Purpose: The aim of this study was to compare symptom expression in advanced cancer patients with depression and anxiety and in patients with no such symptoms.
Methods: Secondary analysis of a previous study assessing the role of an acute palliative supportive care unit (APSCU) in a comprehensive cancer center. Patients completed the Edmonton Symptom Assessment System (ESAS) at admission (T0) and 7 days after or at discharge (T7).
Results: Three hundred-fourteen consecutive cancer patients admitted to the APSCU were surveyed. Eighty-six and 66 patients improved their level of depression and anxiety, respectively (passing from = 4 to 0–3, from T0 to T7), after that palliative care intervention resulted in a significant improvement of the other symptoms. Changes were statistically significant for both symptoms (P < 0.0005). Patients admitted for uncontrolled pain were more likely to be anxious, while patients admitted for other symptoms or end-of-life care were more likely to be depressed. The presence of anxiety and depression (= 4/10 on ESAS) was significantly associated with a higher level of symptom expression at admission and at T7 (P < 0.0005). In patients presenting both psychological symptoms, symptom expression was significantly more relevant in comparison with patients not reporting moderate-severe psychological symptoms. Pain and depression were independently associated with anxiety at T0. Variables independently associated with depression at T0 were drowsiness, appetite, and anxiety.
Conclusions: Psychological symptoms of ESAS concur to hyper-express some symptoms and make symptom control more difficult. A clear association between anxiety and depression exists.
AIM: The aim of this study was to assess the factors which influence the care pathway after discharge from an acute palliative supportive care unit (APSCU).
METHODS: Patients' demographics, indications for admission, kind of admission, the presence of a caregiver, awareness of prognosis, data on anticancer treatments in the last 30 days, ongoing treatment (on/off or uncertain), the previous care setting, analgesic consumption, and duration of admission were recorded. The Edmonton Symptom Assessment Scale (ESAS) at admission and at time of discharge (or the day before death), CAGE (cut down, annoy, guilt, eye-opener), and the Memorial Delirium Assessment Scale (MDAS), were used. At time of discharge, the subsequent referral to other care settings (death, home, home care, hospice, oncology), and the pathway of oncologic treatment were reconsidered (on/off, uncertain).
RESULTS: A total of 314 consecutive cancer patients admitted to the APSCU were surveyed. Factors independently associated with on-therapy were the lack of a caregiver, home discharge, and short hospital admission, in comparison with off-treatment, and less admission for other symptoms, shorter hospital admission, discharge at home, and better well-being, when compared with "uncertain." Similarly, many factors were associated with discharge setting, but the only factor independently associated with discharge home was being "on-therapy."
CONCLUSIONS: The finding of this study is consistent with an appropriate selection of patients after being discharged by an APSCU, that works as a bridge between active treatments and supportive/palliative care, according the concept of early and simultaneous care.
AIM: The aim of this study was to investigate the relationship between delirium and symptom expression in patients with advanced cancer admitted to an acute supportive/palliative care unit (ASPCU).
METHODS: A consecutive sample of patients with advanced cancer who were admitted to an ASPCU was prospectively assessed for a period of 10 months. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS (Memorial Delirium Assessment Scale) were measured at admission (T0) and after 7 days of palliative care (T7).
RESULTS: Two hundred forty-six patients had complete data regarding MDAS measurements, at either T0 and T7. Of these, 75 (30.5%) and 63 patients (25.6%) had delirium at T0 and after a week of palliative care (T7), with a decrease in the frequency of delirium of 4.9% (from 30.5% to 25.6%); that means that 16% of patients with delirium improved their cognitive status after initiation of palliative care. Intensities of pain, depression, poor well-being, and global ESAS were significantly higher in patients with delirium. Patients who did not have delirium at T0 but developed delirium during admission after 1 week of palliative care had a higher level of symptom expression for pain, weakness, nausea, anxiety, dyspnea, appetite, and consequently global ESAS. Patients who did not develop delirium at any time had a relevant decrease in intensity of all ESAS items after 1 week of palliative care. The decrease of symptom intensity was significant for pain, insomnia, appetite, poor well-being, and global ESAS in patients with delirium either at T0 and T7, although these differences were less relevant than those observed in patients without delirium. In patients with delirium at T0 who improved their cognitive function at T7 (no delirium), significant changes were found in most ESAS items.
