Family caregiving in cancer pain management

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

Epidural Analgesia: A Viable Option for Pain Control

Epidural analgesia is an important intervention for both acute and chronic pain management. It has been in use since the early 1900s, but the technique using local application of opiate analgesics has only been in use since the late 1970s (Moulin & Coyle, 1986). Today, many patients receive epidural analgesia for postoperative pain control, and its use for acute or chronic pain management in a hospital, pain clinic, or home setting also continues to increase. Epidural analgesia is also being utilized to manage acute pain in the pediatric client. Epidural analgesia requires meticulous techniques, beginning with placement of the epidural catheter and continuing with administration of medications and nursing management of the catheter. Nursing assessment and development of protocols along with preoperative and postoperative patient and family teaching are vital components of the total plan of care. The nurse practitioner (NP) or other health care provider must be cognizant of safety considerations, whether in the hospital environment, pain clinic, or home setting.     

Pain management in the home

There is a major shift in responsibility for day-to-day pain management when a patient is to be cared for at home. What was primarily the responsibility of the nurse/physician team in the inpatient setting now becomes the responsibility of the patient and family. Poorly controlled pain affects not only the patient, but the family system as a whole. Successful pain management at home depends on a patient and family who feel reasonably confident in understanding the cause of the pain and in their ability to use the analgesics as prescribed (eg, around-the-clock doses and “rescue” doses), how to recognize and report changes in the pain site, character and severity, how to recognize and report adverse side effects from the analgesic prescribed, how to use non-drug measures to help relieve the pain, and how to access help and support on a 24-hour basis. Therefore, family education is key.     

Enhancing the role of case managers with specialty populations: development and evaluation of a palliative care education program

Palliative home care is an important component of the care system for patients at the end of life and case management is considered an essential element of the Canadian home care system. Case managers play a critical role in allocating resources, thus influencing the costs and the viability of palliative home care. Case management education programs focused on care coordination with specialty palliative care populations are nonexistent. An education program targeted at improving the knowledge and skills of case managers in allocating resources to palliative care populations was developed and pilot-tested in a metropolitan Canadian city home care program. Core curriculum was based on an initial learning needs assessment and used case-based problem solving to enhance case-management skills. An improvement in knowledge was noted on posttests and case managers described increased comfort and confidence in their role as case managers to this patient population. Home care organizations caring for palliative care populations must ensure case managers are prepared for case management roles with specialty populations if the home is to be rendered an appropriate and viable care setting for patients at the end of life.     

Issues in cancer pain management

In this article, three aspects of recent issues in cancer pain management such as pain assessment, drowsiness with morphine, and problem in home care setting. First, the assessment of 'impact of pain' is to assess whether the treatment is sufficient for the patient. On the other hand, assessment of 'pain intensity' is the effectiveness of the treatment. Therefore, to reduce the gap in pain evaluations between cancer patients and medical stuffs by assessing the 'impact of pain' in addition to 'intensity of pain'. Second, increasing dosage of morphine often reduces pain, at the same time patients become drowsy. This is often observed soon after starting morphine administration, especially, patients who have renal dysfunction. An active morphine metabolite morphine-6-Glucuronide is excreted into urine, so that, renal dysfunction causes drowsiness. Third, at home care setting, patients tend to be into poor pain control condition. It is necessary that paying attention on patient's knowledge of medications and having support program for pain management for home care setting.     

