Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study

BACKGROUND

The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability.

AIM

To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers.

DESIGN

Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure.

SETTING

European.

PARTICIPANTS

International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation.

RESULTS

A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided.

CONCLUSIONS

This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.

Edmonton Classification System for Cancer Pain: Comparison of Pain Classification Features and Pain Intensity across Diverse Palliative Care Settings in Canada

Background: The goal of the Edmonton Classification System for Cancer Pain (ECS-CP) is to create an international classification system for cancer pain. Previous studies reinforce the need for standardized training to ensure consistency across assessors. There is no universally accepted classification for neuropathic pain. Objectives: Our primary objective was to describe the prevalence of ECS-CP features in a diverse sample of advanced cancer patients, using assessors with standardized training. The secondary objectives were to: (1) determine the prevalence of neuropathic pain using the Neuropathic Pain Special Interest Group (NeuPSIG) criteria and (2) examine the relationship between specific predictors: ECS-CP features, age, Palliative Performance Scale, Morphine Equivalent Daily Dose (MEDD), setting, and pain intensity; and neuropathic pain. Methods: A total of 1050 adult patients with advanced cancer were recruited from 11 Canadian sites. A clinician completed the ECS-CP and NeuPSIG criteria, and collected additional information including demographics and pain intensity (now). All assessors received standardized training. Results: Of 1050 evaluable patients, 910 (87%) had cancer pain: nociceptive (n = 626; 68.8%); neuropathic (n = 227; 24.9%); incident (n = 329; 36.2%); psychological distress (n = 209; 23%); addictive behavior (n = 51; 5.6%); and normal cognition (n = 639; 70.2%). The frequencies of ECS-CP features and pain intensity scores varied across sites and settings, with more acute settings having higher frequencies of complex pain features. The overall frequency of neuropathic pain was 24.9%, ranging from 11% (hospices) to 34.2% (palliative outpatient clinic) across settings. Multivariate logistic regression analysis revealed that age <60 years, MEDD ≥19 mg, pain intensity ≥7/10, and incident pain were significant independent predictors of neuropathic pain (p < 0.05). Conclusion: The ECS-CP was able to detect salient pain features across settings. Furthermore, the frequencies of neuropathic pain utilizing the NeuPSIG criteria fits within the lower-end of literature estimates (13%-40%). Further research is warranted to validate the NeuPSIG criteria in cancer pain.

Investigating the benefits and harms of hypodermoclysis of patients in palliative care: A consecutive cohort study

BACKGROUND

Palliative populations are at risk for dehydration which can cause discomfort, distress and cognitive symptoms. Subcutaneous hydration ('hypodermoclysis') has been used as an alternative administration route to the more invasive intravenous route, but research is lacking on its net clinical effects (harms and benefits) for palliative populations, particularly in real world settings.

AIM

To quantify prospectively the net clinical effects of hypodermoclysis in palliative patients with advanced disease who required supplementary fluids.

DESIGN

Multisite, multinational consecutive cohort study.

SETTING/PARTICIPANTS

Patients receiving hypodermoclysis in an inpatient palliative care setting.

RESULTS

Twenty sites contributed data for 99 patients, of which 88 had complete benefits and harms data. The most common primary target symptom for infusion was generalised weakness (18.2%), and the most common non-symptom indication was supplemental hydration (31.8%). Benefits were experienced in 33% of patients in their primary target symptom, and in any symptom in 56.8%. Harms were experienced in 38.7% of patients (42% at Grade 1). Benefits increased with higher performance status, while harms were more frequent in patients with lower performance status (Australia-modified Karnofsky performance status ⩽40). Patients in the terminal phase of their illness experienced the least benefit (15.4% in any indication only) and had more frequent harms (38%).

CONCLUSIONS

Hypodermoclysis may improve certain symptoms in patients in palliative care but frequency of harms and benefits may differ at certain timepoints in the illness trajectory. Further research is needed to better delineate which patients will derive the most net clinical benefit from hypodermoclysis.

Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus

OBJECTIVES

Despite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and management of opioid-related harms. The Delphi technique was used to develop expert consensus recommendations about how to promote opioid safety in adults receiving PC in Canada and the USA.

METHODS

Through a Delphi process comprised of two rounds, USA and Canadian panellists in PC, addiction and pain medicine developed expert consensus recommendations. Elected Canadian Society of Palliative Care Physicians (CSPCP) board members then rated how important it is for PC physicians to be aware of each consensus recommendation.They also identified high-priority research areas from the topics that did not achieve consensus in Round 2.

RESULTS

The panellists (Round 1, n=23; Round 2, n=22) developed a total of 130 recommendations from the two rounds about the following six opioid-safety related domains: (1) General principles; (2) Measures for healthcare institution and PC training and clinical programmes; (3) Patient and caregiver assessments; (4) Prescribing practices; (5) Monitoring; and (6) Patients and caregiver education. Fifty-nine topics did not achieve consensus and were deemed potential areas of research. From these results, CSPCP identified 43 high-priority recommendations and 8 high-priority research areas.

CONCLUSIONS

Urgent guidance about opioid safety is needed to address the opioid crisis. These consensus recommendations can promote safer opioid use, while recognising the importance of these medications for PC symptom management.

