Variation in medication use in cancer patients at the end of life: a cross-sectional analysis

Purpose

Despite advances in cancer treatment, patients still die with unnecessary suffering. Therefore, high-quality end-of-life care is needed. Variations in medication use at the end of life may suggest areas for improvement. This study aims to describe the use of medications during the last days of life of cancer patients and to explore the possibility of using it as a quality measure.

Methods

We conducted an international survey on experts’ opinions regarding potentially inappropriate medications for dying patients. Subsequently, a chart review of deceased cancer patients was conducted, which assessed the current medication use in different settings.

Results

The mean number of medications used in the last 3 days of life was 4.8 (SD 2.1). Hospital patients were less likely than hospice patients to receive opioids, midazolam, haloperidol, and drugs for pulmonary secretions or nausea/vomiting. Over 90 % of experts rated 12 medications as unlikely to be appropriate. Hospital patients were more likely than hospice patients to receive these potentially inappropriate medications. Before the implementation of an end-of-life care pathway, hospital patients had a higher probability, than after, to receive potentially inappropriate medication. Moreover, after implementation of such pathway, patients for whom a pathway was not used were more likely to receive potentially inappropriate medications than patients for whom it was used.

Conclusion

Medication use at the end of life varies widely by setting, both for potentially appropriate and inappropriate medications. Combining experts’ opinion and current medication use resulted in the identification of 16 medications that might be used to assess the quality of cancer care at the end of life.     

Behandlung von übelkeit und Erbrechen mit Prokinetika und Neuroleptika bei Palliativpatienten

Background

Many recommendations concerning the treatment of nausea and vomiting in palliative care patients exist but what is the evidence for this? Most studies dealing with this topic have focused on cancer patients under chemotherapy and/or radiation therapy or on patients with postoperative nausea. Cancer patients without chemotherapy or radiation therapy, patients without postoperative nausea, and patients having other diseases with palliative care aspects, such as acquired immunodeficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), progressive heart failure, amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) have been underrepresented in studies on nausea and vomiting so far.

Objectives

The aim of this review was to determine the level of evidence for the treatment of nausea and vomiting with prokinetics and neuroleptics in palliative care patients suffering from far advanced cancer and no longer being treated with chemotherapy or radiation therapy, AIDS, COPD, progressive heart failure, ALS or MS.

Methods

Two different electronic databases (PubMed und Embase) were used to identify studies. Furthermore, a hand search for related articles was performed. No restriction was made concerning study types. Studies with patients undergoing chemotherapy radiation therapy or suffering from postoperative nausea, pediatric studies and studies published neither in English nor in German were excluded.

Results

A total of 30 studies fulfilling the inclusion criteria were found. All studies focused on cancer patients. Despite intensive research studies in patients with AIDS, COPD, heart failure, ALS or MS were not detected. Metoclopramide is seen as an effective drug in many studies whereas the evidence for it is moderate at best. Within the group of neuroleptics, levosupiride and levomepromazine seem to have good antiemetic potential but the evidence level is low.

Conclusion

In patients with advanced cancer not being treated with chemotherapy or radiation therapy, metoclopramide can be used to reduce nausea and vomiting. Neuroleptics, such as levosulpiride or levomepromazine are alternatives but their adverse effects have to be considered carefully. The evidence level for prokinetics and neuroleptics is moderate to low. Concerning palliative care of patients with diseases other than cancer no studies exist. More well designed studies in palliative care patients are needed in order to facilitate evidence based antiemetic therapy. The English full text version of this article will be available in SpringerLink as of November 2012 (under “Supplemental”).     

Medikament?se Therapie der Angst bei Patienten mit fortgeschrittenen Tumorerkrankungen bzw. Patienten in der palliativen Situation

Background

Pharmacological treatment of anxiety is an important part of drug treatment in palliative care. In this review we searched for the current evidence of pharmacological treatment of anxiety in palliative care.

