For your consideration
November 10th 2020 Health Services research-
Title: Lessons learned from supervising an academic training program in palliative medicine - a narrative review.
Dr. Rahul D. Arora, MD Palliative Medicine (India), xerxes85@ymail.com, Room no. 207, Postgraduate Men’s Hostel, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka,India, +91-9810785246, Fellow-in-training, Palliative Medicine, Dept of Palliative Medicine, Kidwai Memorial Institute of Oncology.
Background/aims: Academic program consisting of thrice a week, one hour sessions (Journal club, seminar, and case presentation) was operational from December 2017 to November 2018.
Methods: This review discusses the content, topics, reasons underlying the discontinuation of program.
Results: Journal club discussions included articles themed upon management of chemotherapy-related adverse effects (emesis, febrile neutropenia, and peripheral neuropathy), symptom management in chronic renal and neurological disease, advanced cancer, discussion of nomenclature at end of life.
Articles from Internal medicine (13.6 %), Medical oncology (4.5 %), and Supportive oncology (13.6 %) were included. Systematic reviews, and meta-analysis (38.1 %), randomized control trials (23.8 %), case report (14.2 %), Delphi study, cost-effectiveness analysis, survey, mixed-methods study, and n-of-one trials (4.7 % each) were discussed. General palliative medicine, end of life care, palliative
pharmacotherapy, and general medicine were the broad domains of seminar topics. A total of 13 assignments covering topics from General palliative medicine, specialist palliative medicine, clinical examination in general medicine, and medical oncology were mailed to the residents every week.
Conclusions: The academic program was conceptualized as a rejoinder to the simmering debate on the ambit of Palliative medicine, aiming to impart training in management of medical issues in advanced cancer and recent advances in Supportive Oncology. Lack of administrative recognition, inability to provide timely incentives, co-existence of parallel academic programs, and differences in personal expectations and goals may have hastened the discontinuation.
The academic program mentioned in the abstract was envisioned and coordinated during my tenure as Senior Resident, Palliative Medicine, All India Institute of Medical Sciences, New Delhi.
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Advance care planning conversations in primary healthcare helps palliative cancer patients to stay at home
Driller, Bardo1; Blomkvist, Gro1; Alme, Tanja2; Talseth-Palmer, Bente3; Brenne, Anne-Tove4
1Department of Oncology, Møre and Romsdal Hospital Trust, Ålesund, Norway, 2Cancer coordination Sula municipality, Norway, 3School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle and NSW Health Pathology, Newcastle, Australia, 4Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Norway, and Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology
Background: A diagnosis of a life-limiting illness, like non-curable cancer, challenges you to think about, talk about and plan for future health. General practitioners and primary healthcare nurses make the necessary advance care planning (ACP) conversations meaningful.
Dying at home is advocated to be a desirable outcome of palliative care. In Norway, 14.3 % of the cancer patients died at home in 2015, which is low compared with other European countries.
Between January and June 2018, ACP conversations and a summarizing palliative plan was systematically implemented in primary healthcare in Møre and Romsdal county.
Method: We identified palliative cancer patients with contact to the local cancer and palliative outpatient clinic. We collected data from primary healthcare about ACP conversations, and from specialist and primary healthcare about where the patients spent the last 90 days of life and place of death.
Results: We identified 250 patients that died between 9/2018 and 8/2020. Of these, 125 had an ACP conversation in primary healthcare.
Home deaths happened significantly more often among cancer patients who had an ACP
conversation; 42% with and 10% home deaths without ACP conversation (Chi-square test; p<0.001).
During the last 90 days of life patients with ACP conversation spent significantly more days at home, mean 65.4 (CI; 61.2, 69.6), than patients without ACP conversation, mean 56.5 (CI; 52.3, 60.7), (Mann-Whitney U-Test; p<0.001).
Conclusion: In the Romsdal region, ACP conversations in primary healthcare contributes to more time at home and more home deaths among palliative cancer patients.
Advanced cancer as an existential threat and implications for patient autonomy
A
qualitative study of patient-physician-communication in the medical encounter
Berit Hofset Larsen1,2, Tonje Lundeby1, Jennifer Gerwing3, Pål Gulbrandsen3,4 & Reidun Førde2
1Oslo University Hospital, Department of Oncology, Norway; 2University of Oslo, Center for Medical Ethics, Norway; 3Akershus University Hospital, Health Services Research Unit, Norway; 4University of Oslo, Institute of Clinical Medicine, Norway.
