Clinical Aspects of Palliative Sedation in Prospective Studies. A Systematic Review

ContextNear the end of life when patients experience refractory symptoms, palliative sedation may be considered as a last treatment. Clinical guidelines have been developed, but they are mainly based on expert opinion or retrospective chart reviews. Therefore, evidence for the clinical aspects of palliative sedation is needed.ObjectivesTo explore clinical aspects of palliative sedation in recent prospective studies.MethodsSystematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered at PROSPERO. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014–December 2019), combining sedation, palliative care, and prospective. Article quality was assessed.ResultsTen prospective articles were included, involving predominantly patients with cancer. Most frequently reported refractory symptoms were delirium (41%–83%), pain (25%–65%), and dyspnea (16%–59%). In some articles, psychological and existential distress were mentioned (16%–59%). Only a few articles specified the tools used to assess symptoms. Level of sedation assessment tools were the Richmond Agitation Sedation Scale, Ramsay Sedation Scale, Glasgow Coma Scale, and Bispectral Index monitoring. The palliative sedation practice shows an underlying need for proportionality in relation to symptom intensity. Midazolam was the main sedative used. Other reported medications were phenobarbital, promethazine, and anesthetic medication—propofol. The only study that reported level of patient's discomfort as a palliative sedation outcome showed a decrease in patient discomfort.ConclusionAssessment of refractory symptoms should include physical evaluation with standardized tools applied and interviews for psychological and existential evaluation by expert clinicians working in teams. Future research needs to evaluate the effectiveness of palliative sedation for refractory symptom relief.     

Oncologic Emergencies: Palliative Care in the Emergency Department Setting

BackgroundPalliative care is an essential component of emergency medicine, as many patients with terminal illness will present to the emergency department (ED) for symptomatic management at the end of life (EOL).ObjectiveThis narrative review evaluates palliative care in the ED, with a focus on the literature behind management of EOL symptoms, especially dyspnea and cancer-related pain.DiscussionAs the population ages, increasing numbers of patients present to the ED with severe EOL symptoms. An understanding of the role of palliative care in the ED is crucial to effectively communicating with these patients to determine their goals and provide medical care in line with their wishes. Beneficence, nonmaleficence, and patient autonomy are essential components of palliative care. Patients without medical decision-making capacity may have an advance directive, do not resuscitate or do not intubate order, or Portable Medical Orders for Life-Sustaining Treatment available to assist clinicians. Effective and empathetic communication with patients and families is vital to EOL care discussions. Two of the most common and distressing symptoms at the EOL are dyspnea and pain. The most effective treatment of EOL dyspnea is opioids, with literature showing little efficacy for other therapies. The most effective treatment for cancer-related pain is opioids, with expeditious pain control achievable with a rapid fentanyl titration. It is also important to address nausea, vomiting, and secretions, as these are common at the EOL.ConclusionsEmergency clinicians play a vital role in EOL patient care. Clear, empathetic communication and treatment of EOL symptoms are essential.     

Nursing assessment and management of dyspneic patients with lung cancer

Dyspnea is a subjective sensation of breathlessness. This distressing symptom is experienced by many patients with lung cancer and often is accompanied by physiologic signs and symptoms, such as tachypnea, tachycardia, pallor, and cyanosis. Dyspnea-induced hypoxia may occur and cause confusion, cognitive impairment, and restlessness. Prompt and accurate nursing assessment of dyspnea can assist in identifying appropriate treatment interventions. Supplemental oxygenation and medications, along with treatment of the underlying cause of the dyspnea, may promote patient comfort. Nurses need to be skilled in assessing dyspnea experienced by patients with lung cancer and knowledgeable in implementing effective symptom management techniques.     

