Opportunities for Palliative Care in Patients With Burn Injury—A Systematic Review

ContextPatients with significant burn injuries likely have palliative care needs.ObjectivesWe performed a systematic review of existing evidence concerning the palliative care needs of burn patients.MethodsThrough November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles involved burn-injured patients treated with an intervention targeting at least one of the eight domains.ResultsOur searches yielded 7532 unique records, which led to 238 articles for full review and 88 studies that met inclusion criteria. Seventy-five studies addressed the domain physical aspects of care and merit a separate systematic review; 13 studies were included in our final review. Four of the seven domains—processes of care, psychologic symptoms, social aspects, and end of life—were addressed by studies but three domains—spiritual, cultural, or ethics—were unaddressed. Included studies highlight potential benefits from peridischarge self-care education programs, peer support, and group therapy in improving quality of life. In patients with severe injuries, end-of-life decision-making protocols were associated with increased utilization of comfort-focused treatments.ConclusionMost existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Opportunities exist for further research of palliative care in burn populations with emphasis on addressing interventions for all domains and better standardizing the language and outcomes for the palliative care interventions.     

Prevalence of QTc Prolongation in Patients With Advanced Cancer Receiving Palliative Care—A Cause for Concern?

ContextMedications commonly used for symptom control along with other known risk factors have the potential to prolong ventricular repolarization as measured by the QT interval (the time from the start of the Q wave to the end of the T wave) on a standard electrocardiogram (ECG).ObjectivesTo document the prevalence of a prolonged QT interval corrected for heart rate (QTc) interval in the palliative/oncology setting, compare automatic ECG QTc measurements with manual readings and identify any correlation between QTc prolongation and the use of drugs or other risk factors.MethodsA convenience sample of consecutive patients with cancer, admitted under or known to the palliative/supportive care teams in two metropolitan hospitals, and willing to provide an ECG recording and basic demographic information including QTc risk factors were included. Both automated and manually calculated QTc intervals were recorded. Multivariable analysis was used to determine risk factors independently associated with prolonged QTc intervals.ResultsOf the 389 participants, there was a significant difference in mean QTc between sites using automated but not manual calculations. Manual readings were therefore used with predetermined cutoffs of 0.44 seconds (males) and 0.46 seconds (females). Seventy-two (18.5%) of the participants had a prolonged QTc with six (1.5%) having a prolongation of >0.50 seconds. At-risk drugs were being taken by 218 participants (56.0% of total cohort). Factors shown to be associated with QTc prolongation included age, gender, performance status, and hypocalcemia. No specific medication was associated with increased risk.ConclusionAlthough almost 20% of patients receiving palliative care had prolongation of QTc, the possibility of serious consequences appeared to be low despite the frequent occurrence of risk factors.     

Aggressiveness of End-of-Life Care for Patients With Colorectal Cancer in Alberta,Canada: 2006–2009

ContextNorth American studies have documented practice variations and deficiencies in end-of-life (EOL) cancer care, such as trends toward treating dying patients aggressively and disparities in access to palliative care or hospice services.ObjectivesTo assess the frequency of aggressive health care usage at the EOL and identify factors associated with receiving aggressive care among patients who died of colorectal cancer.MethodsData from the Alberta Cancer Registry, in/outpatient hospital records, and cancer electronic medical records were linked. Death in an acute care hospital, chemotherapy use in the last 14 days of life, more than one emergency room (ER) visit, more than one hospital admission, and any intensive care unit (ICU) admission in the last 30 days of life were used as indicators of aggressive care. Logistic regression was used to identify risk factors associated with each indicator.ResultsA total of 2074 patients were included: 50.1% died in an acute care hospital; 3.7% received chemotherapy in the last 14 days of life; and 12.5% had multiple ER visits, 9.5% had multiple hospitalizations, and 2.2% had an ICU admission during the last 30 days of life. Age had the strongest association with chemotherapy use. Geographical region of residence had the strongest association with multiple ER visits and hospitalizations and dying in an acute care hospital. Tumor stage and duration of disease were associated with the ICU admission.ConclusionThe percentage of patients who died in an acute care hospital is higher than the 17% U.S. benchmark. Other indicators of receiving aggressive EOL care are consistent with existing care quality benchmarks. The considerable regional variation, however, indicates potential for system improvements.     