Introduction
Respect for patient autonomy is a guiding principle in todays’ health care worldwide. In advanced cancer care, however, well-defined and available choices are not necessarily present. Further, severe illness represents an existential threat and may reduce a person’s autonomous capacity. Previous research and current practice focus little on addressing existential issues in patient-physician-communication.
Aim
To explore whether and how patients display their perceived existential threats in the medical encounter and discuss implications for patient autonomy.
Materials and methods
We apply interaction analysis of 13 video-recorded consultations with patients having advanced cancer. The study has a qualitative and exploratory design using principles from microanalysis of face-to-face-dialogue and conversation analysis.
Results
The patients displayed that illness constituted a threat to their physical, psychological, social and spiritual being which entailed uncertainty about future, uncertainty about own coping, dependency and search for meaning. However, existential expressions were often hesitant, subtle or indirect; typically hidden in questions wrapped up in biomedical terms.
Conclusion
Our findings suggest that patients wish to discuss existential issues with the physician.
Physicians should be aware of underlying existential concerns that might be embedded in the patient’s questions in order to provide tailored information; not only for autonomous choices, but also to reduce uncertainty and support coping, and hence restore patient autonomy.
Key words: Advanced cancer, patient autonomy, existential threats, uncertainty, vulnerability, coping, patient-physician-communication.
For your consideration
November 10th 2020
Pain and Symptom management-
Development of a composite cancer pain prognostication model – a pilot, observational study.
Dr. Rahul D. Arora, MD Palliative Medicine (India), xerxes85@ymail.com, Room no. 207, Postgraduate Men’s Hostel, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka,India, +91-9810785246, Fellow-in-training, Palliative Medicine, Dept of Palliative Medicine, Kidwai Memorial Institute of Oncology.
Background
There have been attempts to revitalize the concept of pain prognostication with inclusion of personalized pain goal and time spent during psychologist liaison to better define the pre-existing construct of “complexity or difficulty in achieving stable pain control” on the Edmonton classification system for cancer pain. The inclusion of biochemical and hematological parameters has been proposed by this author as a means of re-defining pain prognostication with an added emphasis on survival.
Methods
A composite pain prognostication tool consisting of the Edmonton classification system for pain Prognostication, Pain intensity on numerical rating scale, Neutrophil lymphocyte ratio, Platelet
lymphocyte ratio, serum albumin, and creatinine was administered to 215 patients in the outpatient and inpatient setting over three months.
Results
Neuropathic pain, presence of incident pain, psychological distress, absence of addiction, and cognitive dysfunction were majority descriptors on ECS-CP. The mean MEDD was 50.3 mg, whereas cumulative MEDD was 54.3mg. Nociceptive pain, presence of incident pain and psychological distress were associated with higher MEDD. There was no statistical significance between MEDD, NLR/PLR, and components of ECS-CP or MEDD, and the use of adjuvant pain medication.
Conclusions
Administration of available prognostication tools (PPI, modified GPS) in combination with ECS-CP needs to be considered. Current version of ECS-CP may be more suited to the advanced cancer population and the inclusion of early cancer patients and in-patients on continuous intravenous morphine infusion may have led to a discrepancy in results.
This pilot study was carried out during my tenure as a Senior Resident in Palliative medicine at All India Institute of Medical Sciences, New Delhi.
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Title: Distress in family caregivers of individuals with newly diagnosed acute leukemia.
Malfitano C1,2,3, Caruso R2, Patterson A1, Rydall A1, Nissim R1, Zimmermann C1,4,5, and Rodin G1,5.
1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Canada
2 Department of Neuroscience and Rehabilitation, University of Ferarra, Italy
3 Department of Social Work, The Hospital for Sick Children, Canada
4 Department of Medicine, University of Toronto, Canada
5 Department of Psychiatry, Faculty of Medicine, University of Toronto, Canada (Max 250 words; currently 250)
Background. Individuals with advanced cancer face substantial distress following the diagnosis, relapse, or progression of their illness. While their family caregivers (FCs) report distress that is often equal or even higher of that of the patient, little research has focused on their experience following these
junctures. Acute leukemia (AL) is the prototypical condition to study this phenomenon due to immediate threat to life and the need for urgent hospitalization to initiate intensive chemotherapy. Objective. To understand the experience of FCs of patients with AL soon after diagnosis. Methods. A grounded theory approach was used to collect and analyze data, which consisted of individual qualitative interviews.
