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Clinical update: Literature abstracts.
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- CLINICAL UPDATE: LITERATURE ABSTRACTS
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- © 2005 Cambridge University Press
SYMPTOMS
Efficacy of Pregabalin in Neuropathic Pain Evaluated in a 12-Week, Randomised, Double-Blind, Multicentre, Placebo-Controlled Trial of Flexible- and Fixed-Dose Regimens
Freynhagen, R., Strojek, K., Griesing, T., Whalen, E., and Balkenohl, M.
Pain, 115 (2005), 254–263
Pregabalin binds with high affinity to the alpha2-delta subunit protein of voltage-gated calcium channels and, thereby, reduces release of excitatory neurotransmitters. This 12-week randomized, double-blind, multicenter, placebo-controlled, parallel-group study evaluated the efficacy and safety of pregabalin in patients with chronic postherpetic neuralgia (PHN) or painful diabetic peripheral neuropathy (DPN). Patients were randomized to placebo (n = 65) or to one of two pregabalin regimens: a flexible schedule of 150, 300, 450, and 600 mg/day with weekly dose escalation based on patients' individual responses and tolerability (n = 141) or a fixed schedule of 300 mg/day for 1 week followed by 600 mg/day for 11 weeks (n = 132). Both flexible- and fixed-dose pregabalin significantly reduced endpoint mean pain score (primary outcome) versus placebo (p = 0.002, p < 0.001) and were significantly superior to placebo in improving pain-related sleep interference (p < 0.001). The most common adverse events (AEs) for pregabalin-treated patients were dizziness, peripheral edema, weight gain (not affecting diabetes control), and somnolence. These results are consistent with previous studies demonstrating pregabalin's efficacy, tolerability, and safety for treatment of chronic neuropathic pain associated with DPN or PHN. Pregabalin dosing aimed at optimal balance of efficacy and tolerability.
Efficacy and Safety of Opioid Agonists in the Treatment of Neuropathic Pain of Nonmalignant Origin
Eisenberg, E., McNicol, E.D., and Carr, D.B.
JAMA, 293 (2005), 3043–3052
In the United States, an estimated 2 million persons have neuropathic pain that is often resistant to therapy. The use of opioids for neuropathic pain remains controversial, in part because studies have been small, have yielded equivocal results, and have not established the long-term risk–benefit ratio of this treatment. The objective of our research was to assess the efficacy and safety of opioid agonists for the treatment of neuropathic pain based on published randomized controlled trials (RCTs). We searched MEDLINE (1966 to December 2004) and the Cochrane Central Register of Controlled Trials (fourth quarter, 2004) for articles in any language, along with reference lists of reviews and retrieved articles, using a combination of nine search terms for RCTs with 32 terms for opioids and 15 terms for neuropathic pain. Trials were included in which opioid agonists were given to treat central or peripheral neuropathic pain of any etiology, pain was assessed using validated instruments, and adverse events were reported. Studies in which drugs other than opioid agonists were combined with opioids or opioids were administered epidurally or intrathecally were excluded. Data were extracted by two independent investigators and included demographic variables, diagnoses, interventions, efficacy, and adverse effects. Twenty-two articles met inclusion criteria and were classified as short-term (less than 24 h; n = 14) or intermediate-term (median = 28 days; range = 8–56 days; n = 8) trials. The short-term trials had contradictory results. In contrast, all eight intermediate-term trials demonstrated opioid efficacy for spontaneous neuropathic pain. A fixed-effects model meta-analysis of six intermediate-term studies showed mean posttreatment visual analog scale scores of pain intensity after opioids to be 14 units lower on a scale from 0 to 100 than after placebo (95% confidence interval [CI], −18 to −10; p < 0.001). According to number needed to harm (NNH), the most common adverse event was nausea (NNH, 3.6; 95% CI, 2.9–4.8), followed by constipation (NNH, 4.6; 95% CI, 3.4–7.1), drowsiness (NNH, 5.3; 95% CI, 3.7–8.3), vomiting (NNH, 6.2; 95% CI, 4.6–11.1), and dizziness (NNH, 6.7; 95% CI, 4.8–10.0). Short-term studies provide only equivocal evidence regarding the efficacy of opioids in reducing the intensity of neuropathic pain. Intermediate-term studies demonstrate significant efficacy of opioids over placebo for neuropathic pain, which is likely to be clinically important. Reported adverse events of opioids are common but not life-threatening. Further RCTs are needed to establish their long-term efficacy, safety (including addiction potential), and effects on quality of life.