Should Neuroleptics Be Used in Patients With Delirium Seen by Palliative Care?

Delirium commonly occurs in the palliative care setting and impacts many aspects of patient care, such as symptom assessment, patient-clinician communication, and medical decision-making. One controversial topic regarding the management of delirium in the palliative care setting is whether neuroleptics should be used. In this “Controversies in Palliative Care” article, 3 expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. Interestingly, all 3 experts arrived at similar conclusions—they underscored the importance of identification and treatment of any reversible causes of delirium and endorsed a trial of non-pharmacologic measures. They also agreed that neuroleptics should be considered for patients with hyperactive or mixed delirium when the conservative measures fail to control delirium symptoms and for delirious patients with days of life expectancy and thus limited time to try other measures. Risk of adverse effects such as extrapyramidal symptoms and seizures should be considered as part of the treatment decision. There is also a need to conduct high quality research to examine both neuroleptics and neuroleptic-sparing strategies for the management of delirium.     

Radiation Therapy Students′ Knowledge,Attitudes, and Beliefs about Palliative and End-of-Life Care for Cancer Patients

Background and PurposeAlthough radiation therapy students are highly interested in providing palliative and end-of-life care (PEOLC), students often lack understanding of what palliative care is and express a lack of confidence when interacting with palliative patients. This study examined radiation therapy students' existing knowledge, attitudes, and beliefs toward PEOLC for cancer patients and how professional and personal experiences influenced those factors.MethodsThis study used a cross-sectional online questionnaire. After informed consent, data were collected from a sample of students in an undergraduate radiation therapy program in Canada. Questions were both quantitative and qualitative in nature. Responses were comprised of Likert scales and true or false responses, a case study–based vignette and several short open-ended questions.ResultsSixty-one students completed the questionnaire; the response rate was 42%. Responses indicate students had an incomplete understanding of PEOLC principles despite reporting positive views and interest in the topic. Professional and personal experiences improved students' knowledge regarding the role of PEOLC and attitudes and beliefs became more positive with increased real-life experiences.ConclusionsExperiential learning influences students' knowledge, attitudes, and beliefs about PEOLC. To better prepare students for their future professional roles, it is necessary for radiation therapy undergraduate programs to include PEOLC educational initiatives in its curricula. These initiatives should emphasize holistic care to prepare students to be competent radiation therapists who can address patients' complex PEOLC needs.     

Intractable Neck Pain in an Oncologic Palliative Care Setting: Is Cancer Always the Answer?

Refractory pain is a common manifestation in an oncologic palliative care setting and represents a major challenge for health care professionals involved in care provision. The underlying neoplasm and its dissemination are the foremost pathophysiologic mechanism for the development of pain in patients with advanced cancer. Nonetheless, other etiologies such as trauma and infections need to be considered by clinicians in this particular care setting. The authors present the case of a patient with a recent diagnosis of hepatocellular carcinoma, suffering from intractable neck pain, progressive worsening of her general conditions, and the onset of a generalized seizure. The clinical suspicion of a bacteremia with central nervous system involvement was confirmed by the performed work-up, and a Listeria monocytogenes meningoencephalitis was diagnosed. The purpose of this case report is to raise clinicians' awareness on infectious complications, which may increase the symptom burden in patients treated in an oncologic palliative care setting. Moreover, the manifestation of such complications may be misinterpreted as the consequence of the underlying neoplasm, further delaying the diagnostic and therapeutic management in this particular population.     

Is There a Role for Palliative Services and Supportive Care in Managing Advanced Penile Cancer?

