Pain Palliative Care Research Articles

Analgesia in the palliative care of children

Due to the increasing incidence of terminal illnesses in children, there is great urgency within pediatric medicine to give these patients the best palliative care possible. The main focus of palliative care is to alleviate suffering resulting from the psychophysical condition of the child, which is mostly due to physical pain. The first phase of managing pain in palliative care is quantifying and qualifying pain levels, although this is sometimes difficult to do with pediatric patients. In addition to implementing strategies that alleviate or remove pain for patients, it is also crucial to give patients and their families a feeling of full control over pain. In practice, non-pharmacological and pharmacological methods of analgesia are present. Pharmacological methods include non-opioid and opioid analgesics, followed by co-analgesics as well as methods of regional anesthesia. In order to give these patients the best care possible, it is necessary that the approach be individual, multimodal, multidisciplinary, and considerate of every detail.

Prefectural Adequacy of Opioid Availability for Cancer Pain and Its Determinants in Japan: A Preliminary Study.

Introduction: Opioid analgesics are the mainstay of cancer pain management. The annual opioid consumption globally indicates adequate opioid availability and the quality of palliative care. We investigated the current situation regarding the adequacy of opioid availability in individual prefectures in Japan and explored the determinants of adequacy. Methods: We analyzed nationwide databases open to public inspection depicting the current Japanese healthcare situation. Opioid consumption for cancer pain was estimated from oxycodone and morphine data in the nationwide database. On the basis of the World Health Organization recommendations, we calculated adequacy based on the annual cancer deaths in each prefecture in 2013 and 2015. We investigated the associations between adequacy and either outpatient medical expenditure for hypertension and diabetes as a proxy of primary care practice or ratios of these risk holders in community. Outpatient medical expenditures for musculoskeletal disorders and neoplasms were also investigated. Results: The nationwide adequacy of opioid availability was approximately 75%. The largest gaps in adequacy between prefectures were more than 65%. The adequacy correlated with expenditure but not local volumes of hypertension and diabetes in both years. The other two expenditures did not relate to opioid availability. Conclusions: Although precise data are required, our preliminary findings indicate that primary care practice is the key regulator of adequate opioid availability. Opioid adequacy in Japan is thus delayed in matching the global standard, and gaps in opioid adequacy among prefectures should be bridged rapidly to expand universal access to effective palliative care and cancer pain relief.

Oral Manifestations of Renal Osteodystrophy in a Patient with Systemic Lupus Erythematosus with Chronic Renal Failure and Systemic Lupus Erythematosus with Chronic Renal Failure and Secondary Hyperparathyroidism: A Case Report Secondary Hyperparathyroidism: A Case Rep

Systemic lupus erythematosus (SLE) is one of the chronic autoimmune diseases that leads to multiple manifestations in several organ systems, including chronic renal failure (CRF). Renal osteodystrophy (ROD) is one of the most common complications of CRF associated with secondary hyperparathyroidism (HPT). A combination of CRF and HPT can result in broad-spectrum disorders in the metabolism of minerals such as calcium, phosphorus, and vitamin D, which can affect bone turnover, mineralization, and volume. Radiographic alterations of ROD are considered as one of the earliest signs of CRF. Objective: To describe the oral manifestations in both the maxilla and mandible of a patient with ROD resulting from SLE with CRF and secondary HPT. Case report: A 37-yearold female patient visited the Faculty of Dentistry, Khon Kaen University, for the management of traumatic ulcers on the left and right buccal mucosa and generalized maxillary and mandibular bony hard swellings with mild paresthesia in the lower left mandible for a period of 4 months. The patient had been suffering from SLE for approximately 20 years. However, secondary HPT and CRF as consequences of refractory SLE were being treated concomitantly. Intraoral examination showed several nonpainful ulcers on the left and right buccal mucosa. Radiographic findings revealed generalized loss of lamina dura with thinning of cortical outlines of the maxilla and mandible. Due to complications associated with treatment and the general conditions of this patient, she was referred for treatment to a palliative care unit. Conclusion: Systemic symptoms and complications of patient with ROD with CRF and secondary HPT are seriously problematic. The role of the dentist in this case is to detect the disease, lessen the complications, and make the patient experience minimal pain and side effects in palliative care.

Does Receipt of Recommended Elements of Palliative Care Precede In-Hospital Death or Hospice Referral?