CONCLUSION: Symptom expression is amplified in patients with delirium, whereas patients without delirium may be more responsive to palliative treatments with a significant decrease in intensity of ESAS items.
IMPLICATIONS FOR PRACTICE: Symptom expression is amplified in patients with cancer who have delirium, whereas patients without delirium may be more responsive to palliative treatments with a significant decrease in symptom intensity.
BACKGROUND: To assess the response to ketamine in patients with difficult pain syndromes.
METHODS: The charts of patients with uncontrolled pain despite opioid dose escalation of at least two opioids or a combination of them, selected for a burst of ketamine and midazolam were reviewed. One hundred mg/day of ketamine and midazolam 15 mg/day by a continuous intravenous infusion for about 48 hours was offered to patients.
RESULTS: Forty-four patients received a burst of ketamine. Ten patients did not achieve any improvement. Pain intensity decreased from a mean of 7.8 (SD, 1.6) to 2.8 (SD, 1.3) (P<0.0005). The outcome was considered optimal, good, and mild in 24, 9, and 1 patients, respectively. Adverse effects attributable to ketamine did not have relevant intensity and no patient discontinued the treatment due to psychomimetic adverse effects.
CONCLUSIONS: This data suggests that a burst of ketamine and midazolam at low doses, may reverse an unfavourable opioid response, assisting the opioid switching. Although the role of ketamine remains controversial, it should not deter physicians to do not use that in specific conditions.
AIM: The aim of this study was to assess the Personalized Dyspnea Intensity Goal, and the achievement of Personalized Goal Response and Patient Global impression, after comprehensive symptom management. The secondary outcome was to assess factors related to personalized goal response.
PATIENTS AND METHODS: Advanced cancer patients admitted to palliative care units rated pain and symptoms intensity, and their Personalized Dyspnea Intensity Goal , by using the Edmonton Symptom Assessment Score (ESAS). After a comprehensive symptom management, achievement of target patients' response and Patient Global Impression were evaluated.
RESULTS: 279 patients were analyzed in this study. The mean Personalized Dyspnea Intensity Goal at T0 and T7 were 0.97 (SD 1.3), and 0.71 (SD 2.1), respectively. 263 (94.2%) indicated a Personalized Dyspnea Intensity Goal of =3 as a target at T0. Patients perceived a bit better, a better improvement, and a much better improvement with a mean decrease in dyspnea intensity of – 2.1, –3.5, and -4.3 points on the dyspnea intensity scale, respectively. In 60 patients (21.5 %), dyspnea intensity did not change, and in 4.7%, dyspnea intensity worsened. Patients perceived a Minimal Clinically Important Difference (little worse) with a mean increase in dyspnea intensity of 0.10, and they perceived a worse with a mean increase of 1.7 points. Higher dyspnea intensity at T0 and lower dyspnea intensity at T7 were independently related to Patient Global Impression. At T7, 93 (33.3%) patients achieved their Personalized Goal Response, based on Personalized Dyspnea Intensity. Patient Dyspnea Goal Response was associated with Memorial Delirium Assessment Scale score and Personalized Dyspnea Intensity Goal at T0, and inversely associated with dyspnea intensity at T0 and T7, and lower Karnofsky level. For Patient Dyspnea Goal Response, no significant differences among categories of dyspnea intensity were found (P>0.05).
CONCLUSION: Patient Dyspnea Goal Response and Patient Global Impression seem to be relevant for evaluating the effects of a comprehensive management of symptoms, including dyspnea, assisting decision making process. Some factors may be implicated in determining the individual target and clinical response.