Materials and methods

A systematic search of PubMed, Embase, PsycLIT, PsycINFO, CINAHL for studies of anxiety in palliative care was carried out in January 2012. Furthermore we searched the Cochrane Library, references of literature and leading textbooks. Studies were identified and information was filled in a standardized extraction sheet. Studies have been categorized and anxiety as an endpoint determined.

Results

A total of four controlled studies, three uncontrolled studies, two retrospective studies, one case report, two surveys, one systematic Cochrane review and one unsystematic review were analyzed and included in this review. This indicates an overall low number of studies for the pharmacological treatment of anxiety in palliative care. According to our results, benzodiazepines are the most commonly used drugs in palliative care. However, based on our review, there is no evidence-based recommendation for the therapeutic use in palliative care.

Conclusions

With the existing evidence no general recommendations for pharmacological treatment of anxiety in palliative care can be given. Even for the commonly used benzodiazepines, neuroleptics, antidepressants, antihistamines and beta blockers for the treatment of anxiety no evidence based recommendations can be made. However, these medications are commonly used to treat anxiety in other patient populations and can also be used in palliative care patients. According to our review we cannot recommend a single drug or give recommendations regarding the dosage of drugs. There is a strong need for randomized controlled trials to evaluate the effect of drug treatment of anxiety in palliative care patients. The English full text version of this article will be available in SpringerLink as of November 2012 (under “Supplemental”).     

Does a regional comprehensive palliative care program improve pain in outpatient cancer patients?

Context

Pain is still a major problem for cancer patients, and the effect of a population-based approach on patients’ experience of pain is not fully understood.

Aims

The primary aim of this study was to clarify the changes in pain intensity in outpatients before and after a regional palliative care program. The secondary aim was to clarify the prevalence of patients who had unmet needs for pain treatment and to clarify the reasons for not wanting pain treatment.

Subjects and methods

A regional palliative care program was implemented in four regions of Japan. A region-representative sample of metastatic/locally advanced cancer patients in outpatient settings took part in questionnaire surveys before and after the regional intervention. Responses were obtained from 859 from 1,880 and 857 from 2,123 in the preintervention and postintervention surveys, respectively.

Results

After a regional palliative care program, neither worst, average, nor least pain levels in outpatients changed significantly. A total of 134 patients (16 %) reported that they needed more pain treatment. There were various reasons for not wanting pain treatment, namely, minimum interference with daily life, general nonpreference for medicines, longstanding symptoms before the diagnosis of cancer, concerns about tolerance and addiction, and experienced neuropsychiatric symptoms under current medications.

Conclusion

The regional palliative care program failed to demonstrate improvement of the pain intensity of cancer outpatients. One possible interpretation is that they are less likely to be regarded as target populations and that the study population experienced generally well-controlled pain. Future study including patients with more severe pain is needed, but to improve pain levels of cancer outpatients, intensive, patient-directed intervention seems to be more promising than region-based intervention.     

Music-based interventions in palliative cancer care: a review of quantitative studies and neurobiological literature

Purpose

This study aimed to review quantitative literature pertaining to studies of music-based interventions in palliative cancer care and to review the neurobiological literature that may bare relevance to the findings from these studies.

Methods

A narrative review was performed, with particular emphasis on RCTs, meta-analyses, and systematic reviews. The Cochrane Library, Ovid, PubMed, CINAHL Plus, PsycINFO, and ProQuest were searched for the subject headings music, music therapy, cancer, oncology, palliative care, pain, anxiety, depression, mood, quality of life, prevalence, neuroscience, functional imaging, endogenous opioids, GABA, 5HT, dopamine, and permutations of these same search terms. Data for the review were comprised of articles published between 1970 and 2012. References of all the cited articles were also reviewed.

Results

Available evidence suggests that music-based interventions may have a positive impact on pain, anxiety, mood disturbance, and quality of life in cancer patients. Advances in neurobiology may provide insight into the potential mechanisms by which music impacts these outcomes.