Preferences for Continence Care Experienced at End of Life: A Qualitative Study

CONTEXT

Functional dependence at end of life often leaves individuals requiring help for personal care, including maintaining continence. Current continence guidelines offer little direction for end of life continence care, and little is known of the perspectives of people receiving palliative care.

OBJECTIVES

The aim of the study was to examine the continence care preferences of people receiving palliative care to understand what approaches to care and what goals of care are important to them.

METHODS

This is a qualitative descriptive exploratory study with data gathered in individual interviews using a semi-structured interview guide. Participants were receiving bladder and/or bowel care on either tertiary or hospice palliative care units.

RESULTS

Fourteen Canadian patients (seven female, seven male), six from tertiary and eight from hospice palliative care units, were recruited. From the analysis, three themes were identified: loss of control, finding a way to manage, and caregivers can help and can hinder. Dignity was often lost as a result of having to receive continence care, with most participants following staff recommendations for management approaches as the easiest way. Patients did not recall being asked about their bladder and bowel preferences.

CONCLUSIONS

As patients approached end of life they were willing to give up dignity if it was required to address symptoms causing them more distress, like pain. Health care professionals and family have an important role in social interactions around continence care. Health care professionals should incorporate patient preferences as best they can and explain the options when treating incontinence at end of life.

Antibiotic Use in the Last Week of Life in Three Different Palliative Care Settings

The purpose of this study was to examine the frequency and types of antibiotics prescribed in the last week of life in three different palliative care settings, including an acute care hospital, tertiary palliative care unit, and three hospice units. A total of 150 consecutive patients were evaluated, 50 in each of the three settings. Twenty-nine patients (58%) in the acute hospital setting, 26 (52%) in the tertiary palliative care unit, and 11(22%) in the hospice settings were prescribed antibiotics. In the acute care and tertiary palliative care settings, the most frequent route of antibiotic administration was intravenous and, in the hospice setting, oral. We conclude that there is marked variability in the numbers and types of antibiotics prescribed in these different palliative care settings in the last week of life. The high use of intravenous antibiotics and the large number of patients who were still receiving antibiotics at the time of death indicate the need for further prospective studies.

Continuous Palliative Sedation for Existential Distress? A Survey of Canadian Palliative Care Physicians' Views

BACKGROUND

Palliative sedation can be used for refractory symptoms during end-of-life care. However, continuous palliative sedation (CPS) for existential distress remains controversial due to difficulty determining when this distress is refractory.

OBJECTIVES

The aim was to determine the opinions and practices of Canadian palliative care physicians regarding CPS for existential distress.

METHODS

A survey focusing on experience and views regarding CPS for existential distress was sent to 322 members of the Canadian Society of Palliative Care Physicians.

RESULTS

Eighty-one surveys returned (accessible target, 314), resulting in a response rate of 26%. One third (31%) of the respondents reported providing CPS for existential distress. On a 5-point Likert-type scale, 40% of participants disagreed, while 43% agreed that CPS could be used for existential distress alone.

CONCLUSION

Differing opinions exist regarding this complex and potentially controversial issue, necessitating the education of health-care professionals and increased awareness within the general public.

Single-Nucleotide Polymorphisms in TAOK3 Are Associated With High Opioid Requirement for Pain Management in Patients With Advanced Cancer Admitted to a Tertiary Palliative Care Unit

PURPOSE

Different amounts of opioid are required for the relief of cancer pain in different individuals, raising the possibility that genetic factors play a role. We tested the hypothesis that genetic variations in the TAOK3 (TAO kinase 3, encoding serine/threonine-protein kinase) explain some of the interindividual variations related to the morphine-equivalent daily dose (MEDD) in patients with cancer.

EXPERIMENTAL DESIGN

We selected two single-nucleotide polymorphisms (SNPs) in the TAOK3, reported earlier to associate with higher MEDD in postoperative pain based on genome-wide association study. We investigated their association with MEDD in Canadian patients with cancer (n = 110) admitted to a tertiary palliative care unit. SNPs analyzed were rs1277441 (C/T, C = minor allele) and rs795484 (A/G, A = minor allele).

RESULTS

Minor allele frequencies in our population were 0.29 (rs1277441) and 0.28 (rs795484). These SNPs were in perfect linkage disequilibrium (r² = 0.97). SNPs in TAOK3 showed a significant association with mean MEDD ≥800 mg. For rs795484, MEDD values ≥800 mg occurred in patients who were GG (7%), GA (18%), and AA (57%) (P = 0.004; Fisher's exact test); similar results were obtained for rs1277441. Homozygous variants for either SNP had received higher numbers of different opioids (P = 0.021).

CONCLUSION

In this cohort of patients with advanced cancer pain, TAOK3 SNPs were associated with opioid doses. This result supports the original findings from a GWAS in postoperative patients. The proportions of variant homozygotes (8.2% of patients) and their requirement for higher doses of opioids would appear potentially clinically important and should be validated in further studies.

What is stable pain control? A prospective longitudinal study to assess the clinical value of a personalized pain goal

BACKGROUND

A universal consensus regarding standardized pain outcomes does not exist. The personalized pain goal has been suggested as a clinically relevant outcome measure.

