case integration assignments, simulations with standardized patients, and Capstone Projects. Students' self-assessed skills on a 39-item scale increased on average to the highest level of 5 (able to perform independently and teach others). Conclusions: The inaugural student cohort reports high levels of engagement and satisfaction, including mastery and synthesis of didactic and experiential content through case integration projects. Students who worked in PC/hospice settings have advanced in their professions; others have transitioned to PC work. The MSPC has capacity to meet projected PC workforce gaps.

Effect of Apoyo con Cariño (Support With Caring) Trial of a Patient Navigator Intervention to Improve Palliative Care Outcomes for Latino Adults With Advanced Cancer: A Randomized Clinical Trial

Importance

Strategies to increase access to palliative care, particularly for racial/ethnic minorities, must maximize primary palliative care and community-based models to meet the ever-growing need in a culturally sensitive and congruent manner.

Objective

To investigate if a culturally tailored patient navigator intervention can improve palliative care outcomes for Latino adults with advanced cancer.

Design, Setting, and Participants

The Apoyo con Cariño (Support With Caring) randomized clinical trial was conducted from July 2012 to March 2016. The setting was clinics across the state of Colorado, including an academic National Cancer Institute-designated cancer center, community cancer clinics (urban and rural), and a safety-net cancer center. Participants were adults who self-identified as Latino and were being treated for advanced cancer.

Intervention

Culturally tailored patient navigator intervention.

Main Outcomes and Measures

Primary outcome measures were advance care planning in the medical record, the Brief Pain Inventory, and hospice use. Secondary outcome measures included the McGill Quality of Life Questionnaire (MQOL), hospice length of stay, and aggressiveness of care at the end of life. This study used an intent-to-treat design.

Results

In total, 223 Latino adults enrolled (mean [SD] age, 58.1 [13.6] years; 55.6% female) and were randomized to control (n = 111) or intervention (n = 112) groups. Intervention group patients were more likely to have a documented advance directive compared with control group patients (73 of 112 [65.2%] vs 40 of 111 [36.0%], P < .001). Both groups reported mild pain intensity (mean pain rating of 3 on a scale of 0-10). Intervention group patients had a mean (SD) reported change from baseline in the Brief Pain Inventory pain severity subscale score (range, 0-10) of 0.1 (2.6) vs 0.2 (2.7) in control group patients (P = .88) and a mean (SD) reported change from baseline in the Brief Pain Inventory pain interference subscale score of 0.1 (3.2) vs -0.2 (3.0) in control group patients (P = .66). Hospice use was similar in both groups. Secondary outcomes of overall MQOL score and aggressiveness of care at the end of life showed no significant differences between groups. The MQOL physical subscale showed a mean (SD) significant change from baseline of 1.4 (3.1) in the intervention group vs 0.1 (3.0) in the control group (P = .004).

Conclusions and Relevance

The intervention had mixed results. The intervention increased advance care planning and improved physical symptoms; however, it had no effect on pain management and hospice use or overall quality of life. Further research is needed to determine the role and scope of lay navigators in palliative care.

Trial Registration

ClinicalTrials.gov identifier: NCT01695382.

Apoyo con Cariño (support with caring): RCT protocol to improve palliative care outcomes for Latinos with advanced medical illness

Latinos are more likely to experience uncontrolled pain, and institutional death, and are less likely to engage in advance care planning. Efforts to increase access to palliative care must maximize primary palliative care and community based models to meet the ever-growing need in a culturally sensitive and congruent manner. Patient navigator interventions are community-based, culturally tailored models of care that have been successfully implemented to improve disease prevention, early diagnosis, and treatment. We have developed a patient navigation intervention to improve palliative care outcomes for seriously ill Latinos. We describe the protocol for a National Institute of Nursing Research-funded randomized controlled trial designed to determine the effectiveness of the manualized patient navigator intervention. We aim to enroll 240 Latino adults with non-cancer, advanced medical illness from both urban and rural clinical sites. Participants will be randomized to the intervention group (five palliative care patient navigator visits plus bilingual educational materials) or control group (usual care plus bilingual educational materials). Outcomes include quality of life (Functional Assessment of Chronic Illness Therapy), advance care planning (Advance Care Planning Engagement survey), pain (Brief Pain Inventory), symptom management (Edmonton Symptom Assessment Scale-revised), hospice utilization, and cost and utilization of healthcare resources. This culturally tailored, evidence-based, theory-driven, innovative patient navigation intervention has significant potential to improve palliative care for Latinos, and facilitate health equity in palliative and end-of-life care.