Desire for Hastened Death, Cancer Pain and Depression: Report of a Longitudinal Observational Study
O'Mahony, S., Goulet, J., Kornblith, A., Abbatiello, G., Clarke, B., Kless-Siegel, S., Breitbart, W., and Payne, R.
Journal of Pain and Symptom Management 29 (2005), 446–457
Desire for hastened death (DHD) is reported in the literature as being common in patients with cancer pain. However, there is currently little evidence to suggest that improvement in pain results in improvement in DHD. Our objectives were to assess (1) the impact of improvements in cancer pain severity and pain's interference with daily functioning and depression on DHD, and (2) the role of factors such as social and spiritual well-being, educational level, and patient age in moderating the impact of pain and depression on DHD. This observational study included patient-rated and clinician-rated scales administered twice at 4-week intervals. We enrolled 131 newly referred patients to the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center or newly admitted patients to Calvary Hospital in New York. One hundred and sixteen patients completed the baseline measures and 64 patients completed both baseline and follow-up measures. The main outcome measures included the Brief Pain Inventory (BPI), Beck Depression Inventory (BDI), and the Desire for Hastened Death Scale (DHD). Sixty-six percent of patients had no DHD at baseline and 45% of patients had BDI scores of 14 or greater (“mild” depression). Only 40% of patients with moderate/severe depression were receiving antidepressants. BPI scores improved significantly from baseline to follow-up (6.36 vs. 4.86, p < 0.01). DHD scores increased significantly from baseline to follow-up (0.84 to 1.38, p = 0.03). All other measures, including depression, were stable. DHD scores were moderately correlated with depression (r = 0.43), low social support (r = 0.38), poor spiritual well-being (r = −0.38), religious well-being (r = −0.25), pain interference (r = 0.27), higher educational level (F = 4.50, p = 0.02), and lower physical functioning (KPRS, r = −0.40), but were unrelated to sex, age, race, or marital status. In multivariate regression analyses, baseline DHD (β = 0.30, p = 0.05) and change in depression (β = 0.36, p = 0.02) were predictive of follow-up DHD. Improvement in pain interference was not predictive of follow-up DHD. The results suggest that improvement in depression moderated the severity of desire for hastened death in a population of patients with cancer pain. Depression was common in this population and was often untreated. Improvements in functional impairment due to pain did not moderate the severity of DHD in a setting of aggressive pain management. Strategies to preemptively screen for depression in the routine assessment of patients with cancer pain may be important to address DHD.
Auricular Acupuncture for Pain Relief after Total Hip Arthroplasty—A Randomized Controlled Study
Usichenko, T.I., Dinse, M., Hermsen, M., Witstruck, T., Pavlovic, D., and Lehman, Ch.
Pain, 114 (2005), 320–327
Auricular acupuncture (AA) is known to be effective in treatment of various pain conditions, but still there have been no randomized controlled studies of AA for treatment of acute postoperative pain. Therefore we tested whether AA of specific points is superior to sham acupuncture for complementary analgesia after total hip arthroplasty in a patient–anesthesiologist–evaluator–analyst blinded study. The patients were randomly allocated to receive true AA (lung, shenmen, thalamus, and hip points) or sham procedure (4 nonacupuncture points on the auricular helix). Permanent press AA needles were retained in situ 3 days after surgery. Postoperative pain was treated with intravenous piritramide (opioid receptor agonist with analgesic potency of 0.7 compared with morphine) using a patient-controlled analgesia (PCA) pump. The time to the first analgesic request, the amount of postoperative piritramide via PCA, and pain intensity on a 100-mm visual analogue scale (VAS-100) were used to evaluate postoperative analgesia. Intraoperative anesthetic requirement, incidence of analgesia-related side effects, inflammation parameters, and success of patients' blinding were also recorded. Fifty-four patients (29 AA and 25 controls) completed the study. Piritramide requirement during 36 h after surgery in AA group was lower than in control: 37 ± 18 versus 54 ± 21 mg; mean ± SD; p = 0.004. Pain intensity on VAS-100 and incidence of analgesia-related side effects were similar in both groups. The differences between the groups as regard patients' opinions concerning success of blinding were not significant. Findings from our study demonstrate that AA could be used to reduce postoperative analgesic requirement.