AIM

To assess the feasibility of obtaining a personalized pain goal and to compare a clinically based personalized pain goal definition versus a research-based study definition for stable pain.

DESIGN

Prospective longitudinal descriptive study.

MEASURES

The attending physician completed routine assessments, including a personalized pain goal and the Edmonton Classification System for Cancer Pain, and followed patients daily until stable pain control, death, or discharge. Stable pain for cognitively intact patients was defined as pain intensity less than or equal to desired pain intensity goal (personalized pain goal definition) or pain intensity ⩽3 (Edmonton Classification System for Cancer Pain study definition) for three consecutive days with <3 breakthroughs per day.

SETTING/PARTICIPANTS

A total of 300 consecutive advanced cancer patients were recruited from two acute care hospitals and a tertiary palliative care unit.

RESULTS

In all, 231/300 patients (77%) had a pain syndrome; 169/231 (73%) provided a personalized pain goal, with 113/169 (67%) reporting a personalized pain goal ⩽3 (median = 3, range = 0-10). Using the personalized pain goal definition as the gold standard, sensitivity and specificity of the Edmonton Classification System for Cancer Pain definition were 71.3% and 98.5%, respectively. For mild (0-3), moderate (4-6), and severe (7-10) pain, the highest sensitivity was for moderate pain (90.5%), with high specificity across all three categories (95%-100%).

CONCLUSION

The personalized pain goal is a feasible outcome measure for cognitively intact patients. The Edmonton Classification System for Cancer Pain definition closely resembles patient-reported personalized pain goals for stable pain and would be appropriate for research purposes. For clinical pain management, it would be important to include the personalized pain goal as standard practice.

Impact of palliative care (PC) consultation on quality of end-of-life (EOL) care in advanced cancer patients receiving care at a tertiary cancer center (TCC)

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Background: Early integration of PC with oncological care has been shown to improve outcomes in patients with advanced cancer, including quality of life and mood. It has also been suggested to have a positive impact on quality of EOL care. The purpose of our study was to examine how occurrence and timing of PC consultation are associated with quality of EOL care in advanced cancer patients receiving care at a Canadian TCC. Methods: In this retrospective study, patients who died between April 1, 2013 and March 31, 2014, had advanced cancer while receiving care at our TCC, and lived in the catchment area of our urban comprehensive integrated PC program were eligible. Date of death, demographics, and cancer type were obtained from the cancer registry. Date of diagnosis of advanced cancer was determined from electronic medical records. Occurrence and date of PC consultation were identified from the PC database. Data on quality of EOL care indicators were retrieved from the cancer registry, including, in the last 30 days of life: emergency room visits, hospital admission, hospitalization > 14 days, ICU admission, death in hospital, and chemotherapy use. Results: Of 1414 eligible patients, 1101 (77.9%) received PC consultation in hospital, outpatient clinic, or community. Patients who received PC consultation were younger than those who did not receive PC consultation (age 68.8 vs. 71.0, p = 0.01), and differed in the frequency of cancer types (p < 0.001), but not sex, marital status, or income. 679 patients (48.0%) had at least 1 indicator of quality of EOL care. Patients who did and did not receive PC consultation did not differ in the frequency of any indicators of quality of EOL care. There were also no differences in frequency of quality of EOL care indicators between patients who received their first PC consultation > 3 months vs. ≤3 months or > 6 months vs. ≤6 months before death. Conclusions: Among advanced cancer patients receiving care at our TCC, occurrence and timing of PC consultation did not affect quality of EOL care. Methodological and healthcare system differences may explain the discrepancy between our results and those of other investigators. Further research is needed.

Impact of Adding a Pictorial Display to Enhance Recall of Cancer Patient Histories: A Randomized Trial

CONTEXT

Current health care delivery models have increased the need for safe and concise patient handover. Handover interventions in the literature have focused on the use of structured tools but have not evaluated their ability to facilitate retention of patient information.

OBJECTIVES

In this study, mock pictorial displays were generated in an attempt to create a snapshot of each patient's medical and social circumstances. These pictorial displays contained the patient's photograph and other disease- and treatment-related images. The objective of this randomized trial was to assess the ability of these snapshots to enhance delayed information recall by care providers.

METHODS

Participating physicians were given four advanced cancer patient histories to review, two at a time over two weeks. Pictorial image displays, referred to as the Electronic Whiteboard (EWB) were added, in a randomized manner to half of the textual histories. The impact of the EWB on information recall was tested in immediate and delayed time frames.

RESULTS

Overall, patient information recall declined significantly over time, with or without the EWB. Still, this trial demonstrates significantly higher test scores after 24 hours with the addition of pictures to textual patient information, compared with textual information alone (P = 0.0002). A more modest improvement was seen with the addition of the EWB for questionnaires administered immediately after history review (P = 0.008). Most participants agreed that the EWB was a useful enhancement and that seeing a patient's photograph improved their ability to retain information.

CONCLUSION

Most studies examining the institution of handover protocols in the health care setting have failed to harness the power of pictures and other representative images. This study demonstrates the ability of pictorial displays to improve both immediate and delayed recall of patient histories without increasing review time. These types of displays may be amenable to generation by software programs and have the potential to enhance information transfer in various settings.

