Nonphysical Symptoms Research Articles

Quality of Care and Satisfaction With Care on Palliative Care Units

ContextThere is little research on quality of care specific to palliative care units (PCUs). ObjectivesTo delineate important aspects of satisfaction with care and quality of care on a PCU, as described by inpatients, family caregivers, and health care professionals. MethodsQualitative interviews and focus groups were conducted across four Toronto PCUs, with a total of 46 patient/caregiver interviews and eight staff focus groups. Interviews and focus groups were semistructured to elicit comments about satisfaction with care and quality of care for inpatients and families on a PCU. Data were analyzed using a grounded theory method, with an inductive, constant comparison approach to identify themes, and were coded to saturation. ResultsKey elements of quality care and patient satisfaction on a PCU were grouped into six domains: 1) interprofessional team: a team of experts comprising multiple disciplines functioning as a unit; 2) communication: developing rapport, addressing expectations, providing information, listening actively, and facilitating end-of-life discussions; 3) attentive, personalized care: anticipatory and responsive compassionate care with tailored management of physical and nonphysical symptoms; 4) family-centered: support of patients and caregivers within a family; 5) accessible and consistent: appropriate resources and adequate staff to provide consistent care; and 6) supportive setting: a bright noninstitutionalized setting allowing both privacy and socialization. ConclusionThe elements identified support the delivery of quality care. They may act as a guide for those planning to develop PCUs and form the basis for measures of satisfaction with care.

Multinational study exploring patients’ perceptions of side-effects induced by chemo-radiotherapy

PurposeWe aimed to prospectively assess the incidence, severity and patients’ perceptions of side-effects induced by radiotherapy and concomitant weekly cisplatin. Patients and methodsThis multinational survey included patients with a diagnosis of gynaecological or head and neck cancer scheduled to receive radiotherapy and concomitant weekly cisplatin. Patients completed a questionnaire prior to anti-cancer treatment and after 3weeks of treatment. Baseline frequency and severity of symptoms were compared to frequency and severity after 3weeks of treatment, and patients were asked to rank the five most severe symptoms experienced. ResultsAn increase in the severity as well as in the mean number of symptoms (18 compared to 24) was observed during treatment. Patients ranked 7 of the 10 most feared baseline symptoms as non-physical, whereas 8 of the 10 most feared symptoms after 3weeks of treatment were physical. Nausea was ranked as the 5th most severe symptom during treatment, despite 98% of patients receiving antiemetic prophylaxis. ConclusionPatients with head and neck cancer or gynaecological cancer suffer from a number of primarily non-physical symptoms before starting combined chemo-radiotherapy. After 3weeks of treatment patients score 8 of the 10 most feared symptoms as physical. Future trials focusing on the prevention of side-effects in patients receiving radiotherapy and concomitant chemotherapy are highly warranted.

PC-FACS

PC-FACS

French Swiss physicians' attitude toward palliative sedation: Influence of prognosis and type of suffering

Palliative sedation is a last resort medical act aimed at relieving intolerable suffering induced by intractable symptoms in patients at the end-of-life. This act is generally accepted as being medically indicated under certain circumstances. A controversy remains in the literature as to its ethical validity. There is a certain vagueness in the literature regarding the legitimacy of palliative sedation in cases of non-physical refractory symptoms, especially "existential suffering." This pilot study aims to measure the influence of two independent variables (short/long prognosis and physical/existential suffering) on the physicians' attitudes toward palliative sedation (dependent variable). We used a 2 × 2 experimental design as described by Blondeau et al. Four clinical vignettes were developed (vignette 1: short prognosis/existential suffering; vignette 2: long prognosis/existential suffering; vignette 3: short prognosis/physical suffering; vignette 4: long prognosis/physical suffering). Each vignette presented a terminally ill patient with a summary description of his physical and psychological condition, medication, and family situation. The respondents' attitude towards sedation was assessed with a six-point Likert scale. A total of 240 vignettes were sent to selected Swiss physicians. 74 vignettes were completed (36%). The means scores for attitudes were 2.62 ± 2.06 (v1), 1.88 ± 1.54 (v2), 4.54 ± 1.67 (v3), and 4.75 ± 1.71 (v4). General linear model analyses indicated that only the type of suffering had a significant impact on the attitude towards sedation (F = 33.92, df = 1, p = 0.000). Significance of the results: The French Swiss physicians' attitude toward palliative sedation is more favorable in case of physical suffering than in existential suffering. These results are in line with those found in the study of Blondeau et al. with Canadian physicians and will be discussed in light of the arguments given by physicians to explain their decisions.