Comparative Efficacy of Oral Extended-Release Hydromorphone and Immediate-Release Hydromorphone in Patients with Persistent Moderate to Severe Pain: Two Randomized Controlled Trials
Grosset, A.B., Roberts, M.S., Woodson, M.E., Shi, M., Swanton, R.E., Reder, R.F., and Buckley, B.J.
Journal of Pain and Symptom Management, 29 (2005), 584–594
Two multicenter, randomized, double-blind, crossover studies with identical designs evaluated the efficacy of oral extended-release hydromorphone (HHER) administered q24h compared with immediate-release hydromorphone (HHIR) dosed four times daily in patients with persistent moderate to severe pain. Patients titrated to a stable HHER dose were randomized to individualized doses of HHER or HHIR for 3 to 7 days before crossover to the second treatment. Primary efficacy end point was the mean of average pain intensity (API) scores, rated on a 0- to 10-point numeric scale, over the last 2 days before the pharmacokinetics/pharmacodynamics day of each double-blind period. Difference between treatments (HHER − HHIR) in study 1 was 0.17 with a 90% confidence interval (CI) (−0.01, 0.34); in study 2, difference was 0.07 with a 90% CI (−0.12, 0.26). There were no significant differences between treatments in API scores or amount of rescue medication used at any time interval within the 24-h dosing period. No reduction in pain control occurred in patients administered HHER at the end of the 24-h dosing period. Most treatment-emergent adverse events were opioid related. In these studies, HHER administered q24h and HHIR dosed four times daily provided comparable analgesia at an equivalent total daily dose.
Association between Symptom Distress and Survival in Outpatients Seen in a Palliative Care Cancer Center
Palmer, J.L. and Fisch, M.J.
Journal of Pain and Symptom Management, 29 (2005), 565–571
Clinical observation and preliminary reports suggest that higher scores for symptoms such as pain may be associated with shorter survival. We undertook a survival analysis to determine whether symptom expression in outpatients with complex cancer is related to the duration of their survival. Participants were 225 outpatients with cancer evaluated in our comprehensive cancer center for pain management or palliative care over a 10-week period ending June 2000. In addition to age and other clinical and demographic information, the patients completed the Anderson Symptom Assessment System (ASAS), which assesses pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath (dyspnea), appetite, sleep, and feeling of well-being on a 0–10 scale. Univariate analyses showed that higher symptoms of dyspnea, drowsiness, problems with appetite, and nausea were significantly associated with shorter survival whereas pain, depression, and other ASAS items were not. In multivariate analyses, only higher levels of dyspnea and drowsiness showed a significant association (p = 0.01 and p = 0.02, respectively) with shorter survival. Knowledge about these symptoms may be important in formulating adaptive randomization techniques for clinical trials and for research concerning estimates of survival.
MEASURES
Prognostication in Hospice Care: Can the Palliative Performance Scale Help?
Head, B., Ritchie, C.S., and Smoot, T.M.