Clinical characteristics of patients having single versus multiple patient encounters within a palliative care programme

OBJECTIVE

The objective of this study was to describe the clinical characteristics of patient initial presentations, and to explore associations between patients' clinical characteristics at initial presentation and number of encounters (single vs multiple) to an integrated palliative care programme.

METHODS

This was a retrospective study of a decedent cohort of 2922 patient initial presentations to the Edmonton Zone Palliative Care Program (EZPCP). Data included age, gender, setting of encounter, diagnosis, Edmonton Symptom Assessment System, CAGE, Mini-Mental Status Examination, Palliative Performance Status, Edmonton Classification System for Cancer Pain and time to death.

RESULTS

On initial presentation to the EZPCP, the mean age was 73 (SD 14 years), with 1358 (46%) being female, and the majority having a cancer diagnosis (n=2376, 81%), the most common of which was gastrointestinal primary (n=681, 29%). In univariate analyses, patients with younger age (<60), higher palliative performance status (>40%), a malignant diagnosis, gastrointestinal primary or unimpaired cognition at initial presentation were significantly associated with multiple encounters with an integrated palliative care programme (p<0.05). In a multivariate regression analysis, a malignant diagnosis, longer survival, higher performance status and initial entry through acute care sites were independently associated with multiple encounters in the programme (p<0.001).

CONCLUSIONS

Larger prospective studies are warranted to further elucidate the complex relationships between patient clinical characteristics, initial presentations and subsequent encounters to an integrated palliative care programme.

Neuropathic cancer pain: prevalence, severity, analgesics and impact from the European Palliative Care Research Collaborative-Computerised Symptom Assessment study

BACKGROUND

Neuropathic pain causes greater pain intensity and worse quality of life than nociceptive pain. There are no published data that confirm this in the cancer population.

AIM

We hypothesised that patients with neuropathic cancer pain had more intense pain, experienced greater suffering and were treated with more analgesics than those with nociceptive cancer pain, and a neuropathic pain screening tool, painDETECT, would perform as well in those with cancer pain as is reported in those with non-cancer pain.

DESIGN

The data were obtained from an international cross-sectional observational study.

SETTING/PARTICIPANTS

A total of 1051 patients from inpatients and outpatients, with incurable cancer completed a computerised assessment on symptoms, function and quality of life. In all, 17 centres within eight countries participated. Medical data were recorded by physicians. Pain type was a clinical diagnosis recorded on the Edmonton Classification System for Cancer Pain.

RESULTS

Of the patients, 670 had pain: 534 with nociceptive pain, 113 with neuropathic pain and 23 were unclassified. Patients with neuropathic cancer pain were significantly more likely to be receiving oncological treatment, strong opioids and adjuvant analgesia and have a reduced performance status. They reported worse physical, cognitive and social function. Sensitivity and specificity of painDETECT for identifying neuropathic cancer pain was less accurate than when used in non-cancer populations.

CONCLUSIONS

Neuropathic cancer pain is associated with a negative impact on daily living and greater analgesic requirements than nociceptive cancer pain. Validated assessment methods are needed to enable early identification of neuropathic cancer pain, leading to more appropriate treatment and reduced burden on patients.

Expert conference on cancer pain assessment and classification--the need for international consensus: working proposals on international standards

An increasing number of cancer patients live longer, and palliative care has become an important part of their treatment. Symptoms are often inadequately assessed and managed. A significant challenge in clinical trials is to control for the variability of the samples being studied. To overcome this problem, classification systems have been developed in order to characterise and stratify patients by grouping them according to major common characteristics. The lack of agreed methods for the assessment and classification of cancer pain has been clearly indicated in clinical trials and in clinical practice and may be one possible explanation for the inadequate treatment of cancer pain. This was the background to an international expert meeting arranged in September 2009 in Milan, Italy. The primary aims were to produce recommendations on how to assess and classify cancer pain and to recommend a strategy for the further development, validation and implementation of an international cancer pain classification and assessment system. The recommendations consisted of two basic working proposals, nine specific working proposals and seven recommendations for the further development of a cancer pain classification system. Examples of specific working proposals were to include pain intensity, pain mechanism, breakthrough pain and psychological distress as the core domains in this classification of cancer pain and to measure pain intensity with a 0-10 numerical rating scale with 'no pain' and 'pain as bad as you can imagine' as anchors. The proposed name for this international standard is Cancer Pain Assessment and Classification System (CPACS).

Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review

CONTEXT

The use of unidimensional pain scales such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), or Visual Analogue Scale (VAS) is recommended for assessment of pain intensity (PI). A literature review of studies specifically comparing the NRS, VRS, and/or VAS for unidimensional self-report of PI was performed as part of the work of the European Palliative Care Research Collaborative on pain assessment.

OBJECTIVES

To investigate the use and performance of unidimensional pain scales, with specific emphasis on the NRSs.

METHODS

A systematic search was performed, including citations through April 2010. All abstracts were evaluated by two persons according to specified criteria.