Do Longitudinally Collected Symptom Scores Predict Time to Death in Advanced Breast Cancer: A Joint Modeling Analysis

ContextPatients with advanced breast cancer have low rates of survival that can be associated with symptom burden.ObjectivesThis study seeks to characterize the effect of longitudinally collected symptom scores on predicting time to death for patients with advanced breast cancer.MethodsA cohort of 993 Stage IV breast cancer patients was constructed using linked population-level health administrative databases that captured longitudinally collected symptom data using the Edmonton Symptom Assessment System. Data were captured on individual symptom scores (20,371 assessments) for pain, tiredness, drowsiness, nausea, appetite, dyspnea, depression, anxiety, and wellbeing, as well as three summative scores of total symptom distress score, physical subscore, and psychological subscore. A joint modeling approach was undertaken to simultaneously model repeated-measures longitudinal data and time-to-event data.ResultsOf patients who died in the study, 56.11% survived for a mean time of less than three years and had lower mean symptom scores for all symptoms except shortness of breath, in comparison with patients who lived for more than three years. Symptom burden was predictive of patient time to death for all symptoms, with risk of death increasing with worsening symptom scores. For total symptom distress score, age at diagnosis (0.009; P < 0.05), chemotherapy (−0.63; P < 0.001), and palliative care (3.15; P < 0.001) were significant predictors of patient time to death.ConclusionPatients with advanced breast cancer experience chronic ongoing low symptom burden, which predicts patient time to death. Future research should examine the mechanisms by which patient characteristics, treatment, and supportive and palliative care can have an impact on patient survival.     

Morphine Versus Midazolam as Upfront Therapy to Control Dyspnea Perception in Cancer Patients While Its Underlying Cause Is Sought or Treated

ContextCancer patients with dyspnea may be able to have the symptom pharmacologically controlled while its underlying cause is sought or treated.ObjectivesThis study was done to determine whether symptom control can be achieved while the cause is evaluated or treated and whether morphine or midazolam would be more suitable in this setting.MethodsSixty-three ambulatory patients with advanced cancer and dyspnea were clinically characterized and then randomized to receive either oral morphine or oral midazolam. A fast in-clinic drug titration scheme was implemented followed by an ambulatory five-day period in which the patients received the effective dose that relieved their dyspnea. During this period, the patients were followed daily while the underlying causes of dyspnea were sought out or treated.ResultsThirty-one patients with dyspnea entered the morphine arm and 32 patients entered the midazolam one. During the initial in-clinic phase, dyspnea was alleviated by at least 50% in all patients, whether they received morphine or midazolam. During the ambulatory phase, midazolam was superior to morphine in controlling baseline and breakthrough dyspnea. Both treatments were well tolerated, with mild somnolence being the most common adverse event. Neither morphine nor midazolam affected the outcome and/or implementation of additional diagnostic and/or therapeutic interventions.ConclusionOur results suggest that cancer-related dyspnea in ambulatory patients can be pharmacologically treated while its most probable specific cause is sought and/or while an etiology-oriented intervention is implemented. In this setting, midazolam appeared to be a better option than morphine for the immediate and long-term relief of the symptom.     

Status of Metastatic Bladder Cancer Treatment Illustrated by a Case

ObjectiveThis study aims to provide an overview of current treatment guidelines within the context of metastatic bladder cancer illustrated by a case report.Data SourcesInternational guidelines from The American Society of Clinical Oncology (ASCO), The European Society of Medical Oncology (ESMO), and scientific references supporting these clinical guidelines. To illustrate the implementation of current evidence-based guidelines a patient case report was presented.ConclusionHistorically, there have been limited treatment options available for metastatic bladder cancer for three decades. However, with the introduction of immunotherapy and emergent targeted therapies for metastatic bladder cancer increasing survival rates are expected.Implications for Nursing PracticeTo achieve improved treatment outcome in people affected by metastatic bladder cancer it is important that both doctors and nurses are aware of contemporary evidence-based treatment options in keeping with ESMO and ASCO international clinical guidelines. Nurses play an important role in educating patients about the potential side effects of therapy and in offering timely, tailored, and supported self-management.     

