Cancer is the most common cause of mortality worldwide. Although recent advances of multiple modality cancer management have significantly improved the cure and control rates, a significant proportion of patients are still refractory to the standard and available treatments. Early initiation of palliative care can reduce cancer suffering, improve health-related quality of life and possibly prolong survival. It also allows patients and their caretakers to perceive the trajectory of their cancer, so that better and advanced care planning can be contemplated and implemented. The traditional beliefs and perceptions of cancer also differ significantly between the East and the West, which may also affect the preferential approach to palliative care. This review provides an overview of palliative care services in Hong Kong, as compared with other parts of the world. In addition, we shall also explore how cancer perceptions affect the decision-making on palliative care.
Background: Opioid refractory pain is a common problem in pain management. Dexmedetomidine is suggested to have opioid-sparing effects, with well-described use in surgical and intensive care unit settings. Some authors advocate its benefit in reducing delirium. Its effects are thought to be exhibited through agonism of pre- and postsynpatic a2-receptors in the central nervous system. It is more selective on a2-receptors than clonidine, accounting for its relatively lower incidence of hypotension. Its use in sedation is favored because it does not depress the respiratory system. The main side effects reported include bradycardia.
Case Description: Twenty-eight-year-old woman with triple negative left breast cancer and a locally destructive tumor was admitted to hospice after exhausting her disease-directed therapy options. Her chief complaint was a throbbing, burning pain to the left chest wall, lower back, and bilateral lower extremities, rated 8/10 on a 10-point verbal scale. Multiple pharmacologic agents for pain, including patient-controlled analgesia infusions with adjuvant methadone and steroids, had failed to provide consistent pain management. Symptoms were difficult to control in the home setting, and she required multiple admissions to our inpatient hospice unit for pain management. She also developed episodes of delirium shortly after hospice admission. We attributed her symptoms to rapid disease progression. After failed pain control with opioids, ketamine, and lidocaine, we trialed a dexmedetomidine infusion. While on the infusion, her pain rating decreased to 0/10 and she had no delirium. Pain recurred soon after cessation of the infusion, initially rated 6/10.
Conclusion: Dexmedetomidine is safe for opioid refractory pain in the hospice inpatient setting. However, its effects may not be sustained. There is potential for use in end-of-life care, with added benefit for possible control of delirium.
Background: A reality of the current political and legal environment is that while marijuana and cannabis-based products remain not approved for human consumption at the federal level in the United States, several states have authorized use for constituents. While state lines represent meaningful cultural and geographical identity markers, the reality is that patients and families readily cross state lines to access medical interventions and care.
Methods: We present the case of a six-year-old child with intractable seizures and severe neuropathic pain managed on medical marijuana (MM) in her home state of Colorado; where medicinal use of marijuana is authorized at the state level; traveling across state lines to access surgical care in Nebraska where MM is prohibited.
Conclusion: The case report shares the communication and creativity invested in adequate symptom management for this child weaned off of MM perioperatively. The case recognizes the unique complexities of shared symptom management goals within state-specific care models.
Background: Pain remains one of the most common and debilitating symptoms of advanced cancer. To date, there is a lack of studies on pain and its treatment among Malaysian palliative care patients.
Objective: This study aimed to explore the prevalence of pain and its treatment outcomes among adult cancer patients admitted to a palliative care unit in Sabah, Malaysia.
Methods: Of 327 patients screened (01/09/15-31/12/17), 151 patients with assessed self-reported pain scores based on the numerical rating scale of 0-10 (current, worst and least pain within the past 24 hours) upon admission (baseline), 24, 48 and 72 hours post-admission and discharge were included. Pain severity and pain score reductions were analysed among those who experienced pain upon admission or in the past 24 hours. Treatment adequacy was measured by the Pain Management Index (PMI) among discharged patients. The PMI was constructed upon worst scores categorised as 0 (no pain), 1 (1-4, mild pain), 2 (5-6, moderate pain), or 3 (7-10, severe pain) which is then subtracted from the most potent level of prescribed analgesic drug scored as 0 (no analgesia), 1 (non-opioid), 2 (weak opioid) or 3 (strong opioid). PMI =0 indicated adequate treatment.