ContextPalliative care aligns treatments with patients' values and improves quality of life, yet whether receipt of recommended elements of palliative care is associated with end-of-life outcomes is understudied. ObjectivesTo assess whether recommended elements of palliative care (pain and symptom management, goals of care, and spiritual care) precede in-hospital death and hospice referral and whether delivery by specialty palliative care affects that relationship. MethodsWe conducted structured chart reviews for decedents with late-stage cancer, dementia, and chronic kidney disease with a hospital admission during the six months preceding death. Measures included receipt of recommended elements of palliative care delivered by any clinician and specialty palliative care consult. We assessed associations between recommended elements of palliative care and in-hospital death and hospice referral using multivariable Poisson regression models. ResultsOf 402 decedents, 67 (16.7%) died in hospital, and 168 (41.8%) had hospice referral. Among elements of palliative care, only goals-of-care discussion was associated with in-hospital death (incidence rate ratio [IRR] 1.37; 95% CI 1.01–1.84) and hospice referral (IRR 1.85; 95% CI 1.31–2.61). Specialty palliative care consult was associated with a lower likelihood of in-hospital death (IRR 0.57; 95% CI 0.44–0.73) and a higher likelihood of hospice referral (IRR 1.45; 95% CI 1.12–1.89) compared with no consult. ConclusionGoals-of-care discussions by different types of clinicians commonly precede end-of-life care in hospital or hospice. However, engagement with specialty palliative care reduced in-hospital death and increased hospice referral. Understanding the causal pathways of goals-of-care discussions may help build primary palliative care interventions to support patients near the end of life.

Opioid usage patterns among Medicare pancreatic cancer patients according to palliative care utilization.

14 Background: Opioid pharmacotherapy is used to manage moderate and severe pain in palliative care (PC). Pain affects 80% pancreatic cancer patients older than 65 years. We assessed the opioid utilization patterns in Medicare patients with pancreatic cancer whom did not use PC (NPC), used community-based PC (CBPC) or used hospital-based PC (HBPC). Methods: We assessed opioid use, types, dispensed days, opioid uptake rates, doses (measured by morphine equivalent doses (MEDs)), and related adverse events (AEs) after pancreatic cancer diagnosis in Medicare beneficiaries selected from the SEER-Medicare database between 2007 and 2013 using the log-binomial, generalized linear mixed, and Cox proportional hazards modeling. Results: 16,106 patients were identified (median age: 78 years; female: 55.2%), of whom 8.3% used CBPC and 19.6% used HBPC. PC users were more likely to use opioids (CBPC: 72.2% vs. HBPC: 63.4% vs. NPC: 56.3%, P<.001). The most commonly prescribed opioid type in NPC, HBPC and CBPC users was fentanyl (54.1%), hydromorphone (27.7%) and morphine (26.1%). Compared to other study patients, CBPC users had shorter median dispensed days per prescription (CBPC: 3 days vs. HBPC: 4 days vs. NPC: 4 days, P<.001) but higher median MEDs per prescription (CBPC: 25 mg vs. HBPC: 25 mg vs. NPC: 0.13 mg, P<.001). Adjusting for demographic and clinical factors, no significantly different uptake rates of opioids were determined in PC users compared to NPC users (CBPC: RR, 1.02, P=.057; HBPC: RR, 1.002, P=.783). HBPC users had higher adjusted daily MEDs than CBPC and NPC users 3 months after diagnosis (135.1 mg/d vs. 126.5 mg/d vs. 65.7 mg/d, P<.001). CBPC users had higher adjusted daily MEDs than HBPC and NPC users 3 months before death (164.3mg/d vs. 155.6 mg/d vs. 92.1 mg/d, P=.0002). CBPC users had lower but HBPC users had higher adjusted hazard ratios of delirium (CBPC: HR, 0.95, HBPC: HR, 1.26, P<.001) and drowsiness (CBPC: HR, 0.94, HBPC: HR, 1.53, P<.001) than NPC users. Conclusions: Older pancreatic cancer patients using PC tended to use opioids and consumed higher opioid doses. CBPC users had lower risks of opioid-related delirium and drowsiness. The factors of the opioid use variations need to be assessed.