Conclusions

More research is needed to determine what subpopulation of cancer patients is most likely to respond to music-based interventions, what interventions are most effective for individual outcomes, and what measurement parameters best gauge their effectiveness.     

Behandlung von übelkeit und Erbrechen mit 5HT3-Antagonisten, Steroiden, Antihistaminika, Anticholinergika, Somatostatinanaloga, Benzodiazepinen und Cannabinoiden bei Palliativpatienten

Background

Various recommendations exist for the treatment of nausea and vomiting in palliative care but only few studies and even less systematic reviews look into antiemetic therapy for patients receiving palliative care.

Objectives

This systematic review aims to analyze the current evidence for antiemetic treatment with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids in palliative care patients with far advanced cancer not receiving chemotherapy or radiotherapy, acquired immune deficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), progressive heart failure, amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). Results regarding evidence of treatment with prokinetic and neuroleptic agents will be published separately.

Methods

The electronic databases PubMed and EmBase were systematically searched for studies (published 1966–2011) dealing with antiemetic therapy in palliative care and electronic retrieval was completed by manual searching. Studies with patients undergoing chemotherapy or radiotherapy, pediatric studies and studies published in languages other than English or German were excluded. Studies addressing therapy with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines or cannabinoids were identified and selected for this systematic review.

Results

In the general search 75 relevant studies were found. Of those 36 addressed 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids, 13 considered 5HT3 receptor antagonists, 10 somatostatin antagonists, 9 steroids, 5 cannabinoids, 4 anticholinergics, 1 antihistamines and none benzodiazepines. Furthermore six systematic reviews exist. Evidence for any drug used as an antiemetic is low. Concerning 5HT3 receptor antagonists data are insufficient for recommendations on the treatment of patients with AIDS and MS due to the small size of included patient groups. For patients with cancer contradictory results were published: the larger studies showed a positive effect of 5HT3 receptor antagonists and better efficacy, as compared to metoclopramide, dexamethasone and neuroleptics. Heterogeneous results were found for steroids, with a positive trend for patients with cancer. Data are insufficient for antihistamines. Studies prove effectiveness of butylscopolammonium in the treatment of nausea and vomiting caused by malignant gastrointestinal obstruction, whereas octreotide is superior to butylscopolammonium. Regarding benzodiazepines for symptom control of nausea and vomiting in palliative care patients no studies were detected. Cannabinoids were found to relieve nausea and vomiting in patients with cancer and AIDS but with notable side effects. Furthermore, the studies compared cannabinoids to less recent antiemetic drugs but not, for example to 5HT3 receptor antagonists. Regarding symptom control of nausea and vomiting in patients with COPD, progressive heart failure and ALS no studies were undertaken in patients receiving palliative care.

Conclusions

In palliative care patients with nausea and vomiting 5HT3 receptor antagonists can be used if treatment with other antiemetics, such as metoclopramide and neuroleptics is not sufficient. There is a trend that steroids in combination with other antiemetics improve symptom relief. Cannabinoids rather have a status as a second line antiemetic. In cases of nausea and vomiting caused by malignant gastrointestinal obstruction octreotide showed the best and butylscopolammonium bromide the second best results. Concerning antihistamines and benzodiazepines insufficient data was found. Recommendations in the literature are mainly based on studies in patients with cancer. The overall strength of evidence is low. More well designed studies in palliative care patients are needed in order to provide evidence-based therapy. The English full text version of this article will be available in SpringerLink as of November 2012 (under “Supplemental”).     

Involvement of general practitioners in palliative cancer care: a qualitative study

Purpose

General practitioners play an important role in palliative care for cancer patients. The intensity of care and its medical complexity make palliative care a demanding task for general practitioners. This study explored general practitioners' perceptions of their involvement in palliative cancer care and the constraints they confront.

Methods

We conducted semi-structured interviews with 13 German general practitioners. Recruitment occurred by means of purposeful sampling to secure maximum heterogeneity. The interviews were electronically recorded, transcribed, and then analyzed using qualitative content analysis according to Mayring.