Results: Upon admission, 61.1% [95%CI 0.54:0.69] of 151 patients presented with pain. Of 123 patients who experienced pain upon admission or in the past 24 hours, 82.1% had moderate to severe worst pain. Throughout patients' ward stay until discharge, there was an increased prescribing of analgesics and adjuvants compared to baseline, excluding weak opioids, with strong opioids as the mainstay treatment. For all pain score types (current, worst and least pain within the past 24 hours), means decreased at each time point (24, 48 and 72 hours post-admission and discharge) from baseline, with a significant decrease at 24 hours post-admission (p<0.001). Upon discharge (n=100), treatment adequacy significantly improved (PMI=0 100% versus 68% upon admission, p<0.001).
Conclusions: Accounting for pain's dynamic nature, there was a high prevalence of pain among cancer patients in the palliative care unit. Continuous efforts incorporating comprehensive pain assessments, evidence-based treatments and patient education are necessary to provide adequate pain relief and end-of-life comfort care.
OBJECTIVE: To select outcomes and indicators of the Nursing Outcomes Classification (NOC), in order to assess patients with cancer under palliative care with Acute and Chronic Pain Nursing Diagnoses; and to construct the conceptual and operational definitions of the indicators.
METHOD: Expert opinion study and literature review. The sample consisted of 13 experts. The data collection was in own tool applied in face-to-face meeting and by e-mail. In the analysis of the data, it was considered between 75% and 100% of agreement.
RESULTS: Eight outcomes and 19 indicators were selected. The results with higher scores were Pain Level, Pain Control and Client Satisfaction: Pain Management. For all indicators selected, conceptual and operational definitions were constructed.
CONCLUSION: The selection of results and priority indicators for the assessment of pain in palliative care, as well as the construction of its definitions, will support clinical practice.
Palmitoylethanolamide (PEA) is a nutraceutical endocannabinoid that was retrospectively discovered in egg yolks. Feeding poor children with known streptococcal infections prevented rheumatic fever. Subsequently, it was found to alter the course of influenza. Unfortunately, there is little known about its pharmacokinetics. Palmitoylethanolamide targets nonclassical cannabinoid receptors rather than CB1 and CB2 receptors. Palmitoylethanolamide will only indirectly activate classical cannabinoid receptors by an entourage effect. There are a significant number of prospective and randomized trials demonstrating the pain-relieving effects of PEA. There is lesser evidence of benefit in patients with nonpain symptoms related to depression, Parkinson disease, strokes, and autism. There are no reported drug-drug interactions and very few reported adverse effects from PEA. Further research is needed to define the palliative benefits to PEA.
Palliative care concentrates on preventing and relieving suffering by reducing the severity of disease symptoms. Consistent treatment of pain and distress must therefore be an integral component of every palliative care concept. In this review non-pharmacological and pharmacological measures for pain and distress management in the context of palliative neonatal care are summarised. Furthermore, recommendations are given focusing on two special palliative neonatal care settings: compassionate extubation and withdrawing artificial nutrition and hydration.
Pain is one of the most commonly experienced and feared symptoms faced by patients with a serious illness. For these patients, intrathecal drug delivery systems (IDDSs) provide greater potency and/or few systemic side effects. However, despite these benefits, the integration and management of IDDS for patients receiving hospice care has not been previous studied. An electronic, 18-question survey was sent to 200 hospice practitioners (physicians, nurse practitioners and nurses) in the state of Minnesota to explore their experience, confidence, and the perceived barriers to caring for patients with IDDS while being cared for on hospice. Providers were identified though mailing lists from the Minnesota Network of Hospice and Palliative Care organization. The survey was administered by the Mayo Clinic Survey Research Center with institutional review board approval. Slightly more than 50% of respondents have ever cared for a patient with an intrathecal pump. If a patient had a pump in place, only 28% of providers expressed confidence in managing their pain. Additionally, only 3 of 10 respondents felt that adjusting an intrathecal pump should be the first option when a patient with an IDDS in place had increased pain. Indeed, the vast majority (over 80%) of respondents preferred the use of systemic therapies for primary pain management. Access to IDDS vendors for changes/refills in the home is identified as another barrier with over 50% of respondents either unaware of an available vendor or reporting no vendor available. There are numerous self-reported barriers to ongoing use of IDDS with patients receiving hospice care.