Discharge planning for the patient with a new tracheostomy

A patient with a new tracheostomy will face threatening changes upon discharge from hospital support. Nurses, particularly in the critical care unit, frequently and closely support a patient and family through new and often difficult situations during hospitalization. The patient leaving the hospital with a new tracheostomy will face problems with secretion management, increased risk of infections, alterations in body image, and impaired vocalization. To ensure a safe transition from the hospital to home, the patient and family must demonstrate competence in all aspects of tracheostomy care, must be able to recognize signs and symptoms that should be reported to the physician, and must have adequate support at home (such as homecare nurses, properly functioning equipment, and access to necessary supplies). These "musts" form the basis of the discharge care plan. Nurses can help a patient successfully manage these problems through comprehensive discharge planning. Although the critical care nurses who initiate the multidisciplinary discharge planning process may not remain involved in that process throughout the patient's hospitalization, their early efforts can provide an orderly, comprehensive discharge plan optimally suited to ensure that the patient and family acquire the necessary skills, confidence, supplies, and support for the eventual transition home. The information, encouragement, skills demonstrations, and referrals to other resources that critical care nurses provide help the patient adjust to a new tracheostomy.     

Putting cancer pain management regimens into practice at home

The purpose of this study was to describe the difficulties with pain management that patients and family caregivers bring to a nurse's attention during a teaching and coaching intervention. Data were obtained from audiotaped and transcribed interactions between intervention nurses and patients (n = 52) and their family caregivers (n = 33) who were participating in a randomized clinical trial of a nursing intervention called the PRO-SELF Copyright Pain Control Program. Using qualitative content analysis, we found that patients had difficulty in seven areas when they attempted to put a pain management regimen into practice, namely: obtaining the prescribed medication(s), accessing information, tailoring prescribed regimens to meet individual needs, managing side effects, cognitively processing information, managing new or unusual pain, and managing multiple symptoms simultaneously. The findings from this study suggest that the provision of information about cancer pain management to patients and their family caregivers is not sufficient to improve pain control in the home care setting. Patients and their family caregivers require ongoing assistance with problem-solving to optimize their pain management regimen.     

New approaches for evaluating the quality of cancer pain management in the outpatient setting.

Both retrospective and prospective methods can be used to evaluate the quality of cancer pain management in the outpatient setting. Retrospective evaluations of the quality of cancer pain management in the outpatient setting provide benchmark data that can be used to change clinical practice for groups of patients or for specific types of cancer pain problems. Prospective evaluations of the quality of cancer pain management with patient diaries in the outpatient/home care setting can help clinicians do "real-time" evaluations and modify the pain management plan for individual patients. This report provides practical suggestions for evaluating the quality of cancer pain management in the outpatient setting.     

Factors associated with the accuracy of family caregiver estimates of patient pain.

This study identified factors associated with inaccurate family caregiver assessments of patient pain. Participants were 31 caregiver-patient dyads receiving hospice home care. All patients had a primary diagnosis of end-stage cancer. As expected, caregivers overestimated patient pain. The degree of disparity for each dyad was calculated by subtracting the patient's pain rating from the caregiver's rating of patient pain. Caregiver knowledge of cancer pain management was not related to the degree of disparity in pain ratings, but caregivers' experience of patient pain was significantly related to accuracy of caregivers' pain ratings. Those caregivers who 1) perceived their loved one to be in a great deal of distress secondary to pain, 2) associated greater efforts at pain relief (i.e., more medication) with greater levels of pain, and 3) were themselves distressed by the patient's pain had the most inaccurate estimates of patient pain. There was a trend for greater disparity in pain estimates to be related to poorer existential quality of life for patients. Overall, the findings suggest that health care providers need to take into consideration family members' interpretation of patient pain when providing pain management education services.     

Utilization of a multidisciplinary team for inpatient diabetes care

Diabetes is often noted as a secondary diagnosis when patients are admitted to the hospital for care. Patients admitted to critical care areas are usually more ill and require aggressive glucose control. Often the education and self-care management skills needed for home management are overlooked until discharge, which can cause an increased length of stay. There is a feeling of frustration among nurses who are unable to adequately meet the needs of these patients and their families. In one community hospital setting, they have designed a model that identifies patient needs on admission and utilizes a multidisciplinary team. Beginning the "discharge" process early in the admission will ensure that a timely discharge with a well-trained patient will occur.     