Journal of Palliative Medicine, 8 (2005), 492–502
Accurate prognostication of the trajectory of an illness provides multiple benefits in end-of-life care. Prognostic information facilitates more realistic decision making regarding ongoing treatment, fosters risk–benefit considerations of specific interventions, and contributes to appropriate utilization of health care services. The Palliative Performance Scale (PPS) has been used as a tool for measurement of functional status in palliative care. This study explores the application of the PPS as a tool for projecting length of stay until death or discharge in a home-based hospice program. Records of 396 patients admitted to a large community-based hospice program between January 1, 2001, and March 31, 2001, were reviewed. PPS scores were evaluated for their predictive ability related to length of hospice survival and consideration for hospice discharge. Other variables analyzed included diagnosis, presence of comorbidities, and age. PPS scores were associated with length of survival. Negative-change scores were predictive of patient decline toward death, whereas stable PPS ratings over time resulted in discharge consideration. The tool as used by this hospice was not highly discriminating between the 30% to 40% scores or the 50% to 70% scores. Conclusion: The PPS scores are associated with patient length of survival in a hospice program and can be used in evaluating hospice appropriateness.
Is the Palliative Performance Scale a Useful Predictor of Mortality in a Heterogeneous Hospice Population?
Harrold, J., Rickerson, E., Carroll, J.T., McGrath, J., Morales, K., Kapo, J., and Casarett, D.
Journal of Palliative Medicine, 8 (2005), 503–509
Hospices provide care to patients with a wide range of prognoses, and must develop care plans that anticipate each patient's likely illness trajectory. However, the tools available to guide prognostication and care planning in this population have limited data to support their use. For instance, one of the most widely used prognostic tools, the Palliative Performance Scale (PPS), has been studied primarily in inpatient settings and in patients with cancer. Its prognostic value in a heterogeneous U.S. hospice population is unknown. The goal of this study was to evaluate the prognostic value of the PPS as a predictor of mortality in a heterogeneous hospice population, and to determine whether it performs equally well across diagnoses and sites of care. This study used a prospective cohort study using existing medical records, conducted at a large community hospice program, and included all patients enrolled in hospice during the study period. Each patient's PPS score was recorded at the time of enrollment and patients were followed until death or discharge from hospice. A total of 466 patients enrolled in hospice during the study period. The PPS score was a strong independent predictor of mortality (log rank test of Kaplan Meier survival curves p < 0.001). Six-month mortality rates for three PPS categories were 96% (for PPS scores 10–20), 89% (for PPS scores 30–40), and 81% (for PPS scores ≤50). Evaluation of interaction terms in Cox proportional hazards models demonstrated a stronger association between PPS score and mortality among nursing home residents and patients with noncancer diagnoses. Analysis of the area under receiver operating characteristic curves demonstrated strong predictive value overall, with somewhat greater accuracy for nursing home residents and patients with noncancer diagnoses. The PPS performs well as a predictor of prognosis in a heterogeneous hospice population, and performs particularly well for nursing home residents and for patients with noncancer diagnoses. The PPS should be useful in confirming hospice eligibility for reimbursement purposes and in guiding plans for hospice care.
Categorizing the Severity of Cancer Pain: Further Exploration of the Establishment of Cutpoints
Paul, S.M., Zelman, D.C., Smith, M., and Miaskowski, C.
Pain, 113 (2005), 37–44
Previous work by Serlin and colleagues [Serlin, R.C., Mendoza, T.R., Nakamura, Y., Edwards, K.R., Cleeland, C.S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277–284] established cutpoints for mild, moderate, and severe cancer pain based on the pain's level of interference with function. Recent work [Jensen, M.P., Smith, D.G., Ehde, D.M., Robinson, L.R. Pain site and the effects of amputation pain: Further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317–322; Zelman, D.C., Hoffman, D.L., Seifeldin, R., Dukes, E. Development of a metric for a day of manageable pain control: Derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35–42] found differences in cutpoints for pain severity for different pain-related conditions. Reasons for these discrepancies may relate to the methods used to determine the cutpoints or to differences based on the type or the cause of the pain. The purposes of this study were to determine the optimal cutpoints for mild, moderate, and severe pain based on patients' ratings of average and worst pain severity, using a larger range of potential cutpoints, and to determine if those cutpoints distinguished among the three pain severity groups on several outcome measures. Results from a homogenous sample of oncology outpatients with pain from bone metastasis confirm a nonlinear relationship between cancer pain severity and interference with function and also confirm that the boundary between a mild and a moderate level of cancer pain is at 4 on a 0–10 numeric rating scale. However, this analysis did not confirm the boundary between moderate and severe cancer pain previously described by Serlin and colleagues [Serlin, R.C., Mendoza, T.R., Nakamura, Y., Edwards, K.R., Cleeland, C.S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277–284]. In addition, these results were not consistent with the cutpoints that were found for back pain, phantom limb pain, pain “in general,” or osteoarthritis pain reported by Jensen and colleagues and Zelman and colleagues [Jensen, M.P., Smith, D.G., Ehde, D.M., Robinson, L.R. Pain site and the effects of amputation pain: Further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317–322; Zelman, D.C., Hoffman, D.L., Seifeldin, R., Dukes, E. Development of a metric for a day of manageable pain control: Derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35–42]. Possible explanations for these differences are discussed, as well as implications for future research.