Virtual Reality as an Adjunct to Management of Pain and Anxiety in Palliative Care

Virtual Reality as an Adjunct to Management of Pain and Anxiety in Palliative Care

CN27 - Mindfulness-based stress reduction in early palliative care for advanced cancer patients: An Italian single-centre study. MINDEEP

Backgroundthere is little solid evidence of the effectiveness of psychological interventions using MBRS program for those with advanced cancer. The objective of this study was to evaluate the acceptability and potential benefits of MBSR for pt with cancer pain in early palliative care. MethodsMain inclusion criteria were: advanced cancer pt in early palliative care; NRS >3;PS >60% according to Karnosky, informed consent. 20 advanced cancer pt were enrolled. Each session included different forms of mindfulness meditation practice, mindful awareness during yoga postures and mindfulness during stressful situations. Participants enter upon enrolling into a commitment to carry out daily 45-min homework assignments .A dedicate nurse with experience in palliative care attended each mindfulness session. Primary outcome was total pain at the end of MBSR intervention evaluated by both VAS and ESAS scales. Secondary outcome was mood state change evaluated by POMS questionnaire. Satisfaction of treatment and compliance were also evaluated. All questionnaires along with a form for collecting personal and clinical data were administered by nurse at baseline and at the end of MBSR intervention. Results19 out of 20 were female with median age 54 years old. 56% were receiving morphine for cancer pain. Preliminary results did show slight reduction in total pain score which however was not statistically significant. The POMS test showed significant changes in the mean scores indicating a statistically significant improvement of mood at the end of mindfulness sessions. Compliance program and homework was 70% while pt satisfaction was 78%. ConclusionsThis program appears to be feasible and well accepted. The improvements in the mood state suggests that the mindfulness techniques could play a role in helping patients to reduce mood disturbance. The role of nurse was optimal to allow critically ill patients to participate in MBRS and to guarantee adherence and satisfaction. Moreover nurse was very helful to support the mindfulness trainer in managing cancer patients according to their physical needs. Finally the presence of nurse has been evaluated by patients as part of cancer caring. Legal entity responsible for the studyFabrizio Artioli. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

A systematic review and meta-analysis of randomized controlled trials of palliative care for pain among Chinese adults with cancer

BackgroundPain is one of the most common symptoms that has a severe impact on quality of life and is associated with numerous psychosocial issues in cancer patients. Palliative care, which is a recent development in China, mainly focuses on symptom control and provides psychosocial support in order to improve quality of life for terminally ill patients. This meta-analysis aimed to evaluate the effects of palliative care on cancer pain in China.MethodsThe four most comprehensive Chinese academic databases-CNKI, Wanfang, Vip and CBM-were searched from their inception until July 2019. Medline/PubMed, Web of Science, EBSCO and internet search (Google and Google Scholar) were also searched. Randomized controlled studies assessing the effects of palliative care on cancer pain were analyzed. The pooled random-effect estimates of standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated. Subgroup analysis was conducted by moderating factors for heterogeneity.ResultsThe present meta-analysis included 18 studies with a total of 1370 patients. The random-effect model showed a significant effect size of palliative care on cancer pain (SMD = 1.475, p < 0.001; 95% CI = 1.071–1.878). Age, pharmacological/non-pharmacological strategies and publication date could account for the heterogeneity through subgroup analysis to some extent.ConclusionsPalliative care was largely effective for relieving pain among Chinese adults with cancer, indicating that an adequate system should be urgently established to provide palliative care for cancer patients in Chinese medical settings. However, given the extent of heterogeneity, our findings should be interpreted cautiously.

Osteopathic Procedure on Pain in Palliative Care

Osteopathic Procedure on Pain in Palliative Care

Short-Stay Palliative Pain Management for Southwestern VA: Process Improvement Plan.

The increased demand for palliative care services has led to concerns surrounding workforce knowledge and resiliency, specifically with regard to palliative pain management for patients with life-limiting illnesses. Educational preparedness of nurses along with best processes and practices is necessary to promote optimal care for patients requiring palliative pain management. Through analyzing Veterans Administration Strategic Analytics for Improvement and Learning data, a deficiency in short-stay self-reported palliative patient pain management at the Southwestern Veterans Administration Medical Center, a level 1B, tertiary care referral center was defined. Best practices in the palliative care industry were then identified, and a quality improvement plan in the form of a nurse-driven palliative care pain education hands-on simulation was generated to promote excellence in care. Quality improvement for short-stay palliative pain management at the Southwestern Veterans Administration Medical Center was the end goal.