Results

A number of themes were identified. General practitioners describe being intensely involved in the final phase of their patients' lives. When providing home-based end-of-life care to cancer patients, general practitioners become aware of the limitations in their medical skills and knowledge and their ability to provide round-the-clock care. They find it helpful and satisfying to collaborate with trusted care providers and seek to cooperate with specialized palliative care services for outpatients.

Conclusions

The substantial involvement of general practitioners in end-of-life care for cancer patients pushes them to their limits because of the major time commitment required, and the need for special skills for which they have received no training. It will be a challenge to provide general practitioners with the structural and personal support they need to provide home-based palliative care for their cancer patients at end of life.     

Physical activity interests and preferences in palliative cancer patients

Goals of the work

The purpose of the present study was to examine the physical activity interests and preferences of palliative cancer patients.

Patients and methods

Fifty advanced cancer patients aged 18 years or older with clinician-estimated life expectancy of less than 12 months and Palliative Performance Scale greater than 30% were recruited from an outpatient palliative care clinic and a palliative home care program. An interviewer-administered survey was used to assess physical activity behavior, interests, and preferences.

Main results

The majority of palliative cancer patients in this sample indicated that they would be interested and felt able to participate in a physical activity program. There were strong preferences for home-based physical activity programs that could be completed alone. The majority of participants in this sample reported walking as the type of physical activity in which they were most interested.

Conclusions

These findings suggest that this sample of palliative cancer patients is interested and feel able to participate in a physical activity program. Examining these unique physical activity preferences may aid in the development of an appropriate physical activity program for palliative cancer patients that can be tested in clinical research.     

Ist die pharmakologische Therapie der Obstipation in der Palliativmedizin evidenzbasiert?

Materials and methods

To evaluate the evidence for clinically established pharmacological therapies for constipation in palliative care, a systematic literature review was performed in different databases (Cochrane Library, Embase, PubMed, Ovid MEDLINE, CINAHL), textbooks, and publications.

Results

Whereas 130 randomized controlled trials were found with patients outside of palliative care settings, only 10?controlled studies with patients in end-of-life situations were identified: three RCTs with methylnaltrexone and one with the combination of oxycodone and naloxone showed the effect and safety of opiate antagonists for patients who are not at risk of gastrointestinal perforation. There have been no studies which test methylnaltrexone against the optimization of therapy with conventional laxatives. Six other controlled studies of limited quality in design and execution and with only few participants tested naloxone, senna, lactulose, Co-danthramer, an Ayurvedic preparation (Misrakasneham), magnesium hydroxide, fluid paraffin, sodium picosulfate and docusate without finding statistically significant differences in efficacy or side effects. Most patients in these studies had cancer. Only case studies with few patients in palliative care were found for meglumine, neostigmine, and other substances mentioned above.

Conclusion

Evidence on medical treatment of constipation in palliative care is sparse and guidelines have to refer to evidence from outside the palliative care setting and to expert opinions. Results from studies with other patient groups can only be transferred with limitations to very ill patients at the end of life who might have a higher risk for potential side effects such as gastrointestinal perforation in case of abdominal tumor manifestation. Therefore further studies are required to evaluate the medical treatment of multiple reasons for constipation in these patients. These studies should focus on feasibility, clinical relevance and quality of life. The English full text version of this article will be available in SpringerLink as of November 2012 (under “Supplemental”).     

Glukokortikoide und Androgene zur Behandlung von Müdigkeit und Schw?che bei Palliativpatienten

Background

The therapy of tiredness, weakness and fatigue in palliative care patients is of growing interest. Glucocorticoids and androgens are habitually mentioned drugs for treatment. In this review evidence for glucocorticoids and androgens for these indications in palliative care patients are presented.