RESULTS

Fifty-four of 239 papers were included. Postoperative PI was most frequently studied; six studies were in cancer. Eight versions of the NRS (NRS-6 to NRS-101) were used in 37 studies; a total of 41 NRSs were tested. Twenty-four different descriptors (15 for the NRSs) were used to anchor the extremes. When compared with the VAS and VRS, NRSs had better compliance in 15 of 19 studies reporting this, and were the recommended tool in 11 studies on the basis of higher compliance rates, better responsiveness and ease of use, and good applicability relative to VAS/VRS. Twenty-nine studies gave no preference. Many studies showed wide distributions of NRS scores within each category of the VRSs. Overall, NRS and VAS scores corresponded, with a few exceptions of systematically higher VAS scores.

CONCLUSION

NRSs are applicable for unidimensional assessment of PI in most settings. Whether the variability in anchors and response options directly influences the numerical scores needs to be empirically tested. This will aid in the work toward a consensus-based, standardized measure.

Can the global uptake of palliative care innovations be improved? Insights from a bibliometric analysis of the Edmonton Symptom Assessment System

Clinical research is undertaken to improve care for palliative patients, but little is known about how to support the broad uptake of resultant innovations. The objectives of this paper are to: (1) explore the uptake of the Edmonton Symptom Assessment System throughout the global palliative care community through the lens of a bibliometric review - a research method that maps out the journey of new knowledge uptake by evaluating where key articles are cited in published literature; (2) construct hypotheses on attributes of the global community of palliative care learners; and (3) make inferences on approaches that could improve knowledge transfer. While preliminary, results of the study suggest several specific approaches that could support widespread uptake of innovations in palliative care: targeting publication in high impact, international journals; explicitly focusing on how the innovation is applied to best practice; encouraging additional research to expand on early studies; consciously targeting key professional groups and organizations to promote discussion in the grey literature; and early translation and promotion within multiple languages.

Prognostic Factors in Patients With Advanced Cancer: Use of the Patient-Generated Subjective Global Assessment in Survival Prediction

Purpose

To determine whether elements of a standard nutritional screening assessment are independently prognostic of survival in patients with advanced cancer.

Patients and Methods

A prospective nested cohort of patients with metastatic cancer were accrued from different units of a Regional Palliative Care Program. Patients completed a nutritional screen on admission. Data included age, sex, cancer site, height, weight history, dietary intake, 13 nutrition impact symptoms, and patient- and physician-reported performance status (PS). Univariate and multivariate survival analyses were conducted. Concordance statistics (c-statistics) were used to test the predictive accuracy of models based on training and validation sets; a c-statistic of 0.5 indicates the model predicts the outcome as well as chance; perfect prediction has a c-statistic of 1.0.

Results

A training set of patients in palliative home care (n = 1,164) was used to identify prognostic variables. Primary disease site, PS, short-term weight change (either gain or loss), dietary intake, and dysphagia predicted survival in multivariate analysis (P < .05). A model including only patients separated by disease site and PS with high c-statistics between predicted and observed responses for survival in the training set (0.90) and validation set (0.88; n = 603). The addition of weight change, dietary intake, and dysphagia did not further improve the c-statistic of the model. The c-statistic was also not altered by substituting physician-rated palliative PS for patient-reported PS.

Conclusion

We demonstrate a high probability of concordance between predicted and observed survival for patients in distinct palliative care settings (home care, tertiary inpatient, ambulatory outpatient) based on patient-reported information.

Which variables are associated with pain intensity and treatment response in advanced cancer patients?--Implications for a future classification system for cancer pain

BACKGROUND

This study is part of a research program to reach consensus on an international cancer pain classification system. A confirmative and explorative approach was applied to investigate which of the variables identified in the literature, by experts and patients that are associated with pain.

METHODS

Data from an international, multicentre, cross-sectional study of cancer patients treated with opioids were investigated. Dependent variables were: average pain, worst pain, and pain relief (11-point Numerical Rating Scales). Forty-six independent variables were chosen based upon previous studies. Bivariate analyses identified independent variables associated with at least one of the dependent ones; 21 were included in multivariate linear regression analyses.

RESULTS

Two thousand two hundred and seventy-eight patients were investigated; 52% males, mean age 62 years, mean Karnofsky Performance Status 59%, mean daily opioid oral equivalent dose 341 mg. Fifty-eight percent had breakthrough pain. Mean pain scores were: average pain 3.5, worst pain 5.3 and pain relief 74%. Variables most strongly associated with these three dependent variables were: breakthrough pain, psychological distress, sleep, and opioid dose.

CONCLUSIONS

Breakthrough pain and psychological distress were confirmed as key variables of a future classification system. Candidate variables were: sleep, opioid dose, pain mechanism, use of non-opioids, pain localisation, cancer diagnosis, location of metastases, and addiction.

Classification of pain in cancer patients--a systematic literature review

One of the aims of the European Palliative Care Research Collaborative (EPCRC) is to achieve consensus on a classification system for cancer pain. We performed a systematic literature review to identify existing classification systems and domains/items used to classify cancer patients with pain. In a systematic search in the databases Medline and Embase, covering 1986-2006, 692 hits were obtained. 92 papers were evaluated to address pain classification. Six standardised classification systems were identified; three of them systematically developed and partially validated. Both pain characteristics and patient characteristics relevant for cancer pain classification were included in the classification systems. All but one of the standardised systems aim at predicting treatment response or adequacy of treatment. Several domains and items used to describe cancer pain but not formally described as part of a classification system were also identified and systematized. The existing approaches to pain classification in cancer patients are different, mostly not thoroughly validated, and none is widely applied. An internationally accepted classification system for cancer pain could improve research and cancer pain management. This systematic review suggests a need for developing an international consensus on how to classify pain in cancer patients.