Informal hospice caregivers often have difficulty managing patient pain at home. We developed a digital application, e-Pain Reporter, for informal caregivers to record and providers to monitor patient pain and pain management. The purpose of this study was (1) to assess the feasibility of informal caregivers using the e-Pain Reporter for 9 days in home hospice by investigating recruitment and retention and caregiver satisfaction with and frequency of use of the e-Pain Reporter and (2) describe patient pain characteristics and caregiver’s barriers to pain management and self-efficacy in providing patient care in the home. One-group pre-post design was used. Patient-caregiver dyads were recruited from 1 hospice agency. Caregivers were asked to report all patient pain and pain management using the e-Pain Reporter. Feasibility of the e-Pain Reporter was assessed by the average number of times caregivers recorded breakthrough and daily pain and caregiver satisfaction with the app. The 27-item Barriers Questionnaire II and 21-item Caregiver Self-efficacy Scale were administered at baseline. Fourteen dyads enrolled, 2 patients died, and 12 dyads completed the study. Mean number of pain reports over 9 days was 10.5. Caregivers reported high overall satisfaction with the e-Pain Reporter. Barriers scores were moderately high, suggesting erroneous beliefs and misconceptions about pain reporting and use of analgesics, but self-efficacy in managing pain was also high (93% confidence). Findings suggest that the e-Pain Reporter is a feasible method to report and monitor caregiver management of pain at home. Caregiver high barriers and high overconfidence suggest the need for an educational component to the e-Pain Reporter to address misconceptions about pain and pain management.
In Norway, approximately 50% of older people die in nursing homes (NH). Holistic care and pharmacological management are key factors in quality at the end of life. The purpose of this longitudinal study was to describe the use of opioids in an NH during a 5-year period. We focused on palliative care, symptoms, and suffering during the last 3 days before death. Data were collected from spring 2013 to spring 2018. We used the interRAI assessment instrument annually and when the resident died. We conducted a semi-structured interview with nurses on duty at the deathbed. At the time of death, the residents had an average age of 88.9 years and an average stay of 2.9 years (N = 100). At the first assessment, 19% of the residents used 1 or more type of opioids. On the day of death, 55% had an active prescription for opioids, mainly as subcutaneous injections. The results illustrate the different uses of opioids, including managing pain, dyspnoea, sedation, for comfort, as a prophylaxis, or a combination of reasons. Cancer- and cardiovascular diagnoses were the strongest predictor for using morphine (P < 0.05). Identification of the residents’ needs for opioids is a challenge for palliative care nurses, both ethically and legally.
Aim: The aim of this study was to evaluate the therapeutic efficacy and safety profile of orally administered low-dose ketamine for procedural pain management in pediatric cancer patients undergoing lumbar puncture (LP) in a resource-limited hospital setting.
Methods: Patients between 4 and 15 years of age, with leukemia, undergoing LP were asked to participate. The study was designed as a two-armed blinded placebo-controlled trial where 0.8 mg/kg (bodyweight) of ketamine mixed in juice was given 30 minutes before the procedure to Group K (ketamine) compared with placebo, only juice, to Group P (placebo). In addition, topical analgesia (EMLA®) was given according to established standard of care. Patients and caregivers assessed the pain using the Wong–Baker Faces Pain Rating Scale.
Results: A total number of 52 patients, equally distributed between Group K and Group P, were included in the study. The placebo-controlled group had significantly higher self-reported pain score than the group receiving ketamine (p = 0.046), as well as in caregiver-assessed pain (p = 0.033). Only three incidents of mild adverse effects were reported.
Conclusion: Low-dose oral ketamine can be safely administered for procedural analgesia in pediatric cancer patients undergoing LP in a resource-limited hospital setting and have significant pain-reducing effect compared with placebo.
OBJECTIVE: The majority of self-management interventions are designed with a narrow focus on patient skills and fail to consider their potential as "catalysts" for improving care delivery. A project was undertaken to develop a patient self-management resource to support evidence-based, person-centered care for cancer pain and overcome barriers at the levels of the patient, provider, and health system.
METHOD: The project used a mixed-method design with concurrent triangulation, including the following: a national online survey of current practice; two systematic reviews of cancer pain needs and education; a desktop review of online patient pain diaries and other related resources; consultation with stakeholders; and interviews with patients regarding acceptability and usefulness of a draft resource.Result : Findings suggested that an optimal self-management resource should encourage pain reporting, build patients' sense of control, and support communication with providers and coordination between services. Each of these characteristics was identified as important in overcoming established barriers to cancer pain care. A pain self-management resource was developed to include: (1) a template for setting specific, measureable, achievable, relevant and time-bound goals of care, as well as identifying potential obstacles and ways to overcome these; and (2) a pain management plan detailing exacerbating and alleviating factors, current strategies for management, and contacts for support.
SIGNIFICANCE OF RESULTS : Self-management resources have the potential for addressing barriers not only at the patient level, but also at provider and health system levels. A cluster randomized controlled trial is under way to test effectiveness of the resource designed in this project in combination with pain screening, audit and feedback, and provider education. More research of this kind is needed to understand how interventions at different levels can be optimally combined to overcome barriers and improve care.