COMMUNICATION
Impact of Physician Sitting Versus Standing During Inpatient Oncology Consultations: Patients' Preference and Perception of Compassion and Duration. A Randomized Controlled Trial
Strasser, F., Palmer, J.L., Willey, J., Shen, L., Shin, K., Sivesind, D., and Beale, E.
Journal of Pain and Symptom Management, 29 (2005), 489–497
The purpose of this study was to determine the impact of physician sitting versus standing on the patient's preference of physician communication style, and perception of compassion and consult duration. Sixty-nine patients were randomized to watch one of two videos in which the physician was standing and then sitting (video A) or sitting and then standing (video B) during an inpatient consultation. Both video sequences lasted 9.5 min. Thirty-five patients (51%) blindly preferred the sitting physician, 16 (23%) preferred the standing, and 18 (26%) had no preference. Patients perceived that their preferred physician was more compassionate and spent more time with the patient when compared with the other physician. There was a strong period effect favoring the second sequence within the video. The patients blinded choice of preference (p = 0.003), perception of compassion (p = 0.0016), and other attributes favored the second sequence seen in the video. The significant period effect suggests that patients prefer the second option presented, notwithstanding a stated preference for a sitting posture (55/68, 81%). Physicians should ask patients for their preference regarding physician sitting or standing as a way to enhance communication.
A New Approach to Eliciting Patients' Preferences for Palliative Day Care: The Choice Experiment Method
Douglas, H.R., Normand, C.E., Higginson, I.J., and Goodwin, D.M.
Journal of Pain and Symptom Management, 29 (2005), 435–445
Palliative day care (PDC) provides individualized care to meet patients' needs and preferences and has posed problems for economic evaluation. Current methods are limited in their ability to capture relevant outcomes. The choice experiment elicits preferences for multiple aspects of care rather than a single outcome. A choice experiment was undertaken at four centers in England. A random effects probit model was used. Interaction terms relating to patient and service characteristics were explored. Seventy-nine patients participated. All characteristics of PDC except bathing and hairdressing were significant (p < 0.001). Access to specialist therapies was three times as important as medical support and twice as important as staying all day. Interaction terms were not significant, except for age and preference for specialist therapies, although the sample may not have been adequate to detect differences. Choice experiments provided useful insights by quantifying preferences for services, providing an alternative to cost-effectiveness analysis.
QUALITY OF PALLIATIVE CARE
Outcome of Cancer Patients Considered for Intensive Care Unit Admission: A Hospital-Wide Prospective Study
Thiery, G., Azoulay, E., Darmon, M., Ciroldi, M., De Miranda, S., Levy, V., Fieux, F., Moreau, D., Le Gall, J.R., and Schlemmer, B.
