Palliative Performance Scale Scores Research Articles

IDENTIFYING THE PHYSIOTHERAPY REQUIREMENTS OF PATIENTS IN PALLIATIVE CARE

Purpose: Palliative care has an important role in the late stages of diseases. Patients deal with many symptoms. Physiotherapy approaches are an essential part of palliative care in symptom control. This study was planned to investigate the level of independence of the patients, their performance status, symptoms, rehabilitation needs, and caregivers’ expectations. Methods: The study was designed as cross-sectional and descriptive. Ninety individuals aged between 18 and 65 years were included. Care needs during palliative care were assessed with the Palliative Performance Scale. Independence level was assessed by the Barthel Index. The severity of the symptoms that the patients frequently experienced was investigated. Caregivers reported their primary expectations from physiotherapy. Results: The most common diagnosis was found to be cerebrovascular accidents. The mean age of the patients was 64±20 years. The mean age of the caregivers was 49±13 years. The mean the Palliative Performance Scale score was 31±17. Most of the patients were totally dependent according to the Barthel Index. Most of the patients faced symptoms, such as reduced muscle strength (94.44%), atrophy (93.33%) and swallowing problems (82.22%). Improved physical functions was the most reported expectation among caregivers. Conclusion: Over 90% of the patients were totally dependent and they had to deal with many symptoms. This result highlights the importance of physiotherapy. Caregivers expected the patient to be able to meet their own needs independently. This is very important for the caregiver, and the patient and caregiver should be in cooperation with the physiotherapist.

Factors associated with non-completion of palliative radiotherapy for spinal metastasis in patients with terminal cancer: a retrospective study.

Predictors of non-completion of radiotherapy (RT) should be identified to determine the optimal RT dose. Therefore, this study aimed to explore factors associated with non-completion of palliative RT in patients with terminal cancer. In this retrospective study, patients with terminal cancer who received RT (not including single-fraction RT) for relief of pain caused by spinal metastasis were categorized into complete and incomplete groups. Baseline characteristics, hematologic test data [e.g., total lymphocyte count (TLC)], performance status, palliative performance scale (PPS) score, psoas muscle index (PMI), Charlson comorbidity index, and age-adjusted Charlson comorbidity index of the patients were compared between the two groups. The complete group comprised 58 patients (median age: 68 years; female/male: 17/41; number of irradiation fractions: ≥2 to <10, 20 patients; 10, 34 patients; and >10, 4 patients), and the incomplete group comprised 9 patients (median age: 68 years; female/male: 3/6; number of irradiation fractions: ≥2 to <10, 2 patients; 10, 7 patients; and >10, 0 patient). The proportion of patient death within 1 week or 1 month was higher in the incomplete group than in the complete group. Compared with that in the incomplete group, TLC measured 1 week before RT (pre-TLC) and PMI recorded before RT were significantly higher in the complete group (P=0.013 and P=0.012, respectively). In multivariable analyses, pre-TLC was significantly associated with the incomplete group (P=0.048). Compared with the complete group, the incomplete group included several patients whose PPS scores rapidly decreased. Pre-TLC can predict non-completion of palliative RT in patients with terminal cancer.

Effect of Education on Symptom Management and Control in Cancer Patients Receiving Palliative Care

This study aims to investigate the effect of an educational intervention on cancer patients receiving palliative care and their caregivers concerning symptom management and family needs. This study involved 120 participants-60 cancer patients and their respective caregivers-divided into intervention and control groups. Over a 2-week period, the intervention group received a comprehensive educational program focusing on symptom management, while the control group did not receive any educational intervention. The Edmonton Symptom Assessment System (ESAS) and Palliative Performance Scale (PPS) were used to assess patients' symptoms, their intensity, and performance, while the Family Need Scale (FNS) was utilized to evaluate caregivers' needs. These assessments were conducted at the beginning and end of the study. Primary outcomes focused on symptom assessment using ESAS and PPS, along with evaluating caregivers' needs through FNS. Secondary outcomes involved assessing participant satisfaction with the intervention. At the end of the study, comparing initial and second evaluations, both ESAS and PPS scores significantly increased in the intervention and control groups (p = .003, p = .002, respectively). Additionally, a statistically significant decrease in the severity of symptoms, except for lethargy/hypokinesis, was observed in the intervention group compared to the control group. The FNS scale indicated that family needs satisfaction was higher in the intervention group compared to the control group. The data obtained demonstrated that there was a reduction the pain, fatigue, depression, anxiety, drowsiness, and shortness of breath levels in the intervention group compared to the control group, but there was no significant difference other than these symptoms. The educational intervention positively impacted symptom management and family needs. Optimizing symptom control would greatly benefit palliative care patients and their caregivers.