Patients’ experience of oxygen therapy and dyspnea: a qualitative study in home palliative care

Background  

Dyspnea is a common and distressing symptom in advanced cancer patients. Our preliminary work shows that in the home palliative care population sampled for this study, the prevalence of dyspnea is 29.5% and of those, 26.2% used oxygen therapy. Previous studies suggested that oxygen therapy can be a burden to patients.     

The Evidence Base for Oxygen for Chronic Refractory Breathlessness: Issues,Gaps, and a Future Work Plan

Breathlessness or “shortness of breath,” medically termed dyspnea, is a common and distressing symptom featuring strongly in advanced lung, cardiac, and neuromuscular diseases; its prevalence and intensity increase as death approaches. However, despite the increasing understanding in the genesis of breathlessness, as well as an increasing portfolio of treatment options, breathlessness is still difficult to manage and engenders helplessness in caregivers and health care professionals and fear for patients. Although hypoxemia does not appear to be the dominant driver for breathlessness in advanced disease, the belief that oxygen is important for the relief of acute, chronic, and acute-on-chronic shortness of breath is firmly embedded in the minds of patients, caregivers, and health care professionals. This article presents current understanding of the use of oxygen for treating refractory breathlessness in advanced disease. The objective is to highlight what is still unknown, set a research agenda to resolve these questions, and highlight methodological issues for consideration in planned studies.     

Safety and Effectiveness of Palliative Drug Treatment in the Last Days of Life—A Systematic Literature Review

Context

Dying patients commonly experience potentially distressing symptoms. Palliative care guidelines recommend opioids, anticholinergics, antipsychotics, and benzodiazepines for symptom relief.

Updates in Cancer-Related Symptom Management of Anorexia and Cachexia Syndrome

ObjectiveTo provide current evidence and updates in cancer-related symptom management of cancer anorexia-cachexia syndrome (CACS).Data sourcesTextbooks, journal articles, and the internet.ConclusionNutrition and the treatment of CACS plays a pivotal role in multimodal cancer care. The pathophysiology of nutrition in patients with cancer is complex and requires active screening and interventions. Treatment of CACS should focus on antitumor treatment, nutrition intervention, supportive pharmacologic intervention and/or other interventions that improve clinical outcomes.Implications for Nursing PracticeOncology nurses are in a pivotal position to provide proactive screening, assessment, clarify treatment options, and follow-up for patients with cancer and associated nutritional issues.     

Barriers to adequate pain and symptom relief at the end of life: A qualitative study capturing nurses’ perspectives

BackgroundSymptom management remains a critical challenge at the end of life. Barriers to symptom relief predominantly focus on perspectives of physicians, patients or care systems but rarely acknowledge the views of nurses.AimExamine nurses’ perceptions of barriers to adequate end-of-life symptom relief.MethodsSemi-structured interviews with 25 nurses across different settings who routinely prescribed and/or administered symptom relief to patients near the end of life in Queensland and New South Wales, Australia. Data were analysed using a six-stage hybrid thematic analysis technique.FindingsNurses identified five barriers to adequate symptom management. Firstly, fears concerning symptom relief such as hastening death, causing addiction, loss of consciousness, and legal/professional repercussions affected clinical practice. Secondly, lack of knowledge, experience and training hindered symptom management. Nurses discussed knowledge gaps regarding medication and palliative care, symptom assessments, recognition of dying and relevant laws. Thirdly, personal, cultural and religious beliefs influenced staff's willingness to offer pain relief, and patients’ and families’ willingness to accept it. Lack of communication between medical teams, patients and families further challenged symptom management. Lastly, institutional barriers played a considerable role as time constraints, insufficient staff support and difficulties accessing resources prevented end-of-life symptom management.DiscussionThe identified barriers highlight a substantial need for targeted interventions. Setting-specific challenges such as limited access to medication, staff and palliative care services must be addressed.ConclusionsTo provide better end-of-life care, services should acknowledge nurses’ unique insights. Particular attention should be on supporting nurses in aged care facilities, community settings and remote areas.     

