OBJECTIVES: Unrelieved pain is present in a majority of terminal cancer patients. However, the treatment of pain in palliative and hospice care is affected by the lack of validated pain assessment. The goal of this study is to evaluate differences in pain evaluation between terminal cancer patients and physicians and evaluate the pain levels as a survival biomarker.
METHODS: Patients were evaluated every 7 days for a total of 4 assessments. Physicians evaluated patients' pain on a NRS scale after clinical examination, after which the patients completed NRS, QLQ-C15-PAL, and ESAS questionnaires.
RESULTS: On average, physicians minimally underestimated the pain level in patients (3.47 vs. 3.94 on a NRS scale). Pain was overestimated in 28% and underestimated in 46% of the patients. However, half of all underestimation was clinically meaningful, compared to 28% of the overestimation. For patients with the NRS score of 7 or more, pain underestimation was both clinically and statistically significant (5.56 vs. 8.17). Pain ratings exhibited a very mild correlation to survival (up to r=-0.22), limiting their use as a survival biomarker.
DISCUSSION: Although physicians can accurately assess mild pain in terminal cancer patients in the hospice setting, the underestimation of the pain is still clinically significant in almost quarter of the patients and especially pronounced in patients with higher levels of pain and females. Hence, validated pain assessment is a necessity in hospice care, with the choice of pain evaluation tool dependent on patient and physician preference.
PURPOSE: Quality of life is the cornerstone of palliative care, and assessing it requires validated and standardized questionnaires. However, the majority of questionnaires are not tested in a hospice setting. The purpose of this study is to evaluate the quality of life in a hospice using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 for Palliative Care (PAL) (EORTC QLQ-C15-PAL) questionnaire and validating it in Croatian language.
METHODS: The study was conducted prospectively on 151 consecutive patients who were evaluated at the admittance to the hospice and after 7 days. Along with the EORTC QLQ-C15-PAL, both evaluations included the Edmonton Symptom Assessment System (ESAS) and the Palliative Performance Score (PPS) version 2. Cronbach a coefficient was used to test the reliability of multi-item scales, while construct and concurrent validity was tested using the Pearson correlation coefficients. Known-group validity was evaluated using the Student t test.
RESULTS: Physical functioning, pain, and emotional functioning scales all exhibited high reliability on both assessments and met the criteria of Cronbach a =.70, while fatigue scale met the predetermined criteria in the follow-up assessment (a = .90). Adequate validity was also displayed, with the highest correlation coefficients between the EORTC QLQ-C15-PAL and ESAS scales recorded for the corresponding items. The EORTC QLQ-C15-PAL was also able to distinguish patients with different PPS scores, exhibiting excellent clinical validity.
CONCLUSIONS: The EORTC QLQ-C15-PAL can be used successfully in Croatian palliative care. However, inevitable issues such as low retest percentage due to short survival and low physical functioning scores need to be acknowledged in further formulations of quality of life questionnaires specific to hospice care.
Opioids and sedatives are the cornerstone of symptom management in the end-of-life patients, but undertreatment is a common problem. Although several studies explored the individual effect of opioids, anxiolytics, and antipsychotics on survival, not much is known regarding their combined use. As these drugs share similar and potentially fatal side effects, primarily respiratory depression which occurs more often during night-hours, it is crucial to explore whether their interaction poses a danger for fragile hospice patients. To analyze the relationship of a combination of opioids, anxiolytics, and antipsychotics on survival and the change of night-time death percentage. A retrospective study of 765 consecutive patients admitted to hospice in Croatia over the period of four years (2013–2017). The main outcome was the total length of survival of hospice patients regarding different drug combination, along with night-time death percentage. Different combinations of opioids, anxiolytics, and antipsychotics were associated with longer survival in hospice compared with patients using no such drugs. When we included different parameters which affected overall survival into a multivariate analysis, only the patients who had the combination of both opioids, anxiolytics, and antipsychotics in their regular therapy were associated with longer survival in hospice (11 vs. five days, hazard ratio 0.54, P < 0.001). No combination of opioids, anxiolytics, and antipsychotics significantly changed the night-time death percentage. This research supports the safety of opioids, anxiolytics, and antipsychotics in the hospice setting when used both individually as well as in combination.