The rapidly changing location of death in Canada, 1994-2004

This 2008 study assessed location-of-death changes in Canada during 1994-2004, after previous research had identified a continuing increase to 1994 in hospital deaths. The most recent (1994-2004) complete population and individual-level Statistics Canada mortality data were analyzed, involving 1,806,318 decedents of all Canadian provinces and territories except Quebec. A substantial and continuing decline in hospitalized deaths was found (77.7%-60.6%). This decline was universal among decedents regardless of age, gender, marital status, whether they were born in Canada or not, across urban and rural provinces, and for all but two (infrequent) causes of death. This shift occurred in the absence of policy or purposive healthcare planning to shift death or dying out of hospital. In the developed world, recent changing patterns in the place of death, as well as the location and type of care provided near death appear to be occurring, making location-of-death trends an important topic of investigation. Canada is an important case study for highlighting the significance of location-of-death trends, and suggesting important underlying causal relationships and implications for end-of-life policies and practices.

The Alberta Breakthrough Pain Assessment Tool for cancer patients: a validation study using a delphi process and patient think-aloud interviews

Breakthrough pain is a prevalent cancer pain syndrome, and research is needed to identify more effective interventions to manage it. A validated tool to assess breakthrough pain in a standard and reliable manner is urgently needed to support the conduct of clinical trials in breakthrough pain. To address this need, we developed a breakthrough pain assessment tool for research purposes. The current study was undertaken to gather validity evidence for this breakthrough pain assessment tool, using a Delphi process involving an expert panel review, followed by a think-aloud process involving patients with cancer-related breakthrough pain. Two expert panels were formed: a national panel (within Canada; n=16) and an international panel (including experts from North America, UK, Europe, the Middle East, Australia, and New Zealand; n=22). Each panel participated in one anonymous survey round. Response rates were 56% (national panel) and 73% (international panel). The Delphi process revealed substantial consensus on the content of the tool, which increased between rounds of review. The overall level of agreement with the tool, averaged over the four evaluated aspects of all items, was 80% among national panelists and 88% among international panelists. Nine patients completed the think-aloud study. They were able to understand and complete the tool and provided specific direction on its improvement. The validity evidence gathered in this study suggests the Alberta Breakthrough Pain Assessment Tool is conceptually grounded and is understandable by patients and clinicians. Further validation of this tool as an assessment measure within clinical trials research is warranted.

Characterization of cancer pain syndromes (PS) seen at a Comprehensive Cancer Center (CCC) and pain response (PR) to palliative care consultation (PCC)

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Background: Comparison of cancer PS across settings is challenging due to differences in prognostic features. Data from 1 CCC participating in a multi-site international study of a pain classification system is presented to characterize cancer PS & response to PCC. Methods: The Edmonton Classification System for Cancer Pain was completed by prospective chart review to characterize PS of 100 consecutive hospitalized patients (pts) seen in PCC. Pts were followed until major PR, hospital discharge or death. Major PR was defined as <2 p.r.n. opioid doses/d & pain intensity (PI) <3/10 for 3 consecutive days (d). Results: 85% of pts had pain (n=85), with age 62.9+13.3, 47.1% male & KPS 44.5+23.1. The most common tumor diagnoses were lung (24.7%) & GU (21.2%). Pts were followed for a median of 4 d (0–27). 39% achieved a major PR. Except for steroids (49.4%) & anticonvulsants (29.4%), other adjuvant analgesic use was all <10%. Pain-associated features: *Numeric Rating Scale 0–10, 10=worst suggestivie of alcoholism + Mean morphine equivalent dailydose On univariate analysis, older age (p=.006), lower initial PI (p=.003), lower final PI (p=.001) & lower final MEDD (p=.002) were significantly associated with achieving major PR. On multivariate analysis, lower initial PI (p=.03) & lower final MEDD (p=.02) retained significance for achieving major PR. Conclusions: Only 39%of pts with cancer pain seen in PCC achieve a major PR by discharge or death. Despite aggressive opioid titration, 61% do not achieve a major PR & require better pain management. Potential strategies for achieving improved PR include earlier PCC, identification of more sensitive prognostic variables &critical evaluation of targeted therapies.

[Table: see text]

No significant financial relationships to disclose.

Utilization and costs of the introduction of system-wide palliative care in Alberta, 1993-2000

BACKGROUND

De-institutionalization of health care services provided to terminally ill cancer patients is a cost-effective strategy that underpins health care reforms in Canada. The objective of this study therefore is to evaluate the economic implications associated with Canadian innovations in the delivery of palliative care services.

METHODS

We identified 16,282 adults who died of cancer between 1993 and 2000 in two Canadian cities with newly introduced palliative care programs. Linkage of administrative databases was used to measure healthcare resource utilization. We sought to describe the utilization of palliative care services and its consequences for overall health care system costs.