Materials and methods

A systematic search of PubMed and Embase for studies on glucocorticoids and androgens for fatigue, asthenia, sedation, tiredness, weakness, exhaustion, cachexia, drowsiness and wasting in palliative care was carried out in August 2011. Furthermore, the Cochrane Library, references from the literature and leading textbooks were also searched. Study information was entered in a standardized extraction sheet. By a categorization of studies five endpoints were distinguished: fatigue, strength/weakness, tiredness, well being/quality of life and energy/activity/performance.

Results

A total of 11 controlled studies with glucocorticoids and 13 controlled studies with androgens were included. In addition four uncontrolled studies, two case series and two surveys with glucocorticoids as well as six uncontrolled studies and one case series with androgen treatment were analyzed. All controlled trials of glucocorticoids were performed in cancer patients and all but one controlled trial of androgens in patients with HIV/AIDS. Glucocorticoids improved quality of life but results for changes of fatigue and weakness were inconsistent. Tiredness and energy were not improved. Androgens had a positive effect on fatigue and quality of life and showed variable effects on weakness. Androgens did not improve energy. Side effects were frequently documented but only rarely resulted in discontinuation of therapy.

Conclusion

With the existing evidence no general recommendation for glucocorticoid and androgen use in tiredness and weakness in palliative care patients can be given; however, glucocorticoids in cancer patients and androgens in HIV positive-patients can be used in an individual trial for improving patient quality of life. The use in patients suffering from other disease entities should be evaluated in randomized controlled trials with a similar setting. The English full text version of this article will be available in SpringerLink as of November 2012 (under “Supplemental”).     

Survival in solid cancer patients following intensive care unit admission

Purpose

One in seven patients admitted to intensive care units (ICU) has a cancer diagnosis but evidence on their expected outcomes after admission has not been synthesised.

Methods

Systematic literature review of solid cancer adult patients admitted to ICU from 2000 onwards using EMBASE and MEDLINE electronic databases.

Results

There were 48 papers identified that reported survival in ICU patients with solid cancers. ICU mortality was reported in 35 studies comprising a total sample of 25,339 patients and ranging from 4.5 to 85 %. The average mortality of the distribution of reported mortality rates within ICU was 31.2 % (95 % CI 24.0–39.0 %). Hospital mortality was reported in 31 studies across a total sample of 74,061 patients. The average hospital mortality was 38.2 % (33.8–42.7 %) and ranged from 4.6 to 76.8 %. Poorer physiological score, invasive mechanical ventilation and poor functional status were associated with higher mortality.

Conclusions

Several factors have been associated with poor survival in ICU cancer patients; however, primary research is still needed to describe outcomes in cancer patients with sufficient case mix and treatment details to be of prognostic value to clinicians.     

Begleitevaluation des F?rderschwerpunkts Palliativmedizin der Deutschen Krebshilfe

Introduction

The German Cancer Aid funded 12 regional projects which developed different models of palliative home care. The realization of the projects were concurrently monitored and evaluated.

Material and methods

The funded projects were asked to document all patients who were cared for beginning in January 2009 using HOPE (Hospice and palliative survey), MIDOS (Minimal documentation system for palliative patients) and the Barthel index. Documentation was mandatory at the beginning and the end of care as well as when patients changed settings, for example when patients were transferred from a palliative care unit to a palliative home care service. Additionally the projects were visited by an independent observer.

Results

Overall the 12 projects documented 2,663 patients. Analysis revealed differences between the projects mainly concerning target groups and interventions.

Discussion

The results of this evaluation can support the discussion about the development of palliative home care in Germany with particular focus on possible interrelations between structures, target groups and possible outcomes of care.     

Subtypes of potentially inappropriate medications in older Chinese-Americans during care transitions: Cross sectional retrospective study

Background

The number of Chinese Americans is growing and nearly 20% of older Chinese-American home care patients have at least one potentially inappropriate medications (PIMs) prescribed at hospital discharge. Further examination of PIMs during care transition is warranted, especially among older Chinese-Americans.

Objectives

To describe, during care transitions from hospital to home care: (i) the subtypes of PIMs, (ii) the difference of PIM prevalence prescribed at hospital discharge as compared to home care admission, (iii) the relationship between subtypes of PIMs, and (iv) issues affecting medication reconciliation among older Chinese-Americans.