BACKGROUND: A supportive palliative care unit (SPCU) may have a positive impact on patients' care. The aim of this study was to compare the pattern of patients admitted to a specialized SPCU and to a traditional oncologic ward (OW) in a consecutive sample of advanced cancer patients.
METHODS: Data on patients demographics, reasons for and kind of admission, care-giver, anticancer treatments, being on/off treatment or uncertain, origin setting, who proposed hospital admission, the use of opioids, and hospitalization were gathered. The same parameters were recorded at discharge. A follow-up was performed by phone 1 month after discharge.
RESULTS: Two-hundred patients were surveyed. Awareness of disease was more complete in OW patients (P = 0.001). Uncontrolled pain and symptoms were the prevalent reasons for admission to SPCU (P < 0.0005). Toxicity from chemotherapy was more frequently reported by OW patients (P = 0.001). SPCU patients received higher doses of opioids (P = 0.004). More SPCU patients were referred from home and were discharged home (P < 0.0005 and P = 0.018, respectively). Emergency admissions were more frequently reported in OW patients (P < 0.0005). One month after, more SPCU patients were at home and were still on active treatment (P = 0.002, and P = 0.05, respectively). More OW patients died within 1 month (P = 0.001).
CONCLUSION: SPCU allows a better planning admission to hospital and a better care trajectory in advanced cancer patients in comparison to a busy OW, where unselected emergencies more frequently occur.
Background: Delirium is often unrecognized in cancer patients. The aim of this study was to investigate the prevalence of delirium assessed by the Memorial Delirium Assessment Scale (MDAS) and possible associated factors on admission to an acute palliative/supportive care unit (APSCU). The secondary outcome was to assess changes in MDAS and symptom burden at time of discharge.
Methods: A consecutive sample of advanced cancer patients who were admitted to an APSCU was prospectively assessed for a period of 10 months. Patient demographics, including age, gender, primary diagnosis, Karnofsky status, stage of disease, and educational level were collected. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS were measured at hospital admission and discharge.
Results: A total of 314 patients were surveyed. Of 292 patients with MDAS available at T0, 74 (25.3%) and 24 (8.2%) had a MDAS of 7-12 and >=13, respectively. At discharge, there was a significant decrease in the number of patients with a MDAS >=7/30. Higher values of MDAS were associated with age (p = .028), a lower Karnofsky status (p < .0005), gender (male, p = .04), low level of education (p = .002), less awareness of disease (p < .0005), more indications for end-of-life care admission (p < .0005) or other symptoms (p = .026), hospital stay (p = .038) and death (p < .0005). Significant decreases in ESAS were observed in all patients independently of MDAS values (p < .0005).
Conclusion: Delirium is highly prevalent in patients admitted to APSCU, characterized by a low mortality due to early referral. Comprehensive assessment and treatment may allow a decrease in the level of cognitive disorders and symptom burden.
Les patients en phase avancée de cancer souffrent souvent de symptômes (douleur, nausée, vomissement, dysphagie, diarrhée, constipation, dyspnée...) qui nuisent à leur qualité de vie. Le but de l'étude était d'évaluer l'impact des soins palliatifs dispensés à domicile par une équipe expérimentée. Les symptômes de 211 patients ont été suivis par une équipe de soins palliatifs. Les résultats ont montré un bon impact des soins palliatifs dans ce groupe de patients.
Dans le but d'examiner les effets de la méthadone sur des patients cancéreux douloureux, en particulier des personnes âgées, 45 patients cancéreux en phase avancée ont été suivis à domicile. Il apparaît que le traitement de la douleur à l'aide de méthadone semble performant pour des patients cancéreux soignés à domicile, et que les risques sont faibles avec des dosages titrés, même chez les personnes âgées ou en présence de mécanismes douloureux neuropathiques.