Results. Nine FCs were interviewed. FCs identified 3 stages in their distress trajectory: 1) anticipatory phase (pre-diagnosis); 2) acute phase (post-diagnosis); and 3) living with trauma. In the first stage, FCs reported fears related to the uncertain diagnosis and the possibility of bad outcomes. Upon patients’
admission and diagnosis, FCs described experiencing a rapid decrease in distress characterized by an adaptive dissociation from difficult emotion and a focus on short-term milestones and practical tasks.
FCs in this stage also reported fluctuating distress related to the patient’s health status. As patients achieve remission and prepare for discharge, FCs began to reflect on the long-term impact of AL, anticipated adjustments, and prepared to grieve losses. Conclusion. This study sheds light on the nature and sequence of distress in FCs’ of adults with AL. Findings may inform tailored interventions to prevent and relieve distress in this population.
Authors:
Anne van Driessche (1) Kim Beernaert (1) Aline De Vleminck (1) Marijke Kars (2) Jurrianne Fahner (2)
Jutte van der Werff ten Bosch (3) Luc Deliens (1)
Joachim Cohen (1) Affiliation:
1. End-of-Life Care Research Group (Vrije Universiteit Brussel (VUB) & Ghent University), Belgium
2. Center of Expertise in Palliative Care, Julius Center of Health and Primary Care, UMC Utrecht, the Netherlands
3. University Hospital Brussels, department of pediatric oncology, Belgium
Essential components of an advance care planning intervention for adolescents with cancer: BOOST pACP
Background: In the adult population advance care planning (ACP) has shown to improve communication on care planning. However, ACP tools or interventions in pediatric oncology are scarce and evidence is lacking. Therefore, the aim of this study was to develop a pediatric ACP (pACP) intervention for adolescents with cancer and their parents.
Methods: We followed the Medical Research Council (MRC) Framework (phase 0). First, we did a scoping review on existing pACP tools and interventions.
Subsequently, we performed 11 interviews with healthcare professionals in pediatric oncology about challenges and facilitators in pACP. Based on these results, we developed a draft intervention, to which 10 international researchers gave input. Finally, in an iterative process, a conceptual framework was
developed and adapted to define the main goal of the intervention and fitting components and content.
Results: The goal of the intervention is to increase communication on ACP topics between parent(s) and the adolescent. We identified five intervention
components: 1) A facilitator, external to the medical team, will lead the conversations; 2) A training and manual for the facilitators; 3) A preparation booklet for adolescents and parents; 4) Three conversation sessions with the adolescent and parent including topics such as hope, worries and care
preferences; 5) Transfer of information to the medical team and documentation in the medical file.
Conclusions: The intervention is called: BOOST pACP (Benefits of Obtaining Ownership Systematically Together in pediatric Advance Care Planning). Trained external facilitators will guide three conversation sessions in which conversation cards play a central role.
Abstract seminar
10
thInternational Seminar of the European Palliative Care Research Centre
Abstract title
Identifying the most important behavioral determinants of starting a conversation about palliative care with the physician: a cross-sectional structured interview study in people with cancer
Identifying the most important behavioral determinants of starting a conversation about palliative care with the physician: a cross-sectional structured interview study in people with cancer
Anne-Lore Scherrens, Kim Beernaert, Luc Deliens, Lore Lapeire, Martine De Laat, Christine Biebuyck, Karen Geboes, Charles Van Praet, Ine Moors, Benedicte Deforche*, Joachim Cohen*
Anne-Lore Scherrens
End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium;
Department of Public Health and Primary Care, Ghent University, Belgium Kim Beernaert
End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium;
Department of Public Health and Primary Care, Ghent University, Ghent, Belgium Luc Deliens
End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium;
Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
Lore Lapeire
Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium; End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
Martine De Laat
Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium Christine Biebuyck
Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium Karen Geboes
Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium Charles Van Praet
Department of Urology, Ghent University Hospital, Ghent, Belgium Ine Moors
Department of Haematology, Ghent University Hospital, Ghent, Belgium Benedicte Deforche*
Department of Public Health and Primary Care, Ghent University, Belgium; Department of Movement and Sport Sciences, Physical activity, nutrition and health research unit, Faculty of Physical Education and Physical Therapy, Vrije Universiteit Brussel, Brussels, Belgium
Joachim Cohen*
End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
*Equal contribution of the last authors
Corresponding author: Anne-Lore Scherrens, End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. Email: anne- lore.scherrens@vub.be or annelore.scherrens@ugent.be (+32 9 332 36 25)
Abstract
BACKGROUND. How people with cancer act (=behavior) in their communication is important. If people with cancer themselves start a conversation about palliative care with their physician, this might improve patient empowerment and lead to more timely initiation of palliative care.