Journal of Clinical Oncology, 1 (2005), 4406–4413
The aim of this study was to evaluate the outcome of cancer patients considered for admission to the intensive care unit (ICU). We conducted a prospective, 1-year hospital-wide study of all cancer and hematology patients, including bone marrow transplantation patients, for whom admission to the ICU was requested. We found that of the 206 patients considered for ICU admission, 105 patients (51%) were admitted. Of the 101 patients who were not admitted, 54 patients (26.2%) were considered too sick to benefit, and 47 patients (22.8%) were considered to be too well to benefit from the ICU. Of these 47 patients, 13 patients were admitted later. Survival rates after 30 and 180 days were significantly associated with admission status (p < 0.0001). Remission of the malignancy (odds ratio [OR], 3.37; 95% CI, 1.25–9.07) was independently associated with ICU admission, whereas poor chronic health status (OR, 0.38; 95% CI, 0.16–0.74) and solid tumor (OR, 0.43; 95% CI, 0.24–0.78) were associated with ICU refusal. In admitted patients, 30-day and 6-month survival rates were 54.3% and 32.4%, respectively. Of the patients considered too sick to benefit from ICU admission, 26% were alive on day 30 and 16.7% on day 180. Among patients considered too well to benefit, the 30-day survival rate was a worrisome 78.7%. Calibration of the Mortality Probability Model (the only score available at triage) was of limited value for predicting 30-day survival (area under the curve, 0.62). Both the excess mortality in too-well patients later admitted to the ICU and the relatively good survival in too-sick patients suggest the need for a broader admission policy.
“Lost to Follow-Up”: Ethnic Disparities in Continuity of Hospice Care at the End of Life
Kapo, J., MacMoran, H., and Casarett, D.
Journal of Palliative Medicine, 8 (2005), 603–608
Hospice has become the major provider of comprehensive end-of-life care in the United States, but is underutilized by African American patients. It is likely that whatever factors are responsible for lower rates of hospice utilization among African Americans also lead to lower rates of return to hospice after discharge, but this is not known. Our objective was to determine whether African American patients who leave hospice are less likely to return before death by using a retrospective cohort study in a University-affiliated hospice. All patients were discharged after a first admission. All patient characteristics were defined by abstraction of electronic medical records at the time of hospice discharge. Results: Of 358 discharged patients, 98 (27%) were decertified and 260 (73%) left voluntarily. Ninety-six patients returned to hospice during the study period. In bivariate analysis, African Americans were less likely to return than were other patients (odds ratio (OR) 0.47, 95% CI: 0.28–0.80; p = 0.005). In a multivariable logistic regression model, African American ethnicity was independently associated with a decreased likelihood of return. Ethnic disparities in hospice utilization may extend even to those patients who do enroll in hospice. African Americans who leave hospice during their first admission and their families may be less likely to have access to the comprehensive services that hospice programs provide near the end of life, including intensive nursing care, pain and symptom management, and education.
End-of-Life Care and African Americans: Voices from the Community
Jenkins, C., Lapelle, N., Zapka, J.G., and Kurent, J.E.
Journal of Palliative Medicine, 8 (2005), 585–592
In 1997, the Institute of Medicine called for reform, improved quality, and expanded research in end-of-life care. Yet little empirical information about preferences of African Americans has been documented. A community–campus partnership was formed to guide a needs assessment related to end-of-life care in a Southern, urban, African American community. This paper presents focus group findings related to end-of-life and palliative care. A qualitative design of multiple-meeting focus groups was used to explore experiences, preferences, needs, and feelings expressed by family members with at least one relative who had died in a hospital (group 1) or at home (group 2). Sessions were taped and transcribed; themes were identified using systematic analytic procedures: Thematic analysis revealed key concerns related to health care provider communications about end-of-life care and dying. Positive communications empowered and showed respect for patients and family members and recognized the importance of their spiritual beliefs; informed them about resources available to assist dying at home; and, for patients dying in the hospital, treated them with nurturing, compassion, and diligent monitoring of the patient's medical status and needs. Other themes related to end-of-life care issues include preparation, planning, and access. A table of quotes from participants is available from the corresponding author. Findings suggest important clinical implications for clinicians and other health professionals. These voices from the community remind us of the heterogeneity in needs and preferences and challenge us to listen and tailor communication to each patient and their families.
Medical Care at the End of Life: Views of African American Patients in an Urban Hospital
Torke, A.M., Garas, N.S., Sexson, W., and Branch, W.T.