Effectiveness of an Occupational Therapy Program on Cancer Patients with Dyspnea: Randomized Trial

Abstract

Background: Dyspnea is one of the leading causes of loss of autonomy among patients with advanced cancer. The management of these symptoms relies exclusively on pharmacological measures.

Aims: To assess the effectiveness of a “occupational therapy program” to improve both personal functionality and respiratory function in patients with dyspnea.

Methods: Experimental, prospective, longitudinal, and randomized study. A total of 102 individuals from the inpatient oncology unit of the University Salamanca Hospital Complex were participated in this study. In addition to pharmacological treatment, the intervention group participated in the occupational therapy program.

Results: The study yielded statistically significant differences between the members of the experimental group and those of the control group in functionality levels, as well as statistically significant differences in the BODE global respiratory index scores (p?<?0.001), and in the dyspnea level scores (p?<?0.001) between both groups.

Conclusions: Comprehensive respiratory rehabilitation program from an occupational therapy perspective improve functionality and overall respiratory function levels in cancer patients suffering from dyspnea.     

Symptom priority and course of symptomatology in specialized palliative care

The study aim was to explore which symptoms/problems cancer patients in palliative care consider most distressing, and to investigate how prioritization at first contact was associated with patient-assessed symptom intensity and change in intensity over time. Initially, 175 patients named and prioritized their five most distressing symptoms. Weekly, they completed the following self-assessment questionnaires: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30, Edmonton Symptom Assessment System, and the Hospital Anxiety and Depression Scale. Initial symptom intensity scores and weekly changes were calculated and compared with prioritization of the same symptom. Pain, fatigue, physical function, appetite, nausea/vomiting, dyspnea, and depression were the symptoms most often prioritized. Priority was associated with initial scoring of pain, appetite, nausea/vomiting, dyspnea, constipation, depression, and anxiety, but not with fatigue, physical function, role function, or inactivity. Priority was associated with change in symptom intensity for pain, reduced appetite, nausea/vomiting, and constipation. Symptom prioritization may be a useful guide to choice of treatment as well as to longitudinal symptom evaluation.     

Efficacy and cost: avoiding undertreatment of chemotherapy-induced nausea and vomiting

Although nausea and vomiting occur in patients with cancer for various reasons, chemotherapy-induced nausea and vomiting (CINV) remains one of the most distressing symptoms associated with cancer therapy. Despite advances in the management of that side effect, patients with cancer receiving chemotherapy continue to report CINV. Oncology nurses should be aware of advances in the management of CINV. Healthcare provider perceptions of CINV may not accurately represent actual occurrence of the symptom, and CINV may affect patients' quality of life or even treatment adherence for selected patients. Although evidence-based guidelines are available, not all healthcare providers, including oncology nurses, follow recommendations for prevention of CINV. Inadequately treated CINV can lead to increased resource costs, as well as patient suffering. This article will review the evidence for the cost of inadequately treated CINV, as well as current clinical guidelines for management of this symptom. Oncology nurses are critical in the assessment and management of CINV, as well as in making recommendations for practice improvement.     

Using Cannabis to Treat Cancer-Related Pain

ObjectiveTo describe which cannabinoids and terpenes are effective for treating pain.Data SourcesPeer-reviewed articles, book chapters.ConclusionCannabis and cannabinoid medicines, as modulators of the endocannabinoid system, offer novel therapeutic options for the treatment of cancer-related pain, not only for patients who do not respond to conventional therapies, but also for patients who prefer to try cannabis as a first treatment option.Implications for Nursing PracticeUnderstanding the endocannabinoid system, cannabinoids, terpenes, routes of administration, potential drug interactions, clinical implications, and potential side effects ensures nurses can better assist patients who use cannabis for the treatment of cancer pain.     