AIM. To assess which factors are (most strongly) associated with having started or intending to start a conversation about palliative care with the physician in people with cancer.
METHODS. We performed a cross-sectional survey among people with incurable cancer, from August 2019 to March 2020. We developed a questionnaire based on an extended theory of planned behavior and included knowledge, attitude, perceived behavioral control, subjective norm and social influence. Computer-assisted personal interviewing was used for data collection. Univariable logistic regression analyses were performed.
RESULTS. 88 participants, of whom 10 already started a conversation about palliative care themselves and 19 had the intention to do so. Holding a more positive attitude (OR 4.260), perceiving more behavioral benefits (OR 2.660), perceiving a higher behavioral control (OR 1.935) and perceiving a positive attitude towards the behavior in family/friends (OR 2.070) and the physician (OR 2.189) were positively associated; perceiving more behavioral disadvantages (OR 0.526) and more barriers (OR 0.313) were negatively associated with performing the behavior or having the intention to do so.
CONCLUSION. This study suggests that attitudinal factors are the strongest determinants of people with cancer initiating a conversation about palliative care. Interventions targeting the identified most important factors can help them in taking the initiative in communication about palliative care.
KEYWORDS. Quantitative research; palliative care; neoplasms; health communication; health promotion; behavior; behavioral theory.
FUNDING: Research Foundation Flanders.
TOPIC: Pain and symptom management Marina de Góes Salvetti
Registered Nurse, PhD
Professor at Medical Surgical Department, School of Nursing – University of São Paulo – Brazil - mgsalvetti@usp.br
Suzana Cristina Teixeira Donato
Registered Nurse, Master DegreeHospital 9 de Julho - Brazil
Caroline Silva Pereira Machado
Registered Nurse, Oncology ResidentMedical Surgical Department, School of Nursing – University of São Paulo - Brazil
Natália Gondim de Almeida Registered Nurse, PhD
Medical Surgical Department, School of Nursing – University of São Paulo - Brazil
Daniela Vivas dos Santos
Registered Nurse, PhD
Cancer Institute from São Paulo State – Faculty of Medicine, University of Sao Paulo - Brazil
Bernardo Pereira dos Santos
Statistician, Master DegreeSchool of Nursing – University of São Paulo - Brazil
Geana de Paula Kurita
Registered Nurse, PhD
Senior Researcher at the Multidisciplinary Pain Centre at Rigshospitalet-Copenhagen University Hospital, Denmark
MULTIMODAL NURSING INTERVENTION FOR SYMPTOM MANAGEMENT IN CANCER PATIENTS: A RANDOMIZED CLINICAL TRIAL
ABSTRACT
Background: Recent advances in cancer treatment have increased survival and chances of healing in patients afflicted by this disease. Effective management of the symptoms, however, is still in the initial phase. This clinical trial assess the effects of a multimodal nursing intervention for symptom control and quality of life improvement in cancer patients.
Method: This is a randomized clinical trial, which was conducted with 107
outpatients in chemotherapy or radiation for malignant neoplasms in a
specialized cancer institute. Participants were randomized (1:1) to control group (usual treatment) or intervention group (multimodal intervention composed by educational strategies, problem-solving and relaxation techniques) with assessments at baseline and in the last day of the intervention.
Sociodemographic information, clinical data, physical performance status, quality of life, anxiety, and depression were assessed. A mixed effects model was applied to compare the effects of the multimodal nursing intervention.