Opioid use in palliative care: new developments and guidelines

The correct use of opioids is the mainstay of effective management of pain in palliative care. This article describes the available analgesic options, reviews recent evidence and guidelines, and explores patients' and doctors' common concerns about opioid use.

Nursing outcomes for pain assessment of patients undergoing palliative care.

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. 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. 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. 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.

Clinical Use of an Order Protocol for Distress in Pediatric Palliative Care

Several children receiving palliative care experience dyspnea and pain. An order protocol for distress (OPD) is available at Sainte-Justine Hospital, aimed at alleviating respiratory distress, pain and anxiety in pediatric palliative care patients. This study evaluates the clinical use of the OPD at Sainte-Justine Hospital, through a retrospective chart review of all patients for whom the OPD was prescribed between September 2009 and September 2012. Effectiveness of the OPD was assessed using chart documentation of the patient’s symptoms, or the modified Borg scale. Safety of the OPD was evaluated by measuring the time between administration of the first medication and the patient’s death, and clinical evolution of the patient as recorded in the chart. One hundred and four (104) patients were included in the study. The OPD was administered at least once to 78 (75%) patients. A total of 350 episodes of administration occurred, mainly for respiratory distress (89%). Relief was provided in 90% of cases. The interval between administration of the first protocol and death was 17 h; the interval was longer in children with cancer compared to other illnesses (p = 0.02). Data from this study support the effectiveness and safety of using an OPD for children receiving palliative care.

Cancer Patients for Pain Complementaries and Integrated Approaches Used in Palliative Care

Nowadays, nursing is an effective and indispensable member of the health team both in Turkey and in the world. Because people need care practices any point their life experiences that end in health, well-being, discomfort, disease and death. While palliative care practices, which are seen as key point of nursing practices among care needs, are only care for patients in the last stage of life, it is opinion that it is necessary to reduce the pain level and improve the quality of life according to the palliative care principles. Recent cancer patients constitute a significant part of patients receiving palliative care and have problems due to symptoms caused by chemotherapy treatment. Pain is the most feared outcome of these symptoms. Pharmacological treatment, pain, community, despite various educational practices, patients often complain of problem. It is important to create complementary and integrated approaches to palliative care for pain, which significantly affects the daily living activities and quality of life of patients. In addition, complementary and integrated care practices in palliative care help to prevent nursing from being a job-oriented profession and to focus on nursing role and practices, not medical applications.

Do Physicians Underestimate Pain in Terminal Cancer Patients? A Prospective Study in a Hospice Setting

Unrelieved pain is present in a majority of terminal cancer patients. However, the treatment of pain in palliative and hospice care is affected by the lack of validated pain assessment. The goal of this study was to evaluate differences in pain evaluation between terminal cancer patients and physicians and evaluate the pain levels as a survival biomarker. Patients were evaluated every 7 days for a total of 4 assessments. Physicians evaluated patients' pain on an numeric rating scale (NRS) scale after clinical examination, after which the patients completed NRS, Quality of Life Questionnaire Core 15 Pal (QLQ-C15-PAL), and Edmonton Symptom Assessment System (ESAS) questionnaires. On average, physicians minimally underestimated the pain level in patients (3.47 vs. 3.94 on an NRS scale). Pain was overestimated in 28% and underestimated in 46% of the patients. However, half of all underestimation was clinically meaningful, compared with 28% of the overestimation. For patients with an NRS score of ≥7, pain underestimation was both clinically and statistically significant (5.56 vs. 8.17). Pain ratings exhibited a very small correlation to survival (up to r=-0.22), limiting their use as a survival biomarker. Although physicians can accurately assess mild pain in terminal cancer patients in the hospice setting, the underestimation of pain is still clinically significant in almost a quarter of patients, and especially pronounced in patients with higher levels of pain and in female patients. Hence, validated pain assessment is a necessity in hospice care, with the choice of pain evaluation tool dependent on patient and physician preference.

Pediatric Medicine Update for the Child Psychiatrist: Palliative Care and Chronic Pain

Pediatric Medicine Update for the Child Psychiatrist: Palliative Care and Chronic Pain

Palliative Nursing Summit: Nurses Leading Change and Transforming Primary Palliative Care: Nursing's Role in Providing Pain and Symptom Management.