Apoyo con Cariño: Strategies to Promote Recruiting, Enrolling, and Retaining Latinos in a Cancer Clinical Trial

Background: We present and describe tailored strategies to address known barriers to minority participation in clinical trial research. The strategies used allowed our team to engage communities and successfully recruit, enroll, and retain a diverse underserved population of Latinos with advanced cancer for this clinical trial. Methods: Participants were recruited from 3 urban and 7 rural sites. We identified 4 critical barriers to recruitment for this underserved population: (1) mistrust; (2) language and communication barriers; (3) lack of access to academic cancer center; and (4) inability to participate due to transportation, childcare, or work responsibilities. We developed tailored strategies to engage referring sites and patients to participate in the clinical trial. Results: We identified 318 potentially eligible participants; 34 were found to be ineligible, and 223 consented to participate in the study, representing a 79.0% enrollment rate. All patients (100%) self-identified as Latino, and 47.5% spoke Spanish as their primary language. Patients were socioeconomically disadvantaged: 53.6% had an annual income <$15,000 USD, and 50.2% had less than a high school education. A total of 177 participants completed the 3-month follow-up; 26 died before the 3-month follow interview, and 20 did not complete the follow-up evaluation (9% withdrawal rate). Conclusions: Our community-informed strategies were highly effective for recruiting, enrolling, and retaining an underserved diverse population of Latinos. The barriers we identified and the strategies we used have the potential to inform research to increase minority participation in cancer clinical trials. ClinicalTrials.gov identifier: NCT01695382.

Systematic Review of Palliative Care in the Rural Setting

BACKGROUND

Many of the world's population live in rural areas. However, access and dissemination of the advances taking place in the field of palliative care to patients living in rural areas have been limited.

METHODS

We searched 2 large databases of the medical literature and found 248 relevant articles; we also identified another 59 articles through networking and a hand search of reference lists. Of those 307 articles, 39 met the inclusion criteria and were grouped into the following subcategories: intervention (n = 4), needs assessment (n = 2), program planning (n = 3), program evaluation (n = 4), education (n = 7), financial (n = 8), and comprehensive/systematic literature reviews (n = 11).

RESULTS

We synthesized the current state of rural palliative care research and practice to identify important gaps for future research. Studies were conducted in the United States, Australia, Canada, Africa, Sweden, and India. Two randomized control trials were identified, both of which used telehealth approaches and had positive survival outcomes. One study demonstrated positive patient quality of life and depression outcomes.

CONCLUSIONS

Research to guide rural palliative care practice is sparse. Approaches to telehealth, community- academic partnerships, and training rural health care professionals show promise, but more research is needed to determine best practices for providing palliative care to patients living in rural settings.

Apoyo con Cariño: a pilot randomized controlled trial of a patient navigator intervention to improve palliative care outcomes for Latinos with serious illness

CONTEXT

Latinos experience significant health disparities at the end of life compared with non-Latinos.

OBJECTIVES

To determine the feasibility of a patient navigator intervention to improve palliative care outcomes for Latino adults with serious illness.

METHODS

This was a pilot randomized controlled trial that included 64 Latino adults with life-limiting illness randomized to an intervention or a control group. All participants received a packet of linguistically matched materials on palliative care. In addition, intervention participants received up to five home visits from the bilingual, bicultural patient navigator. Visits focused on addressing barriers to palliative care through education, activation, and culturally tailored messaging. Outcomes included feasibility and advance care planning rates, documentation of pain management discussions in the medical record, and hospice utilization.

RESULTS

Of the 32 patients randomized to the intervention arm, 81% had at least one home visit (range 1-5) with the patient navigator. Overall, advance care planning was higher in the intervention group (47% [n = 15] vs. 25% [n = 8], P = 0.06), and 79% of intervention participants had a discussion about pain management documented in their medical record vs. 54% of control patients (P = 0.05). Hospice enrollment between the two groups (n = 18 decedents) was similar (n = 7 intervention vs. n = 6 control); length of stay in the intervention group was 36.4 ± 51.6 vs. 19.7 ± 33.6 days for control patients (P = 0.39).