Results: The most frequent symptoms were fatigue (76.6%), insomnia (47.7%), pain (42.1%) and loss of appetite (37.4%). The symptom intensity analysis showed that insomnia was the most intense symptom, followed by fatigue, loss of appetite and pain. The intervention group experienced a significant improvement in terms of loss of appetite (p=0.002) and a tendency toward less insomnia (p=0.053). The nursing intervention did not significantly affect global quality of life and other symptoms.
Conclusions: The intervention improved appetite and sleep in cancer patients undergoing chemotherapy and radiation. However, no effects were observed in the global quality of life of these patients.
Keywords: Oncology nursing; Quality of life; Signs and symptoms; Neoplasms.
For your consideration
November 10th 2020
Health services research –
An online survey to understand the attitudes of Palliative medicine professionals on standards of academic training.
Dr. Rahul D. Arora, MD Palliative Medicine (India), xerxes85@ymail.com, Room no. 207, Postgraduate Men’s Hostel, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India, +91-9810785246, Fellow-in-training, Palliative Medicine, Dept of Palliative Medicine, Kidwai Memorial Institute of Oncology.
Background
Good clinical practice in palliative medicine can be built on the edifice of a consensus on the scope, structure and composition of academics among stakeholders.
Methods
An online survey questionnaire was sent to registered delegates of a national conference.
Results
33 out of more than 600 subjects who were invited to participate, completed the survey. While, majority of respondents agreed on the requirement for administrative partnership, need to ascribe to the highest standards of postgraduate training and adopting an approach to clinical case presentation, on similar lines as in general medicine, consensus on the extent of involvement in the management of medical issues in the cancer patient, necessity of inclusion of management options not available in the country of training, appropriateness of teaching core topics in medical oncology and need for an objective structured clinical examination along with spotters in the university exit examination was lacking.
Amongst the journal club topics listed, only 9/33 respondents felt that cost effectiveness of a tunneled catheter for abdominal paracentesis was included within the purview of palliative medicine. Topics such as a systematic review on use of bisphosphonates in metastatic bone disease, oral cannabinoids in nausea and vomiting and interventions for management of metastatic extradural spinal cord compression, were endorsed by only 2 out of 33 respondents.
Conclusions
The lack of clarity on the composition of the curriculum could be a direct reflection of the challenges that a trainee faces, while trying to understand the purview of this relatively nascent specialty.
This survey was carried out during my tenure as a Senior Resident in Palliative medicine at All India Institute of Medical Sciences, New Delhi.
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For your consideration
November 10th 2020
RELATIONSHIP BETWEEN SARCOPENIA AND CARDIAC MUSCLE IN PRE- OPERATIVE OESOPHAGEAL CANCER PATIENTS
Bernadette Brady
1,2,3, Gerard King
3,4, Jessie Elliott
5,6, Suzanne Doyle
5,6,7, Sinead King
5,6, John Reynolds
5,6,8, Ross Murphy
4,8, Declan Walsh
1,2,8,91. School of Medicine, University College Dublin, Ireland
2. Academic Department of Palliative Medicine, Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin, Ireland
3. Royal City of Dublin Hospital Research and Education Institute, St. James’s Hospital, Dublin, Ireland
4. Institute of Cardiovascular Science, Department of Cardiology, St. James’s Hospital, Dublin, Ireland
5. Department of Surgery, St. James’s Hospital, Dublin, Ireland 6. Trinity Centre for Health Sciences, Trinity College Dublin, Ireland
7. School of Biological and Health Sciences, Technological University of Dublin, Ireland
8. School of Medicine, Trinity College Dublin, Ireland
9. Department of Supportive Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
Abstract topic: Nutrition/cachexia
Introduction
Sarcopenia is prevalent in cancer and associated with morbidity and mortality. Loss of smooth muscle including cardiac muscle may occur in parallel with loss of skeletal muscle, leading to myocardial dysfunction. This can increase symptom burden.
Aim
Identify the relationship between sarcopenia and cardiac muscle in pre-operative oesophageal cancer patients.
Methods
Sarcopenia was calculated on computed tomography (CT) skeletal muscle index (SMI) at L3 vertebra. Echocardiographs were analysed using EchoPAC™. Cardiac muscle was compared (independent t-tests) in patients with and without sarcopenia while SMI was tested for correlation (Pearson) with the same cardiac dimensions:
left ventricular (LV) ejection fraction (EF, %), End Diastolic Diameter (EDD, mm), Isovolumic relaxation time (IVRT, ms), LV Mass Index (g/m2), posterior wall (PWD, mm) and septal diameters (mm).