Effective pain and symptom management is a crucial part of the care of those with life-threatening illnesses and their family members. Nurses in all settings have a vital role in providing this essential care. A recent summit held on May 12, 2017, "Nurses Leading Change and Transforming Palliative Care," convened by the Hospice and Palliative Nurses Association and attended by leaders of 26 nursing organizations strongly endorsed the importance of nursing's role in pain and symptom management and developed an agenda to advance these efforts. The agreed-upon goals of pain and symptom treatment include care that is effective (as defined by the patient), efficient (delivered in a timely manner), and safe (reduced risk of respiratory depression, prevention and early management of adverse effects, as well as attention to methods to prevent diversion such as safe storage and disposal). Through an iterative process, desired patient outcomes and nursing actions were outlined to support effective pain and symptom management in primary palliative care. These recommendations were categorized as education, clinical care, research, and regulatory concerns. This article reports on the outcomes of this summit related to pain and symptom management.

Intensity and treatment of symptoms in 3,030 palliative care patients: A cross-sectional survey of the EAPC Research Network

This study aimed to describe intensity and treatment of symptoms other than pain in European palliative care units. A total of 3,030 patients, including 2,064 that used an opioid, were included from 143 palliative care centers, in 21 European countries. Pain was treated with analgesics corresponding to the WHO pain ladder step I (n = 374), II (n = 497), and III (n = 1,567). Frequencies of symptoms observed as moderate or severe were for generalized weakness (50 percent), fatigue (48 percent), anxiety (28 percent), anorexia (26 percent), constipation (18 percent), focal weakness (18 percent), depression (18 percent), and dyspnoea (15 percent). When comparing WHO-groups, cancer diagnoses, metastasis sites, countries, and genders, we found that some of the symptom intensities and treatments differed significantly between subgroups. A majority of patients used drugs for symptom management. Still, more than one-third of patients assessed to have moderate or severe constipation did not receive any treatment. The corresponding numbers for depression, confusion, nausea, vomiting, or anxiety were approaching 40 percent and for poor sleep about 50 percent. Prescription practice of antiemetics, laxatives, and psychotropic drugs varied widely between countries both in terms of preparation and percent of patients receiving a specific treatment. This survey shows that clinically relevant symptoms are frequent and that one-third to half of the patients with a symptom observed as moderate or severe do not receive any treatment aimed to reduce the symptom intensity. Several symptoms and treatments differed between WHO-groups, cancer diagnoses, metastasis locations, countries, and genders. Prescription practice varied between countries both in terms of medication administered and percent of patients receiving specific treatment.

Total pain in patients with uterine cervix cancer in palliative care

Introduction: Cervical cancer is the second most frequent neoplasm in the female population. Among its range of symptoms, pain is one of the most exceeded. Total pain is a set of physical, psychic, social, and spiritual problems that may be present at any time of illness. More precisely in cervical neoplasia in young patients, this type of pain may be present due to falling ill in the productive phase. Objective: to discuss the presence of total pain in patients with uterine cervix cancer in palliative care. Methodology: This is an integrative review of the literature. The LILACS and SciELO databases were used. The following descriptors were used: Cancer pain; Nursing care and cervical neoplasias. From this, 45 articles were found. Contextualizing the inclusion criteria, which were: available text, language in Portuguese and year of publication from 2011 to 2016, 18 articles emerged. With the reading, it was noticed that 10 of these met the objective of the research. Results and Discussion: It was verified that all articles bring the definition of pain according to the National Association for the Study of Pain, in which it is a sensitive and emotional experience, which may be associated with actual or potential tissue damage. 40% demonstrate that poor pain relief is a reality for many patients. Already 30% report that the tendency to focus only on the physical aspect of pain and to exclude the other components is a great obstacle to the management of pain in palliative care. Conclusion: Total pain in patients in palliative care is influenced by several factors, necessitating a multidimensional approach. It has been realized that it is not possible to control physical pain, nor any other symptom, without the simultaneous control of all other aspects that cause suffering to patients.

Pain Management: Time to Minimize Variations in Practice.

There continue to be great variations in the management of pain in palliative care. Efforts need to be made within the field develop strategies to address this to avoid undue distress in patients.