Journal of Palliative Medicine, 8 (2005), 593–602
Although one goal of end-of-life care is to honor the wishes and needs of patients, little research has been done to characterize what is important to seriously ill African American patients at the end of life. Our objective was to characterize the views of seriously ill African American patients toward end-of-life care. A qualitative study using semistructured, in-depth interviews was done with patients in a large, urban, public hospital who are facing a serious illness. Twenty-three African American patients were interviewed. Although most acknowledged a point at which they would want to cease aggressive care, some equated this with giving up. Most subjects expressed that the end of life was in God's hands. Many expressed a concern to be free of pain and suffering. Few saw a significant role for the physician at the end of life. Some had expressed their wishes for care to a family member. Others thought such discussions were unnecessary because a family member would make decisions or because death was not imminent. Subjects raised concerns about trust in the physician and the burden of end-of-life discussions. African Americans in an urban, public hospital who are facing a severe illness have clear desires for care at the end of life and are willing to discuss their views at length. Such discussions should explore patients' desire for aggressive care, consider spiritual views and the importance of family in end-of-life decisions, and consider that some patients will not believe such discussions are necessary.
Are We Referring Patients to Hospice Too Late? Patients' and Families' Opinions
Kapo, J., Harrold, J., Carroll, J.T., Rickerson, E., and Casarett, D.
Journal of Palliative Medicine, 8 (2005), 521–527
Patients typically receive hospice care only in the last days or weeks of life, and there is widespread agreement among experts that patients enroll in hospice too late. However, it is not known whether patients and their families believe that they are enrolling in hospice too late. We conducted a prospective interview study in a not-for-profit, Medicare-certified hospice with patients and families recruited at consecutive hospice enrollment visits. Interviews were done at the time of hospice enrollment and 1 month after death or discharge from hospice assessed patients' and families' perceptions of the timing of hospice enrollment (“too soon,” “too late,” “at about the right time”). Interviews were conducted at 274 enrollment visits. Very few patients (1/85; 1%) and family members (12/261; 5%) said that they believed they were enrolling in hospice too late. In follow-up interviews with families after the patient's death or discharge, families were more likely to believe that enrollment was too late (n = 38/218; 17%; sign test p < 0.001). Families who believed they had enrolled too late had shorter lengths of stay in hospice compared to those who said that enrollment was too soon or at the right time (median 10 vs. 24 days; rank-sum test p < 0.001). Despite late enrollment in hospice and very short lengths of stay, most patients and families believe that they are enrolling in hospice at the right time.
Pilot of a Pathway to Improve the Care of Imminently Dying Oncology Inpatients in a Veterans Affairs Medical Center
Luhrs, C.A., Meghani, S., Homel, P., Drayton, M., O'Toole, E., Paccione, M., Daratsos, L., Wollner, D., and Bookbinder, M.
Journal of Pain and Symptom Management, 29 (2005), 544–551
We report on the implementation of a previously developed clinical pathway for terminally ill patients, Palliative Care for Advanced Disease (PCAD), on a Veterans Administration (VA) acute care oncology unit, comparing processes of care and outcomes for patients on and off the pathway. The PCAD pathway is designed to identify imminently dying patients, review care goals, respect patients' wishes, assess and manage symptoms, address spirituality, and support family members. Retrospective chart reviews from 15 patients who died on PCAD, 14 patients who died on general wards during the same time, and 10 oncology unit patients who died prior to PCAD revealed that PCAD patients were more likely to have documentation of care goals and plans of comfort care (p = 0.0001), fewer interventions, and more symptoms assessed (p = 0.004), and more symptoms managed according to PCAD guidelines (p = 0.02). Implementation of PCAD improved care of dying inpatients by increasing documentation of goals and plans of care, improving symptom assessment and management, and decreasing interventions at the end of life.