A cluster randomized trial of a primary palliative care intervention (CONNECT) for patients with advanced cancer: Protocol and key design considerations

BackgroundThe addition of specialty palliative care to standard oncology care improves outcomes for patients with advanced cancer and their caregivers, but many lack access to specialty care services. Primary palliative care—meaning basic palliative care services provided by clinicians who are not palliative care specialists—is an alternative approach that has not been rigorously evaluated.MethodsA cluster randomized, controlled trial of the CONNECT (Care management by Oncology Nurses to address supportive care needs) intervention, an oncology nurse-led care management approach to providing primary palliative care for patients with advanced cancer and their family caregivers, is currently underway at 16 oncology practices in Western Pennsylvania. Existing oncology nurses are trained to provide symptom management and emotional support, engage patients and families in advance care planning, and coordinate appropriate care using evidence-based care management strategies. The trial will assess the impact of CONNECT versus standard oncology care on patient quality of life (primary outcome), symptom burden, and mood; caregiver burden and mood; and healthcare resource use.DiscussionThis trial addresses the need for more accessible models of palliative care by evaluating an intervention led by oncology nurses that can be widely disseminated in community oncology settings. The design confronts potential biases in palliative care research by randomizing at the practice level to avoid contamination, enrolling patients prior to informing them of group allocation, and conducting blinded outcome assessments. By collecting patient, caregiver, and healthcare utilization outcomes, the trial will enable understanding of the full range of a primary palliative care intervention's impact.     

Fertility Preservation in Gynecologic Cancer

ObjectivesTo review current conservative fertility-sparing options for patients undergoing surgical and medical management of cervical, endometrial, and ovarian cancers. Standard and investigational fertility preservation alternatives using assisted reproductive technologies are described.Data SourcesA review of articles dated 2006–2018 from PubMed.ConclusionWhile a frequently reported concern among female cancer survivors of childbearing potential, fertility preservation education and procedures continue to be an unmet need for this population.Implication for Nursing PracticeKnowledge of current fertility-sparing options is imperative for nurses to ensure fertility preservation is introduced early, and often, into education for patients from diagnosis, through treatment, and in survivorship.     

Advancing Oncology Nursing Practice Through the Adoption of Patient Monitoring Digital Tools

ObjectiveThe objective of this paper is to describe the use of oncology digital symptom monitoring and patient self-management coaching tools, how nurses and nurse practitioners (NPs) can optimize their use as an adjunct in improving oncology care and discuss issues and strategies needed for adoption within a variety of clinical settings.Data SourcesA review of the research literature regarding digital health in oncology symptom management in PubMed provided the foundation for this paper.ConclusionDigital symptom monitoring technology provides a variety of opportunities for oncology nurses and NPs to efficiently extend and improve symptom management in multiple settings including cancer patients at home between clinic visits, at clinic visits, and during inpatient stays. Digital monitoring and patient engagement make possible frequent symptom assessments, just-in-time personalized self-management reinforcement, and judiciously alert nurses and NPs about key times for follow-up with patients supported with evidenced-based guidelines. Oncology nurses at all levels have the opportunity to be leaders in the adoption and expansion of digital tools to enhance their practice.Implications for Nursing PracticeOncology nurses and NPs can lead practice changes that improve patient outcomes through understanding and shaping the use of digital tools.     

Respiratory Failure,Noninvasive Ventilation,and Symptom Burden: An Observational Study

Background

Noninvasive ventilation (NIV) is commonly used to manage acute respiratory failure due to decompensated cardiorespiratory disease. We describe symptom burden in this population.

Intrathecal therapy for the management of cancer pain

Inadequately managed cancer pain continues to be a significant problem despite increased awareness, improved knowledge and understanding of pain pathophysiology, and standardized treatment guidelines of this distressing and debilitating symptom complex. Small subsets of patients who are refractory to optimal medical management because of drug toxicity or unsatisfactory analgesia may be candidates for exteriorized or implantable intrathecal drug delivery systems. By delivering opioids and other agents directly to the central nervous system, intrathecal drug administration can offer superior pain relief with less toxicity at a fraction of the systemic dose. With adjuncts such as local anesthetics and clonidine, intrathecal therapy also allows for broader therapeutic options in the most difficult of cases. In general, intrathecal therapy is underused despite evidence of its efficacy, safety, and cost-effectiveness.