Results
48 participants, 40 male, 42 Adenocarcinoma
Comparisons in patients with and without sarcopenia [mean(SD)]: LVEF 68 (7), 66 (7); LVEDD 51 (5), 50 (5); IVRT 105 (19), 100 (18); LV Mass Index 99 (25), 82 (19)*;
PWD 10 (1), 9 (1); Septal Diameter 10 (1), 9 (1)*.
Correlations with SMI: LVEF 0.1; LVEDD 0.3*; IVRT 0.2; LV Mass Index 0.1; PWD 0.0; Septal Diameter 0.1.
*p<0.05
Conclusions
LV mass index and septal diameter differed significantly in those with sarcopenia compared to those without.
Significant correlation between LVEDD and SMI.
LV mass index higher in the sarcopenia group, suggesting cardiomyopathy/hypertrophy rather than atrophy.
Evidence of diastolic dysfunction in both groups (prolonged IVRT).
Assessment of sarcopenia and cardiac status could facilitate identification and
treatment of burdensome symptoms.
Scopolamine butylbromide given prophylactically for death rattle (the SILENCE study): a double-blind randomised, placebo-controlled multicentre trial.
Harriëtte J. van Esch¹²³, Lia van Zuylen⁴, Eric C.T. Geijteman¹, Esther Oomen–de Hoop¹, Bregje Huisman⁵, Heike Noordzij⁶, Renske Boogaard⁶, Agnes van der Heide², Carin C.D. van der Rijt¹
¹Department of Medical Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands,²Department of Public health, Erasmus Medical Centre, Rotterdam, the Netherlands, ³Laurens Cadenza, Rotterdam, The Netherlands, ⁴Department of Medical Oncology, Amsterdam, University Medical Centre, the Netherlands, ⁵Hospice Kuria, Amsterdam, The Netherlands,
⁶Hospice Calando, Dirksland, The Netherlands, ⁷Palliative care unit “de Regenboog”, Rotterdam, The Netherlands
Background: Death rattle (DR) is a common symptom of the dying phase. It is treated with anticholinergics, started after the development of death rattle. However, the effectiveness of treatment has never been proven. Prophylactic use would be more appropriate as anticholinergics diminish mucus production, not remove it. The SILENCE study is a randomised, double-blind, placebo-controlled trial to evaluate the effect of prophylactically given scopolamine butylbromide (SB) on the occurrence of DR.
Methods: Patients in six participating hospices gave advanced consent at admission. After recognition of the dying phase 20 mg of SB or placebo, randomly allocated, was given
subcutaneously, four times a day. The primary outcome was the occurrence of death rattle grade 2 or higher according to the scale of Back measured at two consecutive time points with an interval of four hours. Adverse events were studied in all patients.
Results: In almost 3 years, 1097 patients were admitted to the hospices, of whom 635 were eligible and 229 signed for informed consent. Eventually, 157 patients could be included in the analyses. The occurrence of DR was significantly lower in the SB group compared to the placebo group (13% versus 27%; p=0∙025). The time to DR analysis confirmed this effect (sHR 0∙44, 95% CI 0∙20-0∙92; p=0∙031).
We found no differences between the two groups in the occurrence of adverse events, other symptoms and medication use.
Discussion: SB prevents death rattle and is safe to use. We showed that performing an RCT among patients in the dying phase is feasible.
Funding ‘Palliantie Programme’ of The Netherlands Organization for Health Research and Development, ‘Laurens Zorg in Balans’ and, ‘Stichting Voorzieningenfonds Calando’
Correspondence to:
Harriëtte J. van Esch, MD, Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. box 2040, 3000CA Rotterdam, the Netherlands; h.vanesch@erasmusmc.nl
Spiritual quality of life in family carers of patients with advanced cancer – a cross-sectional study
Ingebrigt Røen1,2, Anne-Tove Brenne1,9, Cinzia Brunelli3, Hans Stifoss-Hanssen4, Gunn Grande5, Tora Skeidsvoll Solheim1, Stein Kaasa6,7,8, and Anne Kari Knudsen6,7
1. European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology and St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
2. Chaplaincy, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
3. Palliative Care, pain therapy and rehabilitation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
4. VID Specialized University, Center of diakonia and professional practice, Oslo, Norway 5. Division of Nursing, Midwifery and Social Work, The University of Manchester, England
6. European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
7. Department of Oncology, Oslo University Hospital, Oslo, Norway 8. University of Oslo, Oslo, Norway
9. Cancer Clinic, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway Corresponding author:
Ingebrigt Røen, European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway St. Olavs hospital HF, Trondheim University Hospital, Norway. ORCID iD: https://orcid.org/0000- 0002-1435-661X.