RESULTS

Use of palliative services increased from 45 to 81% of cancer patients during the study period. Identifiable public health care services cost dollars 28093Cdn/patient (19033US dollars, 11,508GBł, 17,778 euro) for terminally ill cancer patients in their last year of life. Acute care accounted for two-thirds (67%) of these costs; physician (10%), residential hospice care (8%), nursing homes (6%), home care (6%) and prescription medications (3%) comprise the remainder. Increased costs associated with the introduction of palliative care programs were offset by cost savings realized when terminally ill cancer patients spent less time in hospital. Palliative home care and residential hospice care accounted for the bulk of this substitution effect. Cost neutrality was observed from the public perspective.

DISCUSSION

These results demonstrate that the introduction of comprehensive and community-based palliative care services resulted in increased palliative care service delivery and cost neutrality, primarily achieved through a decreased use of acute care beds.

Antibiotic use in the last week of life in three different palliative care settings

The purpose of this study was to examine the frequency and types of antibiotics prescribed in the last week of life in three different palliative care settings, including an acute care hospital, tertiary palliative care unit, and three hospice units. A total of 150 consecutive patients were evaluated, 50 in each of the three settings. Twenty-nine patients (58%) in the acute hospital setting, 26 (52%) in the tertiary palliative care unit, and 11(22%) in the hospice settings were prescribed antibiotics. In the acute care and tertiary palliative care settings, the most frequent route of antibiotic administration was intravenous and, in the hospice setting, oral. We conclude that there is marked variability in the numbers and types of antibiotics prescribed in these different palliative care settings in the last week of life. The high use of intravenous antibiotics and the large number of patients who were still receiving antibiotics at the time of death indicate the need for further prospective studies.

Pain measurement tools and methods in clinical research in palliative care: recommendations of an Expert Working Group of the European Association of Palliative Care

An Expert Working Group was convened under the auspices of the Steering Committee of the Research Network of the European Association of Palliative Care to review the status of the use of pain measurement tools (PMTs) in palliative care research conducted in a multilingual-multicenter setting. Based on a literature review and on the experts' opinion, the present work recommends that standardized methods should be applied for the use of PMTs in research in palliative care. Visual analogue scales, numerical rating scales, and verbal rating scales are considered valid to assess pain intensity in clinical trials and in other types of studies. Among the multidimensional questionnaires designed to assess pain, the McGill Pain Questionnaire and Brief Pain Inventory are valid in many multilingual versions. Specific recommendations for PMT use and administration, depending on the study type and aim, are reviewed. Special population requirements specific of clinical situations encountered in palliative care (elderly, terminal, cognitively impaired patients, pediatric patients) are also considered.

Randomized, double-blind, cross-over trial comparing safety and efficacy of oral controlled-release oxycodone with controlled-release morphine in patients with cancer pain

PURPOSE

Use of oxycodone for chronic cancer pain has been hampered by its short elimination half-life. This study was designed to compare the efficacy and safety of controlled-release formulations of oxycodone and morphine for cancer pain.

PATIENTS AND METHODS

Thirty-two adult patients with cancer pain and a > or = 3-day history of stable analgesia with oral opioids provided written informed consent and were randomized to controlled-release oxycodone or controlled-release morphine for 7 days. To blind the study using available tablet strengths, the dose ratio of oxycodone to morphine was set at 1:1.5. On day 8, patients were crossed over to the alternate drug for 7 days. Pain intensity was assessed using a visual analog scale (VAS 0 to 100 mm) and a categorical scale (CAT 0 to 4). Side effects were assessed using a checklist (four-point categorical severity) and a nondirected questionnaire. Patients and investigators made blinded global ratings of efficacy and treatment preference.

RESULTS

Twenty-three patients completed the study (10 men, 13 women). The VAS and CAT scores were (mean+/-SD) 23+/-21 and 1.2+/-0.8 on controlled-release oxycodone, and 24+/-20 (P=.43) and 1.3+/-0.7 (P=.36) on controlled-release morphine. No period or carryover effect was detected. There were no significant differences in adverse effects (P=.40) or ratings of efficacy and preference. The median oxycodone/morphine dose ratio was 1.5 and the maximum was 2.3.

CONCLUSION

Controlled-release oxycodone is as safe and effective as controlled-release morphine in the treatment of cancer pain.

Assessment and knowledge in palliative care in second year family medicine residents

Inadequate physician knowledge, particularly in areas of pain assessment and use of analgesics, has been identified as a major factor contributing to poor pain management in cancer patients. In most medical schools, teaching in Palliative Care at both the undergraduate and postgraduate levels is limited or nonexistent. Baseline knowledge and changes in knowledge in areas relevant to Palliative Care were assessed by the use of 2 16-question examinations (Exams A and B) in 78 second-year Family Medicine Residents from the University of Alberta Family Medicine Residency Program. The residents participated in a two-week rotation on the Acute Palliative Care Unit at the Edmonton General Hospital or Grey Nuns Community Health Centre between September 1991 and February 1996. The residents were randomly assigned on their first day (Time 1) to complete either Exam A or B and were subsequently crossed over on their final day of the rotation to complete the alternate Exam (Time 2). Six domains were represented in the Exams as follows: pain assessment, opioid use, adjuvant medications, delirium, urinary catheterization, and hydration. Improvements were noted in the mean percentage results in Time 2 compared with Time 1 for Exams A, B, and A and B combined. Mean global percentage results were 53 +/- 15 versus 73 +/- 13 (p < 0.001) at Times 1 and 2, respectively. There were significant improvements for domains in Time 2 compared to Time 1 (p < or = 0.05) for combined A and B Exam except for urinary catheterization. Despite these documented improvements in scores, serious deficiencies were identified particularly in the areas of pain assessment and opioid use, namely opioid sude effects and issues involving dependence, addiction, and tolerance. Examinations, such as the two used in this study, can be a useful aid in assessing physician knowledge in addition to structuring teaching in Palliative Care. Examination content will require updating as knowledge in Palliative Care evolves.