PSYCHOSOCIAL INTERVENTIONS
Treatment of Complicated Grief: A Randomized Controlled Trial
Shear, K., Frank, E., Houck, P.R., and Reynolds, C.F., III
JAMA, 293 (2005), 2601–2608
Complicated grief is a debilitating disorder associated with important negative health consequences, but the results of existing treatments for it have been disappointing. Our objective was to compare the efficacy of a novel approach, complicated grief treatment, with a standard psychotherapy (interpersonal psychotherapy). We used a two-cell, prospective, randomized controlled clinical trial, stratified by manner of death of loved one and treatment site. The trial was conducted in a university-based psychiatric research clinic as well as a satellite clinic in a low-income African American community between April 2001 and April 2004. A total of 83 women and 12 men aged 18 to 85 years recruited through professional referral, self-referral, and media announcements met criteria for complicated grief. Participants were randomly assigned to receive interpersonal psychotherapy (n = 46) or complicated grief treatment (n = 49); both were administered in 16 sessions during an average interval of 19 weeks per participant. Treatment response, defined either as independent evaluator-rated Clinical Global Improvement score of 1 or 2 or as time to a 20-point or better improvement in the self-reported Inventory of Complicated Grief. Results: Both treatments produced improvement in complicated grief symptoms. The response rate was greater for complicated grief treatment (51%) than for interpersonal psychotherapy (28%; p = 0.02) and time to response was faster for complicated grief treatment (p = 0.02). The number needed to treat was 4.3. Conclusion: Complicated grief treatment is an improved treatment over interpersonal psychotherapy, showing higher response rates and faster time to response.
Enhancing End-of-Life Care in Nursing Homes: Palliative Care Educational Resource Team (PERT) Program
Ersek, M., Grant, M.M., and Kraybill, B.M.
Journal of Palliative Medicine, 8 (2005), 556–566
By the middle of this century, approximately 40% of people who will die from chronic illness are expected to do so in a nursing home. This trend will create challenges for nursing homes to ensure that staff possess the necessary knowledge and skills to care for dying residents. The purpose of this paper is to describe the development and evaluation of a comprehensive curriculum called Palliative Care Educational Resource Team (PERT), which is designed to enhance end-of-life (EOL) abilities of nursing assistants and licensed nurses working in nursing homes. Sixty-one nursing assistants and 108 licensed nursing staff from 44 facilities have participated in PERT. Subjects were recruited in three successive cohorts, each targeting a different geographic area. Program evaluation included multiple tools evaluating participants' knowledge, skills, and confidence in providing EOL care. Evaluation of outcomes revealed significant increases in EOL knowledge, self-evaluation of EOL skills, and supervisors' evaluations of participants' EOL care. These results show that the PERT Program is an effective means to enhance the palliative care expertise of nursing home staff. In addition to describing the PERT program and its evaluation, suggestions for implementing similar programs are included in this paper.
A Quality Improvement Intervention to Increase Palliative Care in Nursing Homes
Hanson, L.C., Reynolds, K.S., Henderson, M., and Pickard, C.G.
Journal of Palliative Medicine, 8 (2005), 576–584
Death is common in nursing homes, but access to palliative care is limited. Our objective in this paper was to test whether a quality improvement (QI) intervention in nursing homes increases hospice, pain management, and advance care planning. The QI intervention was tested in seven nursing homes using a pre–poststudy design. Two additional nursing homes served as control sites: nine nursing homes serving 1169 residents. The intervention included recruitment and training of Palliative Care Leadership Teams in each facility, followed by six technical assistance meetings for team members. Hospice providers delivered six educational sessions for all nursing home staff using a structured curriculum. Teams received feedback of performance data on hospice enrollment, pain management, and advance care planning at 0, 3, and 6 months. Main outcome measures included percentage of residents receiving hospice or palliative services, pain assessment, pain treatment among residents in pain, and documented advance care planning discussions. Intervention facilities increased hospice enrollment from 4.0% of residents at baseline to 6.8% postintervention (p = 0.01) and increased pain assessments from 18% to 60% (p < 0.001). Among resident in pain, orders for nonpharmacologic pain treatments increased from 15% to 35% (p < 0.001), but pain medication use did not change. Residents with in-depth discussions about end-of-life care increased from 4% to 17% (p < 0.001). There were no significant changes in control sites. A quality improvement intervention was effective in increasing hospice enrollment, pain assessment, nonpharmacologic pain treatment, and advance care planning discussions.
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