Predictors of home death of home palliative cancer care patients: a cross-sectional nationwide survey

Objectives

To identify factors influencing the place of death among home palliative cancer care patients, focusing on the role of nurses in terms of pre- and post-discharge from hospital to home care settings.

Design, settings and participants

A cross-sectional nationwide questionnaire survey was conducted at 1000 randomly selected homecare agencies in Japan. The questionnaires were completed by primary community nurses of home palliative patients just after their discharge. A total of 568 responses were analyzed (effective response rate, 69%).

Results

Multivariate logistic regression analysis revealed the following independent factors of place of death among those patients: desire for home death at referral by both patient and family caregiver; caregiver relationship to patient as daughter or daughter-in-law; totally bedridden functional status of patient; patient not suffering from depression and/or anxiety at referral; patients and caregivers duly informed about the dying process/death in detail, as well as instructed by community nurses about pain management and how to treat/prevent bedsores in home care settings.

Conclusions

This study demonstrated the importance of both the hospital and community nurses’ role in increasing the patients’ chance of dying at home. Hospital nurses should support early transfer to home palliative care according to their assessment of the desire of patient/family caregiver for home death, the patients’ clinical status, and caregivers’ ability to provide patient care at home. Community nurses should inform patients/family caregiver in detail about the dying process/death just after discharge, relieve patient pain, treat/prevent bedsores, and instruct family caregivers on their symptom control.     

Can just-in-time, evidence-based "reminders" improve pain management among home health care nurses and their patients?

The purpose of this randomized, controlled, home care intervention was to test the effectiveness of two nurse-targeted, e-mail-based interventions to increase home care nurses' adherence to pain assessment and management guidelines, and to improve patient outcomes. Nurses from a large urban non-profit home care organization were assigned to usual care or one of two interventions upon identification of an eligible cancer patient with pain. The basic intervention consisted of a patient-specific, one-time e-mail reminder highlighting six pain-specific clinical recommendations. The augmented intervention supplemented the initial e-mail reminder with provider prompts, patient education material, and clinical nurse specialist outreach. Over 300 nurses were randomized and outcomes of 673 of their patients were reviewed. Data collection involved clinical record abstraction of nurse care practices and patient interviews completed approximately 45 days after start of care. The intervention had limited effect on nurse-documented care practices but patient outcomes were positively influenced. Patients in the augmented group improved significantly over the control group in ratings of pain intensity at its worst, whereas patients in the basic group had better ratings of pain intensity on average. Other outcomes measures were also positively influenced but did not reach statistical significance. Our findings suggest that although reminders have some role in improving cancer pain management, a more intensive approach is needed for a generalized nursing workforce with limited recent exposure to state-of-the-art pain management practices.     

Using the BIS monitor in palliative care: a case study.

The majority of deaths occur in the hospital setting, and of these deaths, 20% are in an intensive care unit (ICU). Care provided on the ICU shifts from curative to palliative when a patient's death appears to be imminent. Nursing care decisions made at the end of life are critical to the experience of the patient, and leave a lasting impression on the patient's family and the nurses involved in providing care. One of the main concerns of family members during this time is the comfort of their loved one. Assessing comfort can be especially difficult in the patient who is unresponsive. One tool that can assist the nurse in the assessment and management of analgesic effectiveness is the Bispectral (BIS) Index Monitor. As the use of BIS monitoring grows in the ICU setting, more information will be available that will help all involved in the palliative care process ensure patients have a peaceful death.     

Nurse-physician collaboration in pain management for terminally ill cancer patients treated at home in Japan

Collaboration between nurses and physicians is essential for successful pain management, especially in home care settings. This study describes how physicians collaborate with nurses for the pain management of terminally ill cancer patients treated at home in Japan, and evaluates the use of standing orders in pain management. Self-administered questionnaires were sent to all 565 institutions listed in a nationwide database of home care service providers for terminally ill cancer patients; 177 responding institutions were analyzed. In general, institutions caring for fewer patients per year were less likely to make specific efforts to collaborate with nurses and less likely to use standing orders in pain management. Given that many institutions provide home palliative care services on a small scale, a standard protocol for care should be developed and applied across all institutions to ensure the availability of quality home palliative care throughout the country.     