Methods

This cross-sectional, retrospective study was conducted in a large urban home care agency from June 2010 to July 2011. From data collected by in-home survey and chart abstraction, PIMs were identified using 2002 diagnosis-independent Beers criteria. The difference of PIM prevalence at hospital discharge and at home care admission was analyzed by Wilcoxon Signed Ranks test. The relationship between subtypes of PIMs was evaluated using Phi coefficient.

Participants

82 older (age 65 years and above) Chinese-American home care patients following recent hospital discharge.

Results

3.38% (22) and another 3.72% (28) of prescribed medications were identified as PIMs at hospital discharge and home care admission, respectively. There was no statistically significant difference in PIM prevalence identified at hospital discharge and at homecare admission (z = −1.732, p = .083). PIMs included: long-term use of stimulant laxatives and high-dosages of ferrous sulfate, and a significant relationship between these two PIMS (r = .224, p = .04). More than 80% (n = 65) of study participants reported low education levels and limited English proficiency.

Conclusions

Subtypes of PIMs were ordered during the post-hospital transfers, indicating the necessity to review the appropriateness of medications during this transition. Guidelines such as Beer's criteria regarding appropriateness of medications should be incorporated in medication reconciliation before adding new medications to treat the older adult's health problems. The medication management process needs to be both culturally sensitive and adapted to literacy level; validating the patients’ full understanding of their medications is paramount.     

H?usliche Behandlung von Tumorschmerzpatienten mit patientenkontrollierter Analgesie (PCA)

Background

Only limited data and experience with patient-controlled analgesia (PCA) in outpatients for palliative home care, related to organization, effectiveness and costs are available.

Patients and methods

In our retrospective study we analyzed the effectiveness, care intensity and pain reduction of 108 palliative cancer pain patients with PCA, included in a palliative home care system.

Results

After equivalent conversion of the opioid doses from oral/transcutaneus to parenteral administration a dose increase was necessary in 12.9% of the patients. The pain therapy was effective until death for an average of 38.9 days (median 21 days). During 3,889 days of PCA therapy there were 76 unscheduled visits based on technical problems.

Conclusion

In cases of cancer pain patients with failed oral or transcutaneous opioid medication, sufficient pain reduction can be achieved with parenteral drug administration by PCA. Domestic PCA requires a lot of human and financial resources, with trained nursing services and regular house visits by physicians experienced in palliative medicine but this method is sufficient and safe to use.     

Physicians’ self-assessment of cancer pain treatment skills—more training required

Purpose

Adequate pain control is essential in cancer treatment. We surveyed Finnish physicians’ perception on their skills and training needs on palliative pain management.

Methods

A structured questionnaire with multiple choices and open ended questions was used for collecting data in 2006–2008. Of 720 physicians participating, 59 were working in oncology and 661 physicians in internal medicine, geriatrics, and primary health care.

Results

The principles of the WHO guidelines of cancer pain management were not well known. Forty-six percent of oncologists and 32% of other physicians (P?Conclusions To have more confidence in treating cancer, pain physicians would benefit in training and education in palliative care. It should be systematically included both in general and specialist training and continuous medical education.     

Thromboprophylaxis in patients receiving inpatient palliative care: a survey of present practice in Austria

Background

There is limited data on the use of thromboprophylaxis in patients with advanced cancer. We therefore aimed to study the practice of thromboprophylaxis in palliative care units in Austria.

Methods

We monitored use, indication, and contraindications to thromboprophylaxis in 134 patients hospitalized in 21 palliative care units in a prospective, cross-sectional study.