Commentary ( Two Hits with One Shot – A Possibility of Simultaneous Targeting Motor Neuron Loss and Depression in ALS by Upregulating ADAR2 )

Commentary ( Two Hits with One Shot – A Possibility of Simultaneous Targeting Motor Neuron Loss and Depression in ALS by Upregulating ADAR2 ) pp.863-863 (1) Author: Laszlo Siklos Abstract: A leading hypothesis for the selective death of motor neurons in sporadic amyotrophic lateral sclerosis (ALS) is excitotoxicity mediated by Ca2+-permeable α-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) receptors. The AMPA receptors are assembled from 4 subunits and their permeability for Ca2+ is determined by the absence of the glutamate receptor subunit type 2 (GluR2), associated with an increased portion of unedited GluR2 mRNA at the glutamine/arginine (Q/R) site. RNA editing at this location is predominantly catalyzed by adenosine deaminase acting on RNA 2 (ADAR2). Thus, the observation that a substantial portion of Q/R site unedited GluR2 mRNA is present in postmortem spinal cord tissue of sporadic ALS patients suggests inefficiency of ADAR2 to be a disease-specific molecular dysfunction in ALS. To decide whether this malfunction could be a cause of motor neuron death in vivo, Hideyama and colleagues developed a conditional ADAR2 knock-out mouse line (designated as AR2), which carries gene-targeted floxed ADAR2 alleles that become functionally ablated by Cre recombinase expressed from a transgene (VAChT-Cre.Fast) in approximately 50% of motor neurons. They demonstrated that only the ADAR2-lacking spinal motor neurons degenerated in these animals, and this could be prevented by generating Q/R site edited GluR2 in the absence of ADAR2 by a point mutation in the endogenous GluR2 alleles. These results convincingly demonstrate that the inefficient GluR2 Q/R site editing found in the spinal cords of patients with sporadic ALS proposes the decreased level of ADAR2 mRNA to be a direct cause of death of motor neurons in mice, which accentuates the detrimental role of elevated Ca2+ influx in motor neurons as a consequence of increased Ca2+-permeability of AMPA receptors. From therapeutic point of view, an interesting aspect of the Ca2+-mediated cell death in ALS is connected with certain emotional reactions of the patients such as depression and anxiety, which has received particular attention in ALS. Although many researchers with experience with ALS challenge the lay opinion of an increased risk of developing major depressive disorder in ALS, studies using standardized methodology assessing nonphysical symptoms reported an occurrence exceeding the prevalence of that in the general population. There is growing evidence that besides the monoaminergic system the glutamatergic system, particularly N-methyl-D-aspartate receptor mediated Ca2+-entry plays an important role in the pathobiology of major depressive disorder. It is thus intriguing that conventional tricyclic antidepressants, specific serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors not only down-regulate N-methyl-D-aspartate receptors but – at least in an in vitro model system – have the potency to enhance GluR2 Q/R site-editing either by up-regulating ADAR2 mRNA expression level, or through other unidentified mechanisms. It will now be important to determine whether these drugs exert a similar protective effect on motor neurons in in vivo models of ALS, and thus constitute a new therapeutic approach for this disease.