CONCLUSION

A culturally tailored patient navigator intervention was feasible and suggests improved palliative care outcomes for Latinos facing advanced medical illness, justifying a fully powered randomized controlled trial.

Measuring pain perceptions and medication taking behavior at the end of life: a pilot study

BACKGROUND

Understanding why some patients with terminal illness are reluctant to take sufficient medication to control pain is critical to effective pain management.

OBJECTIVE

As a first step toward exploring the pain medication-taking behavior of palliative care patients, this pilot study tested a survey regarding pain medication adherence, medication beliefs, and quality of life (QoL).

DESIGN

Convenience sample; survey.

SETTING/SUBJECTS

Six patients receiving inpatient Palliative Care consultations at an academic medical center answered questions about their outpatient pain medication-taking behavior.

MEASUREMENTS

Medication Adherence Report Scale (MARS), Beliefs about Medications Questionnaire (BMQ), Brief Pain Inventory (BPI), closed-response items from a pain medication adherence study in terminally ill patients, the McGill Quality of Life Questionnaire (McGill), and demographic items.

RESULTS

The battery of questionnaires took approximately 53 minutes; five of six participants were able to complete all items. Respondents reported moderate to severe pain (mean 4.3/10 for pain on average; 7/10 for worst pain in past 24 hours), and excellent medication adherence. When asked how much relief was provided by pain therapies, respondents reported a mean 73% (range 50-100%) relief. They expressed little concern about addiction, but more concern about medication-induced nausea and constipation. Overall QoL was good (mean 6.8/10, range 5-10, higher score better), with notably high scores in existential and support domains.

CONCLUSIONS

Inpatients receiving palliative care consultation were able to complete interviewer-administered questionnaires regarding their pain perceptions, medications, and QoL. Further studies using these instruments are feasible and could inform shared decision making about pain management.

A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia

OBJECTIVE

Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates.

DESIGN

Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial.

SETTING

Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007.

PARTICIPANTS

Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible.

INTERVENTION

Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education.

MEASUREMENTS

Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding.

RESULTS

Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections.

CONCLUSIONS

Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.

PLASMA PROTEIN METABOLISM-NORMAL AND ASSOCIATED WITH SHOCK : OBSERVATIONS USING PROTEIN LABELED BY HEAVY NITROGEN IN LYSINE

Labeled plasma proteins are produced by administering to dogs the amino acid lysine synthesized with heavy nitrogen. Such labeled proteins are apparently indistinguishable biologically from proteins of normal isotope concentration. Labeled plasma proteins, as plasma, injected into normal dogs pass out of the blood stream at an initially rapid but constantly decreasing non-logarithmic rate. This outflow is balanced by a simultaneous inflow of plasma proteins from the tissues. Fifty per cent of the labeled protein is out of the blood stream in about 24 hours; 75 per cent in about 6 days. Shock due to trauma of intestine or leg shows a dilution curve of labeled plasma protein not unlike that of the normal dog. If anything, dilution appears a little less rapid in shock. Since the usual shrinkage of plasma volume and plasma protein mass is present in these shocked dogs, these data are compatible with a decreased inflow of protein into the plasma during shock. Methods are described which are suitable for the use of heavy nitrogen incorporated in the epsilon group of lysine and its subsequent analysis in body fluids. These data may indicate that the plasma proteins are normally in constant and rapid exchange with a mobile pool of body protein.

The impact of dry versus moist heat on peripheral IV catheter insertion in a hematology-oncology outpatient population

PURPOSE/OBJECTIVES

To determine whether dry versus moist heat application to the upper extremity improves IV insertion rates.

DESIGN

Two-group, randomized, controlled clinical design.

SETTING

An academic cancer infusion center in the western United States.

SAMPLE

136 hematologic outpatients with cancer or other malignancies.

METHODS

Participants were randomly assigned to dry or moist heat with warmed towels wrapped around each patient's arm for seven minutes prior to IV insertion. Skin and room temperatures were monitored pre- and postwarming. Two experienced chemotherapy infusion nurses performed the venipunctures according to protocol. Outcomes were examined using variance analysis, with 34 patients for each combination of nurse and heat type.

MAIN RESEARCH VARIABLES

Number of IV insertion attempts, time to achieve IV insertion postheating, patient anxiety levels pre- and postheating, and patient comfort.

FINDINGS

Dry heat was 2.7 times more likely than moist heat to result in successful IV insertion on the first attempt, had significantly lower insertion times, and was more comfortable. Heat type had no effect on patient anxiety.