ObjectivesWe aim to review the benefits of palliative care, describe why a palliative approach to care is needed for patients with advanced penile squamous cell carcinoma and propose ways in which oncology nurses can improve access to and provision of palliative care.Data SourcesA review of the literature was performed and identified a range of randomized trials and systematic reviews regarding the benefits of palliative care in this patient group. Cohort studies of patients with penile cancer were used to describe the psychosocial and physical disease burden of penile cancer.ConclusionThroughout each phase of penile cancer and its treatment, oncology nurses can engage in care that goes beyond cancer-directed treatments to address the whole person, thereby improving quality of life by delivering person-centered palliative care in line with individual needs.Implications for Nursing PracticeOncology nurses are in key positions to explore many concerns that patients with penile cancer have for themselves or their caregivers. Through speaking directly with patients and caregivers, oncology nurses can uncover sources of distress, assess for unmet needs, and advocate for improved primary palliative care or early referral to specialty palliative care teams.     

Physical Activity–Based Interventions Using Electronic Feedback May Be Ineffective in Reducing Pain and Disability in Patients With Chronic Musculoskeletal Pain: A Systematic Review With Meta-Analysis

Objective

To investigate the effectiveness of physical activity–based interventions using electronic feedback in reducing pain and disability compared to minimal or no interventions in patients with chronic musculoskeletal pain.

Impact of Targeted Therapy on the Quality of End-of-Life Care for Patients With Non–Small-Cell Lung Cancer: A Population-Based Study in Taiwan

Context

Targeted therapies with epidermal growth factor receptor tyrosine kinase inhibitors have been widely used in the treatment of advanced non–small-cell lung cancer (NSCLC). However, little research has focused on the use of targeted therapies at the end of life (EOL).

Population Pharmacokinetics of Erlotinib in Patients With Non–small Cell Lung Cancer: Its Application for Individualized Dosing Regimens in Older Patients

PurposeErlotinib is an oral first-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor approved for non–small cell lung cancers (NSCLC) with EGFR-activating mutations. Older patients experience more toxicities compared with younger patients at the standard recommended dose of 150 mg once daily. The aims of this study were to describe the pharmacokinetic profile of erlotinib in unselected patients with NSCLC, to quantify and explain its variability, to challenge the standard recommended dose in older patients, and to propose clinical recommendations for the therapeutic management of patients taking erlotinib.Methods: A population pharmacokinetic model was developed using erlotinib plasma concentrations collected from patients with NSCLC participating in a routine therapeutic drug monitoring program (with the nonlinear mixed effect modeling program NONMEM). Relevant demographic characteristics, clinical factors, and co-medications were tested as potential covariates. An independent dataset was used for model validation. Simulations based on the final model allowed comparison of expected erlotinib concentrations under standard and alternative dosing regimens for smokers and for several age groups.FindingsA total of 481 erlotinib plasma concentrations from 91 patients with NSCLC were used for model building and 239 plasma drug concentrations from 107 patients for model validation. A one-compartment model with first-order absorption and elimination provided the best fit. Average erlotinib CL/F with interindividual variability (%CV) was 3.8 L/h (41.5%), and V/F was 166 L (53.8%). The absorption rate constant was 1.48 h⁻¹. The external validation showed a negligible bias of −4% (95% CI, −7 to −1) in the individual predictions, with a precision of 23%. Current smoking and use of proton pump inhibitors were associated with higher CL/F, whereas age was associated with lower CL/F. Simulations suggest that a lower dose in older patients would decrease the risk of overexposure.ImplicationsThis large cohort study confirms the substantial interindividual variability in erlotinib plasma exposure and the impact of smoking and proton pump inhibitor intake. This large variability in erlotinib pharmacokinetics indicates that the standard recommended dose of 150 mg once daily is likely not appropriate to reach the expected concentrations in each patient. Concentration monitoring should be performed to individually adjust the erlotinib dosing regimen. The observed decrease in erlotinib CL/F with age suggests that a lower starting daily dose of 100 mg with concentration-guided dose adjustment would prevent overexposure and potential toxicity in older frail patients with co-morbidities.     