BACKGROUND: More than 15,000 children die annually in the United States due to an underlying life-limiting disease and the majority of those children experience distressing symptoms, which are not adequately relieved, such as pain and dyspnea. Multimodal analgesia, that is multiple agents, interventions, rehabilitation, psychological modalities, and integrative (nonpharmacologic) therapies, act synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. However, opioids, such as morphine, fentanyl, hydromorphone, oxycodone, and methadone (in the United Kingdom: diamorphine) remain the mainstay medication to effectively treat pain and dyspnea in children with serious illness.
METHODS: This article reviews commonly used opioids in Pediatric Palliative Care, which a special emphasis on 2 potentially particularly effective multimechanistic opioids: tramadol and methadone.
RESULTS: Methadone, due to its multimechanistic action profile, is possibly among the most effective and most underutilized opioid analgesics in children with severe unrelieved pain at end of life. However, methadone should not be prescribed by those unfamiliar with its use: Its effects should be closely monitored for several days, particularly when it is first started and after any dose changes.
CONCLUSIONS: Tramadol appears to play a key role in treating episodes of inconsolability in children with progressive neurologic, metabolic, or chromosomally based condition with impairment of the central nervous system. However, the recent 2017 United States Food and Drug Administration (FDA) warning against pediatric use of tramadol does not seem to be based on clinical evidence, and therefore puts children at risk for unrelieved pain or increased respiratory depression.
Cancer pain is an unrelenting symptom with the potential to alter the quality of life of patients. To adequately manage pain, nurses caring for cancer patients need to fully understand each patient's pain experience. The purpose of this study was to identify the intensity, distress, frequency, or constancy of pain in patients treated for cancer or cancer symptoms and to better understand patient barriers to pain management. This cross-sectional study included patients (N = 105) treated for cancer or cancer symptoms at 2 outpatient medical centers. Assessments included the Pain Barriers Scale, the Cancer Symptom Scale, and the Multidimensional QOL Scale–Cancer. Descriptive statistics and Spearman correlations were used to analyze the data. Sixty-nine percent of patients reported present pain of moderate to severe intensity that caused distress, was frequent/constant, or interfered with their lives. Patients with the greatest pain distress reported the greatest intensity of pain (r = 0.77) and the greatest interference (r = 0.78) with daily lives. Cancer pain was associated with significant distress and interference with life activities and occurred frequently or constantly for many study patients.
BACKGROUND: Temporomandibular disorder (TMD) is the most common cause of orofacial and cervical skull pain and is considered to be a public health problem, affecting 5% to 12% of the world population. TMD is multifactorial and there are several types of treatment, with the conservative types being indicated more often as they are less aggressive and reversible. The main aim of these treatments is to relieve symptoms, reduce of pain, and restore orofacial and cervical skull functions. Photobiomodulation therapy (PBMT), a noninvasive therapy, is an option for the management of musculoskeletal disorders due to its analgesic, anti-inflammatory, and regenerative effects.
METHODS: The aim of the proposed study is to verify whether PBMT is effective for use in palliative care of TMD and orofacial and cervical skull pain. A randomized, triple-blinded, placebo-controlled clinical trial is proposed. This study will involve 200 adult participants (over 18 years of age) who will be randomly divided into two groups (n = 100): Group 1, active treatment (PBMT); and Group 2, placebo. Participants will be subjected to three sessions of PBMT or placebo and will be evaluated using the research diagnostic criteria (RDC) for TMD. Pain level (measured by a visual analog scale (VAS)), mandibular movements (measured by ruler and caliper), quality of life (measured by the Oral Health Impact Profile (OHIP)-14), and quality of sleep (measured by the Epworth scale) will be recorded. This study is being conducted at the Special Laboratory of Lasers in Dentistry (LELO) of the School of Dentistry of the University of Sao Paulo (USP).
DISCUSSION: This study will verify whether PBMT is effective in reducing TMD and orofacial and cervical skull pain. PBMT may be an option for the management of musculoskeletal disorders due to its analgesic, anti-inflammatory, and regenerative effects, in addition to being a noninvasive technique.
CONTEXT: Cancer-related pain is associated with significant suffering and is one of the most challenging symptoms to manage. Studies indicate that front-line clinicians often lack the knowledge on best practices in cancer pain management.
OBJECTIVES: The current project, a quality improvement (QI) initiative, evaluated the outcome of an online educational intervention for nurses on complex cancer pain management.