CONCLUSIONS

Dry heat application decreases the likelihood of multiple IV insertion attempts and procedure time and is comfortable, safe, and economical to use in an outpatient oncology setting.

Nursing Home Resident Barriers to Effective Pain Management: Why Nursing Home Residents May Not Seek Pain Medication

OBJECTIVES

Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior.

DESIGN

Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication.

SETTING

The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings.

PARTICIPANTS

A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices.

MEASUREMENTS

A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication.

RESULTS

More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01).

CONCLUSION

Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication

OBJECTIVES

Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior.

DESIGN

Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication.

SETTING

The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings.

PARTICIPANTS

A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices.

MEASUREMENTS

A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication.

RESULTS

More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01).

CONCLUSION

Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Hyaluronic acid degradation by ascorbic acid and influence of iron

The effects of ascorbic acid, iron and ADP on hyaluronic acid, a compound present in inflamed joints, were investigated in an in vitro system. Ascorbic acid induces degradation of hyaluronic acid which increased in the presence of FeCl3 and which is additionally stimulated by ADP chelated ferric ions. The hyaluronic acid degrading reactions induced by the Fe-III/ADP/ascorbic acid system were inhibited by catalase and formate to various extents whereas the presence of superoxide dismutase did not exert any inhibitory effect. Desferrioxamine, a specific iron chelator, completely inhibited hyaluronic acid depolymerisation by ascorbic acid as well as in combination with FeCl3 or FeCl3/ADP, respectively. We suggest that the ultimate hyaluronic acid degrading species is OH, generated via the Fe-III/ADP catalysed Haber Weiss reaction. There is also an indication for the involvement of perferryl or/and ferryl species in the degradation process.

Effects of hyperthermic conditions on the reactivity of oxygen radicals

Generation and reactivity of superoxide (O2.-) and hydroxyl (OH.) radicals in enzymatic and radiolytic systems were investigated over the temperature range from 20 degrees-50 degrees C. The generation rate and reaction kinetics of both enzymatically and radiolytically produced superoxide radicals were determined by a cytochrome c reduction assay. For OH. radical reaction studies the degradation of hyaluronic acid was assayed. An increase in temperature leads to a greater reactivity of both radicals, but in the case of an enzymatic source a disproportionate increase in the rate of generation is observed. In the pulse radiolysis system, the reactivity of superoxide radicals was found to be stimulated 15-fold over the temperature range from 20 degrees C to 60 degrees C, although the activity of superoxide dismutase was only minimally increased (about 1.6-fold). The results are discussed with respect to the possible importance of active oxygen species to the biological effects of hyperthermia.

Comparison of different methods for the determination of phenylalanine hydroxylase activity in rat liver and Euglena gracilis

Three different methods for the determination of phenylalanine hydroxylase activity have been compared: a) Differential photometric assay of the increase in tyrosine concentration in the presence of phenylalanine; b) Product separation by thin layer chromatography and scintillation counting of the [14C]tyrosine formed; c) HPLC separation and spectrofluorometric quantification of derivatized amino acids. A comparison of the activities of phenylalanine hydroxylase in rat liver and Euglena gracilis clearly showed that only rat liver contains this enzymic activity as shown by methods b) and c) although pseudo-activity of Euglena gracilis preparations was found during the spectrophotometric test a). The HPLC method proved to be the fastest, most reliable and convenient method for direct tyrosine determination and thus for measuring phenylalanine hydroxylase activity.

Studies on the possible mechanism of inactivation of phenylalanine hydroxylase by destructive oxygen species

The enzymic hydroxylation of phenylalanine by phenylalanine hydroxylase (E.C. 1.14.16.1.) in vitro is dependent on the presence of hydrogen peroxide removing processes. The loss of phenylalanine hydroxylase activity can be prevented to the same extent by catalase as well as the presence of optimized amounts of both peroxidase and superoxide dismutase. Peroxidase alone exhibited only two third of the maximal protective effect of catalase whereas superoxide dismutase alone was not able to exert any protective influence on phenylalanine hydroxylase. These findings suggest that the termination of phenylalanine hydroxylation in the absence of hydrogen peroxide removing reactions is probably due to destructive oxygen species generated at the active site iron of phenylalanine hydroxylase in the presence of H2O2 and the tetrahydropterin cofactor.