Results

Forty-seven percent of patients were on low molecular weight heparin on the day of the study for primary or secondary thromboembolism. Thromboprophylaxis had been withdrawn in 18% of the patients upon admission to the palliative care unit. Contraindications for thromboprophylaxis were present in 27% of all patients. Cancer was present in 86% of the patients. The use of thromboprophylaxis was similar in cancer patients and in non-cancer patients (49% vs. 42%). Contraindications for thromboprophylaxis were present in 24% of all cancer patients. Significantly more bedridden cancer patients had contraindications for prophylaxis when compared with mobile cancer patients (35% vs. 16%; p?=?0.03). Low performance status was by far the most frequent contraindication among these patients (89%). Seventy-one percent of all bedridden cancer patients were treated in accordance with common guidelines for thromboprophylaxis when contraindications were taken into account. Eighty-seven percent of patients who had been involved in decision making opted for getting prophylaxis.

Conclusions

Our data reveal that about half of all cancer patients in palliative care units are treated with thromboprophylaxis. Low performance status was the most frequent contraindication for thromboprophylaxis.     

A systematic review of opioid effects on the hypogonadal axis of cancer patients

Purpose

Opioids are the mainstay of analgesic therapy in patients with cancer-related pain. While many of the side effects of opioids are well documented, the effect on the hypogonadal axis is less well understood. The aim of this systematic review is to examine the relationship between opioid therapy and hypogonadism in patients with cancer.

Methods

An electronic search of the following databases was undertaken: MEDLINE, Embase and CINAHL from 1974 to August 2013. To be eligible for inclusion, studies had to meet the following criteria: adult patients (>18 years) with cancer taking any opioid by any route for any duration, gonadal function measured and the relationship between opioid use and gonadal function examined. All potentially eligible papers were reviewed independently and data extracted using a pro forma.

Results

Four studies met the inclusion criteria. Due to the heterogeneous nature of the studies, it was not possible to amalgamate the results. Three studies suggested a relationship between opioid use and hypogonadism in patients with cancer. These studies also suggested this relationship to be dose dependent. There was evidence to suggest that hypogonadism was symptomatic and associated with reduced survival. One study showed no link between opioids and hypogonadism.

Conclusions

Studies conducted have suggested an association between opioids and hypogonadism in patients with cancer. This warrants further investigation. A longitudinal study examining the impact of opioids on the hypogonadal axis would be of interest.     

Exploring the perceived changes and the reasons why expected outcomes were not obtained in individual levels in a successful regional palliative care intervention trial: an analysis for interpretations

Context

The Japan Outreach Palliative Care Trial of Integrated Model (OPTIM) study, a mixed-methods study to evaluate the effects of a comprehensive regional palliative care program, revealed that the program provided broad positive outcomes at the regional level: increased home death, palliative care use, patient- and family-reported qualities of care, and health care professionals’ difficulties. Not all participants however obtained positive outcomes and thus exploring the reasons why expected outcomes were observed in individual levels could be of value.

Aims

The primary aims were to explore why expected outcomes were not obtained in individual participants, and the perceived changes in daily practices of physicians and nurses were explored.

Subjects and methods

Postintervention questionnaire survey on 857 patients, 1,137 bereaved family members, 706 physicians, and 2,236 nurses were analyzed.

Results

The reasons for not achieving home deaths included unexpected rapid deterioration, caregivers unavailable, concerns about adequate responses to sudden changes, and physical symptoms uncontrolled, while lack of physician availability at home and lack of information from physicians were less frequently reported. The reasons for not receiving specialized palliative care services were the lack of recommendations from physicians and no information about palliative care services. The reason for evaluating the quality of palliative care as not high was that clinicians tried to relieve symptoms, but there were limited effects and insufficient time. Many physicians and nurses reported that they became more aware of palliative care, that the availability of palliative care specialists and knowledge about palliative care improved, and that they cooperated with other regional health care providers more easily.

Conclusion

The OPTIM study seemed to succeed in optimizing physician availability at home, improves physician information about home care, achieved maximum efforts to relieve patient distress by clinicians, and increased communication among regional health care professionals. To achieve further better outcomes, multiple interventions to the health care system to be performed on the basis of a comprehensive regional palliative care program are proposed.