The Effects of Self–Pain Management on the Intensity of Pain and Pain Management Methods in Arthritic Patients

The aims of this study were to investigate the effects of pain management education on the intensity of pain and frequency of utilization of pain management methods in two groups of patients with arthritis of different pathogenesis and clinical features, and to compare whether a significant difference existed between the two groups. The study was carried out between September 2007 and June 2008 on 30 female patients with gonarthrosis and 30 female patients with rheumatoid arthritis (RA) followed at the rheumatology outpatient clinic of a university hospital. Data on sociodemographic characteristics and those related with the illness were collected using a special survey. Each patient was given information about the features, causes, and treatment of the arthritis and how to cope with pain, emphasizing the importance of pain management methods. The intensity of pain and efficacy of pain management methods were assessed using the McGill Pain Questionnaire and the Pain Management Inventory at baseline and the second and sixth weeks after the education. The SPSS (v15.0) statistical package was used for statistical analysis. After education, significant improvements in pain intensity scores compared with baseline scores were observed in both groups (p < .05), and there was no significant difference between the RA and gonarthrosis groups. Among the various pain management methods, the education program led to significantly more utilization of massaging the painful area, exercising, and using complementary methods to control stress in both groups of patients, and there was no significant difference between the groups. In conclusion, the pain management education given in this study alleviated the intensity of pain and significantly increased the use of some pain management methods in both gonarthrosis and RA cases.     

Has Pain Management in Cancer Patients with Bone Metastases Improved? A Seven-Year Review at An Outpatient Palliative Radiotherapy Clinic

The primary objective of this study was to determine the prevalence of underdosage of analgesics for pain associated with bone metastases in outpatients referred to the Rapid Response Radiotherapy Program at the Odette Cancer Centre from 1999 to 2006. A prospective database containing data for all patients with bone metastases who were referred to the Rapid Response Radiotherapy Program for palliative radiotherapy from 1999 to 2006 was analyzed. The database included patient demographic information, including age at referral for radiation to the bone, gender, primary cancer site, and Karnofsky Performance Status; information on treatment-related factors, such as worst pain ratings and analgesic consumption in the past 24 hours (recorded as oral morphine equivalent doses); pain intensity ratings (none [rating=0], mild [rating=1-4], moderate [rating=5-6] or severe [rating=7-10]; and analgesic consumption (rated as none, nonopioids, weak opioids [e.g., codeine] and strong opioids [e.g., morphine and hydromorphone]). Patients who experienced moderate or severe pain and were prescribed no pain medication, nonopioids, or weak opioids were considered to be undermedicated. Between January 1999 and December 2006, 1,038 patients were included in the study database. Approximately 56% of patients were male and 44% were female. The median age was 68 years (range 28-95) and the median Karnofsky Performance Status was 70 (range 10-100). The percentages of undermedicated patients were 40% in 1999, 34% in 2000, 29% in 2001, 37% in 2003, 39% in 2004, 36% in 2005, and 48% in 2006. No appreciable decline was noted in the proportion of patients with moderate-to-severe pain who received no pain medication, nonopioids, or weak opioids during the study period. Despite the publication of pain management guidelines and the dissemination of data regarding the proportion of patients with bone metastases who are being prescribed inadequate analgesics, our findings suggest that a significant proportion of patients continue to be undermedicated.     

“What is Killing Me Most”: Chronic Pain and the Need for Palliative Care in the Eastern Cape,South Africa

ABSTRACT

Palliative care and the provision of pain relief medicine are essential components of health care, yet little research has been conducted on access to pain medicine in rural areas of sub-Saharan Africa. The objective of this study was to examine patient experiences and health care provider attitudes towards chronic pain and palliative care in Eastern Cape Province, South Africa. The study used a mixed-methods approach to evaluate experience of chronic pain in a district hospital and associated clinics. Questionnaires and in-depth interviews were conducted with 45 current and former patients receiving care and 26 health care providers. Forty-six percent (n = 19) of patients rated their pain in the last month as severe. Thirty-nine percent (n = 17) of individuals stated that they had never been provided with an explanation for the cause of their pain. Multiple regression analysis found that being female, not having received a social welfare grant, and not having received an explanation for the cause of pain were associated with higher ratings of pain (P < .10 for each variable). Factors inhibiting the provision of palliative care included insufficient access and availability of pain medication and providers’ association of palliative care with end-of-life care. Adequate pain relief is often deprioritized in a busy health care setting. Ensuring patients receive sufficient relief for their pain requires interventions at clinical and policy levels, including the provision of needed pain medication and training in palliative care for all providers.