Steady-state pharmacokinetic evaluation of a novel, controlled-release morphine suppository and subcutaneous morphine in cancer pain

Although the oral route is the preferred method for morphine administration for cancer pain, many patients will require an alternate route of administration at some point during their illness. The authors studied the steady-state pharmacokinetics of morphine after administration of a novel, controlled-release suppository (MS-CRS) and subcutaneous morphine in a randomized, double-blind, two-way crossover evaluation in 10 patients with cancer pain. When administered at a 2.5:1 analgesic ratio, MS-CRS given every 12 hours showed an equivalent extent of absorption compared with subcutaneous morphine given every 4 hours (AUC0-12, 132.5 +/- 30.1 versus 123.8 +/- 27.3 ng.h.mL-1, P = not significant [NS]). Peak morphine concentrations were lower, time of peak was later, and percent fluctuation less after MS-CRS than after subcutaneous morphine (Cmax, 14.7 +/- 2.9 versus 29.9 +/- 5.4 ng/mL, P = .0110; tmax, 3.33 +/- 0.75 versus 2.22 +/- 0.15 hours, P = .0160; fluctuation, 122 +/- 71 versus 356 +/- 123%, P = .00160). Relative bioavailability of MS-CRS using the 2.5:1 analgesic ratio was 105%, and bioavailability from data dose normalized without regard to route specificity in metabolism was 42%. For both routes of administration there was a significant linear relationship between morphine dose and AUC (MS-CRS, r = .8568, P = .0032; subcutaneous morphine, r = .8314, P = .0055). MS-CRS morphine provides a pharmacokinetic profile consistent with dosing every 12 hours; at steady state, the extent of absorption is comparable with that of subcutaneous morphine when administered at a 2.5:1 dose ratio.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical efficacy and safety of a novel controlled-release morphine suppository and subcutaneous morphine in cancer pain: a randomized evaluation

PURPOSE

A significant number of cancer patients will require an alternate route of morphine administration at some point during their illness. This study compared the clinical efficacy and safety of a novel morphine sulfate controlled-release suppository (MS-CRS) and subcutaneous (SC) morphine in patients with cancer pain.

METHODS

Thirty patients with cancer pain were randomized in a double-blind crossover study to MS-CRS every 12 hours or SC morphine every 4 hours for 4 days each, using a 2.5:1 analgesic equivalence ratio. Pain intensity was assessed using a visual analog scale (VAS) and the Present Pain Intensity Index of the McGill Pain Questionnaire. Nausea and sedation were also assessed with a VAS. Evaluations were made by the patient at 8 AM, noon, 4 PM, and 8 PM and rescue morphine consumption recorded.

RESULTS

Twenty-three patients completed the study (13 men and 10 women; mean age, 64.0 +/- 2.0 years) and were treated with mean daily MS-CRS and SC morphine doses of 326 +/- 69 mg and 138 +/- 28 mg, respectively. There was a small but significant difference in overall ordinal pain-intensity scores in favor of MS-CRS (0.7 +/- 0.1 v 0.9 +/- 0.1, P = .0459). There were no significant differences between MS-CRS and SC morphine in overall VAS scores for pain intensity (13 +/- 3 v 13 +/- 3 mm), sedation (23 +/- 3 v 25 +/- 4 mm), and nausea (8 +/- 2 v 9 +/- 2 mm). The mean daily rescue analgesic consumption during MS-CRS and SC morphine did not differ significantly (1.2 +/- 0.4 v 1.2 +/- 0.4 doses/d).

CONCLUSION

MS-CRS, administered every 12 hours, provides analgesia comparable to SC morphine and represents a reliable, noninvasive alternative method of pain control for patients unable to take oral morphine.

Use of the Edmonton Injector for parenteral opioid management of cancer pain: a study of 100 consecutive patients

In this retrospective study, we reviewed the patterns of use of the Edmonton Injector (EI) in 100 consecutive cancer patients. Seventy-eight patients used the EI for an average of 23 +/- 27 days. The main reasons for starting the EI were nausea (37 patients) and severe pain (31 patients). The median opioid dose equivalent to parenteral morphine (MEDD) was 264 +/- 443 mg/day. The mean duration of the subcutaneous injection site was 6.5 +/- 9.2 days. The most frequent reasons for change were accidental needle pulling (59%) and erythema (12%). Only two patients developed local infection (1% of 196 sites). The average cost of treatment was $1.65 Canadian per patient per day. No mechanical problems or refusals to start or continue treatment were detected. We conclude that the EI is a safe and simple device that allows for cost-effective parenteral administration of opioids for cancer pain.