Postal address: 4. etg. Kunnskapssenteret vest, St. Olavs Hospital, 7006 Trondheim, Norway E-mail: ingebrigt.roen@stolav.no
Abstract
Purpose Caring affects carers’ psychological and physical health, mortality, and quality of life (OoL) negatively. Lower spiritual OoL is associated with anxiety and depression, but the spiritual dimension is rarely investigated in carers. The present study aimed to explore which patient- and carer-related characteristics were associated with spiritual QoL in carers of patients with advanced cancer.
Methods Adult patients with advanced cancer and their carers were included in a prospective study investigating integration between oncology and palliative care. Baseline data considering
demographics, clinical characteristics, symptoms, social support, and QoL were analyzed. The Functional Assessment of Chronic Illness Therapy - Spiritual well-being questionnaire (FACIT-Sp-12) was applied for self-report of carers’ spiritual QoL. Bivariate and multivariate regression models were used.
Results 84 carers were included, median age was 62.5 years, 52 (62%) were female, and the average spiritual QoL score was 23.3. In bivariate analyses, higher education, social support, and lower patients’ symptom burden were significantly associated with higher spiritual QoL. The multivariate regression model (n=77) had an explained variance (R2) = 0.34, and confirmed a significant association for social support and higher education. In addition, a significant association was found for having children < 18 years living at home, and patient’s age.
Formatert: Engelsk (USA) Feltkode endret Formatert: Engelsk (USA) Formatert: Engelsk (USA) Formatert: Engelsk (USA)
1
Conclusion The study indicates that spiritual QoL is likely to be lower in carers of younger patients, in carers with low education level and/or low social support as well as in carers not having children living at home. Health care professionals should be aware that these carers may need extra support.
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For your consideration
November 10th 2020
Health services research –
Survey among Medical oncologists on attitudes towards scope, purview and integration with Palliative Medicine.
Dr. Rahul D. Arora, MD Palliative Medicine (India), xerxes85@ymail.com, Room no. 207, Postgraduate Men’s Hostel, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, +91-9810785246, Fellow-in- training, Palliative Medicine, Dept of Palliative Medicine, Kidwai Memorial Institute of Oncology. Background
Medical Oncology and Palliative Medicine are considered two opposite ends of the spectrum of cancer care.
Methods
A survey was conducted among Medical oncology faculty and residents.
Results
3/17 respondents agreed that Supportive care was being provided in Palliative medicine ward.
While one respondent expressed concerns about the lack of understanding of palliative principles, none had overt concerns about the role of opioids in causing disease progression.
Treatment of Chemotherapy related side effects and management of medical conditions in advanced cancer were considered components of an early palliative liaison by 3 and 7 respondents respectively, None agreed that the provision of chemotherapy constituted an indication for admission. 5/15 respondents agreed that provision of supportive care constituted an indication for admission. Symptom clusters in Supportive management were not
immediately recognized (as indications for admission). 1/17 agreed that Palliative medicine had been successful in providing supportive care. 10/17 agreed that provision of Palliative and supportive care involved distinct professionals. General agreement that inclusion of Pain and supportive care services could make the existing model more cost-effective existed. A majority agreed on the following barriers to closer assimilation – failure to recognize patient needs, absence of administrative coordination, misconceptions, lack of legally defined framework safeguarding practices in specialist palliation and absence of guidelines.
Conclusions
The results point towards the need for an informed discussion on the conceptual suitability of including Supportive care services within the ambit of Palliative medicine.
This survey was carried out during my Medica oncology posting during tenure as a Senior Resident in Palliative medicine at All India Institute of Medical Sciences, New Delhi.
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