METHODS: An online 7-module educational intervention, Advanced Pain Assessment and Management, was offered from 2012 to 2017. Pre-post course evaluations included self-reported knowledge and confidence across cancer pain management domains. In-course competency assessments included knowledge examination, online discussion forum participation, opioid dosage calculation assignment, and small-group-based case study. A mixed-model statistical analysis was used to assess pre-post course change in pain management confidence level.
RESULTS: In all, 306 nurses from 89 hospitals in Ontario, Canada, were enrolled in the course; 81.4% returned the precourse survey and 71.9% successfully completed the course. The average confidence level on pain management was low at baseline (57.5%) but improved significantly post-course. In-course competency assessments ranged from 81% to 89%. Mixed-model results showed post-course improvements in confidence levels, independent of sociodemographic background, clinical role, and professional educational level. Nurses with longer years of practice and more cancer cases reported greater confidence.
CONCLUSION: A facilitator-led online educational intervention focusing on complex cancer pain management can significantly improve nurses' knowledge, confidence, and skills. Low baseline knowledge among nurses highlights the pressing need for health-care organizations to implement cancer pain management training as an integral part of health-care QI initiative.
BACKGROUND: The integration of palliative care into standard oncology care is supported by research to improve quality of life and symptom distress in patients with advanced cancer. In 2016, the American Society of Clinical Oncology (ASCO) released practice guidelines for oncology palliative care that emphasized interprofessional assessment and management of this patient population.
OBJECTIVES: The purpose of this study was to evaluate the effect of clinical guidelines on symptom distress in patients with advanced cancer.
METHODS: In two oncology palliative care clinics, the Edmonton Symptom Assessment Scale (ESAS) scores for pain, fatigue, and anxiety were measured prior to consultation (T1) and at two subsequent visits (T2 and T3). A standardized documentation template was used to measure fidelity for key guideline components.
FINDINGS: Pain, fatigue, and anxiety ESAS scores were statistically lower from T1 to T3. The frequency of patients having a decrease of 2 or more points for all symptoms increased compared to baseline data. There was 100% compliance to the documentation template during the guideline implementation.
Introduction: This case-control study evaluates the success of indwelling pain catheters in nonoperatively treated femoral neck fractures (FNFs) for end-of-life pain management.
Methods: Patients older than 65 years with nonoperatively treated FNFs were retrospectively identified at a level 1 trauma center between March 2012 and September 2015. Twenty-three received indwelling continuous peripheral pain catheters (experimental) and 10 received traditional pain control modalities (control). Pain scores 24 hours before/after pain management interventions, ambulation status at admission and discharge, mortality at 30 days/1 year, and length of hospital stay (LOS) were compared between treatment groups.
Results: The experimental and control groups were similar with respect to demographics, differing only in pre-fracture ambulatory status (P = .03). The 30-day mortality was 52% versus 50% (odds ratio, OR: 1.1 [95% confidence interval, CI: 0.25-4.82], P = .99) and 1-year mortality was 87% versus 80% (OR: 1.67 [95% CI: 0.23-11.9], P = .63) for experimental and control groups, respectively. The LOS did not statistically significantly differ for experimental and control groups (5.3 ± 3.56 days vs 3.8 ± 1.81 days, P = .15), respectively. The experimental group experienced twice the improvement in ambulation status (1.0 ± 0.56 vs 0.5 ± 0.71, P = 0.03) and greater improvement in pain scores (4.5 ± 2.19 vs 1.2 ± 2.72, P = .002).
Discussion: Operative management of FNFs may not be indicated in patients with advanced age and comorbidities. Regardless, these patients require pain palliation and early mobilization while minimizing hospital LOS and opiate consumption.
Conclusion: This case-control study demonstrates significant improvement in both pain level and ambulatory status for patients treated with indwelling continuous peripheral catheters. Future studies should further evaluate with a larger sample size; however, this study provides an excellent launching point for palliative management of this complex population.
It is common for patients with cancers in Hong Kong seeking Chinese Medicine (CM) therapies as supportive care during cancer treatment and to manage treatment-related side effects. This article provides clinical practice guideline (CPG) on the use of CM for specific clinical indications caused by cancer and during cancer treatment, including pain, constipation, and insomnia, and aims to guide local licensed CM practitioners and provide beneficial reference for social medical decision makers and patients. In this manuscript, we summarize the clinical manifestation, CM pattern classification, and CM intervention including herbal treatment, acupuncture treatment, regulating, and nursing based on pattern differentiation.