Palliative care crises in the community: a survey

With the rising age of the population, hospital cutbacks, and increased attention to home-based care for the dying, the community can expect to experience more intense care situations and a greater potential for palliative care crises developing in the home setting. Whether the crisis is precipitated by hemorrhage, severe uncontrolled pain, or agitation, the demands placed on the family unit and careprovider can be phenomenal. Only with a greater awareness of the difficulties encountered in the home setting can the community begin to respond to the needs of the family in crisis. An open-question survey regarding palliative care crises in the community was conducted among community visiting RNs, home care case managers, and palliative outreach clinicians in southwestern Ontario, The objectives were: 1) to determine the pattern of events that precipitated a crisis; 2) to understand how crises were managed; 3) to identify barriers to effective crisis management; 4) to investigate the impact on the family unit and careprovider. Participants were also asked to list the essential resources they needed to deal effectively with a crisis situation. This paper highlights the results of the survey and suggests implications for the future direction of palliative care in the home.     

Integrating case management and palliative care

Most seriously ill Americans live at home under the care of their primary physician and with the support of family caregivers. To reduce costs while simultaneously improving the quality of patient care, insurers have increasingly turned to the concept of case management. While case management is targeted to individuals with life-threatening illnesses, palliative care assessment and interventions are typically not included in the management protocols. An academic/care management/health plan partnership between Mount Sinai School of Medicine, Franklin Health, a care management organization, and South Carolina Blue Cross Blue Shield, was formed in 1998 to test the utility of integration of case management with formal palliative care assessment, feedback and recommendations to treating physicians, and ongoing support for implementation of a palliative care plan. The goal of the project was to ensure identification and optimal care of seriously ill patients' complex needs, while facilitating doctor-patient continuity, improving patient/family/physician communication, providing assistance with decision-making, ensuring quality care at home, and promoting efficient use of health care resources. Care management nurses were randomly assigned to a control (usual care) group or to the intervention (palliative care) group. Intervention nurses were trained in formal palliative care assessment and interventions, supported by treatment protocols and communication strategies with treating physicians. Measurements included symptom burden, prescribing practices, advance care planning status, satisfaction, and health care utilization. These results are pending completion of study run-out and analysis. Preliminary programmatic results indicate that combining palliative care with the case management approach is a logical, feasible, and effective strategy to improve the care of seriously ill patients living in the community. Franklin Health has offered the program to their entire client base because they feel that the integration of palliative care into their case management program improved the standard of patient care. Blue Cross Blue Shield of South Carolina has also chosen to sustain this enhanced model of care management for seriously ill patients.     

Road to excellence in pain management: research,outcomes and direction (ROAD)

Effective pain management is a critical patient care goal mandated by numerous health care organizations. There remains great opportunity to improve pain management across all sites of care. This article describes an interdisciplinary model for process improvement within an integrated health care system. An outcome-based approach to pain management resulted in the development of four key clinical indicators that are measured across sites, including acute care, long-term, ambulatory, and home care. Early outcome data are presented. Strategies for improving pain management focus on visibility, staff accountability, patient rights, and education.     

Continuous home heparin infusion therapy in the ambulatory patient.

Until recently, continuous heparin infusions have been rendered only in the hospital setting. With the expansion of high technology, proper monitoring, and patient and family participation, it is practical and safe to administer heparin anticoagulation therapy in the home setting. The home care coordinator plays a key role in coordinating a smooth transition from hospital of home. This article provides an overview of the history of heparin, the indications for home heparin anticoagulant therapy, patient teaching goals, and the role of the home care coordinator.