Ethnic and migrational impact on the clinical manifestation of depression

Depressive disorders are still underdiagnosed. Ethnic and cultural factors may influence the way depression is presented and therefore contribute to problems in assessing these disorders in different ethnic populations appropriately. In this investigation, the impact of both ethnicity and migration on the manifestation of depression was studied. Three groups of depressed female patients (n = 136) were included in this investigation on the variation in depressive symptomatology by ethnic groups. Group 1 consisted of Austrian patients living in Austria, group 2 were Turkish patients who had migrated to Austria and group 3 were Turkish patients living in Turkey. Participants were rated using the Montgomery-Åsberg Depression Rating Scale (MADRS), the Beck Depression Inventory (BDI), the Bradford Somatic Inventory (BSI) and an additional list of physical symptoms. Both Turkish groups had significantly higher BSI scores and more somatic symptom severity. Migrated Turkish patients scored significantly higher in the items headache, backache and dry mouth than Turkish patients in Turkey. In addition, there were between-group differences in non-physical symptoms. Depressive symptomatology varies between ethnic groups. These differences are mainly due to ethnicity as such but migration may play an additional role. It is essential for physicians to be aware of atypical presentation forms of depression in minority groups.

The Practice of Continuous Palliative Sedation in Elderly Patients: A Nationwide Explorative Study Among Dutch Nursing Home Physicians

To study the practice of continuous palliative sedation (CPS) by Dutch nursing home physicians in 2007. A structured retrospective questionnaire. Nationwide nursing home physician study in the Netherlands. One thousand two hundred fifty-four nursing home physicians received a questionnaire concerning their last case of CPS in 2007; 54% (n=675) responded. Characteristics of CPS and requests for euthanasia were measured. Three hundred sixteen patients were described. The majority had cancer or dementia. The most-reported refractory symptoms were pain (52%), anxiety (44%), exhaustion (44%), dyspnea (40%), delirium (24%), loss of dignity (18%), and existential distress (16%). In 98% of cases, CPS was aimed at symptom relief. Of patients with cancer, 17% had previously requested euthanasia. The mean starting dose of midazolam was 31 mg every 24 hours (range 0-240 mg/24 h), and the mean end dose was 48 mg every 24 hours (range 0-480 mg/24 h). In addition to physical symptoms, anxiety, exhaustion, loss of dignity, and existential distress are often mentioned as refractory symptoms in the decision to start CPS by nursing home physicians. Furthermore, close to one in five patients with cancer had made a previous request for euthanasia. The dosage range of midazolam in this study fits the recommendations of the Dutch national guideline on palliative sedation, although international studies show smaller dosage ranges. Finally, prospective research about the acceptability and assessment of nonphysical symptoms as indications for CPS is recommended.

The primary care physician and palliative care

Palliative care is about total patient care, management of disabling and debilitating symptoms, and the role of the primary care physician. As physicians, we must understand who, what, when, how, and where to institute, or refer patients for palliative care. Who? Any patient needing assistance with the control of physical and nonphysical symptoms can benefit from palliative care. What? An interdisciplinary team coordinating care planning of the patient. When? The earlier in the disease process the patient is referred, the sooner symptom control can be maximally achieved. How? The primary care physician makes the initial referral to the palliative care physician or team. Where? All hospices should have a palliative care physician or consultant. This article provides a broad overview of palliative care management and incurable illnesses.

Prospective study of symptom control in 133 cases of palliative care inpatients in Shatin Hospital.

We report a prospective study assessing the prevalence and severity of physical and nonphysical symptoms, and the benefits from treatment and intervention, in advanced cancer patients presenting to a local palliative care unit in Hong Kong. Patients were assessed by a modified version of the support team assessment schedule (STAS). The study highlighted some symptoms which needed better control, and also reinforced the team morale by demonstrating aspects where there was definite improvement. In general, the STAS was found to be practicable and acceptable by our patients and staff. The most important benefit gained from the study was the successful dissemination of the concept of audit and quality assurance throughout the unit, which is essential for continuous improvement in the future.