EVALUATION OF INTERVENTIONS AND QUALITY OF LIFE FOR ADVANCED STAGE CANCER PATIENTS APPLYING TO THE EMERGENCY DEPARTMENT

Objective: This study aimed to evaluate the palliative care needs of advanced stage&#x0D; cancer patients who applied to the emergency department.&#x0D; Material and Method: The research is descriptive and was conducted with 159 patients&#x0D; who met the selection criteria in the emergency departments of three public hospitals in&#x0D; Istanbul. The data for the study was collected using three tools: the Patient Information&#x0D; Questionnaire Form, the Palliative Performance Scale (PPS), and the Quality of Life in&#x0D; Palliative Cancer Care Patients (EORTC-QLQ C15-PAL) Scale.&#x0D; Results: Patients frequently applied to the emergency department for pain (31.7%),&#x0D; dyspnea (16.2%), and nausea- vomiting (15.8%). In general, consultation was requested&#x0D; from 88.7% of the patients, and the most frequently consulted clinics were 49.8%&#x0D; internal medicine, 25.1% anaesthesia, 6.5% surgery and 6% chest diseases. Consultation&#x0D; was requested from 88.7% of the patients, and the internal medicine unit was consulted&#x0D; most frequently with a rate of 49.8%. The most common outcome was 38.4% clinical&#x0D; admission. 67.2% of the patients had a PPS score of 70 or less. The patients' emergency&#x0D; service visits resulted in 38.4% clinical admission, 32.1% discharge, 23.3% intensive&#x0D; care unit and 6.3% exitus. The patients' follow-up time in the emergency department&#x0D; was also determined to be a minimum of half an hour, a maximum of 5 hours, and an&#x0D; average of 1.9±1.2 hours.&#x0D; Conclusion: The study found that 93% of the patients did not receive palliative care&#x0D; support. Considering this basis, it can be recommended to provide the necessary&#x0D; guidance for cancer patients who apply to emergency departments to receive palliative&#x0D; care support and to structure this step within the health system. Such a structure may&#x0D; contribute to the diagnosis of patients who need palliative care support.

Biceps brachii muscle cross-sectional area measured by ultrasonography is independently associated with one-month mortality: A prospective observational study.

Studies examining mortality in palliative care units are limited. We aimed to investigate the mortality and associated factors including ultrasonographic muscle parameters in hospitalized palliative patients with a subgroup analysis of older patients. A prospective-observational study. We recorded the demographics, number of diseases, diagnoses, and the Charlson comorbidity index (CCI), palliative performance scale (PPS), and nutritional risk screening-2002 (NRS-2002) scores. We noted the nutritional parameters and mortality. We measured the subcutaneous fat thickness (SFT), muscle thickness (MT), and cross-sectional area (CSA) of the rectus femoris and biceps brachii using ultrasonography. We enrolled 100 patients (mean age: 73.2 ± 16.4 years, 53%: female). One-month mortality was 42%. The non-survivors had significantly higher malignancy, increased CCI and NRS-2002 scores, lower required energy intake, calorie sufficiency rate, and biceps brachii SFT, MT, and CSA than the survivors. The independent mortality predictors were malignancy and biceps brachii CSA while the PPS score and malignancy were significantly associated with mortality in the older subgroup. The malignancy and biceps brachii CSA might have prognostic value in predicting mortality in palliative patients. This was the first study investigating the mortality-associated factors including ultrasonographic muscle measurements of both the lower and upper limbs in a palliative care center.

The Evaluation of the Burden and Burnout Levels of the Caregivers of the Inpatients in Palliative Care

The study was conducted to evaluate the care burden and burnout levels of caregivers for patients hospitalized in palliative care. This descriptive study was conducted with 76 caregivers who were hospitalized in the palliative care services of a university and state hospital between 02.12.2019 and 02.06.2022 in Turkey. After obtaining the permissions of the ethics committee and the institution, the data were collected with the Descriptive Characteristics Form, Palliative Performance Scale, Caregivers Burden Inventory, and Maslach Burnout Inventory. The total score of the Caregivers Burden Inventory was 50.31±15.37, sub-dimensions of time-dependency burden, developmental burden, physical burden, social burden, and emotional burden scores were 18.30±3.23, 10.94±6.03, 13.54±5.99, 4.09±4.68, and 3.42±3.89, respectively. The Maslach Burnout Inventory sub-dimensions were emotional exhaustion, depersonalization, and personal accomplishment, with mean scores of 24.78±10.33, 11.59±4.20, and 28.64±5.67, respectively. The mean Palliative Performance Scale score of the patients was 32.76±16.86. As the burden of caregivers increased, so did their exhaustion scores. Caregivers had moderate care burdens, high time dependency and physical burdens, high emotional exhaustion, and low personal accomplishment burnout. All patients who were cared for were bedridden. The presence of incontinence in the patient affected the time dependency burden of the caregivers, and the presence of chronic disease in the caregiver and living with the patient also affected the caregivers' emotional exhaustion. These results show that studies must be conducted to develop multidisciplinary interventions to reduce caregivers’ care burden and burnout.

Survival Prediction of Patients Who Were Terminally Ill Using the EORTC QLQ-C15-PAL Scores and Laboratory Test Values.

Prognostics for patients with cancer is especially important for the supportive care of those who are terminally ill. We previously found that symptom scores as patient-reported outcomes (PROs)-such as dyspnea and fatigue scores-some biochemical parameters, the palliative performance scale (PPS) scores, and symptom clusters were useful prognostic factors; however, the predictability of a prognosis based on these factors remains unclear. To identify appropriate three-week survival predictive factor(s), in terms of performance, in patients who were terminally ill. We collected symptom scores as PROs using the Japanese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL). We used data from terminally ill patients with cancer who were hospitalized at the palliative care unit of the Higashisumiyoshi-Morimoto Hospital (Osaka, Japan) from June 2018 to December 2019 (n = 130), as well as additional data obtained from the same clinical study from January to March 2020 (n = 31). To evaluate predictive performance, indices such as sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated. We found that the presence of a symptom cluster showed high sensitivity but low specificity and that a higher PPS value (>30) showed high specificity but low sensitivity, suggesting that these factors could provide relevant information for survival prognosis (less than or equal to three weeks). Symptom clusters obtained from patients is important for effective supportive care of those who are terminally ill.

Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study

Background: Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups. Aim: To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care. Design: Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information. Setting/participants: Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019. Results: The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05–1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019. Conclusions: Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.

Investigating trial feasibility of music care in hospice and palliative care

The nature of hospice and palliative care (HPC) settings necessitates supporting residents’ ever-changing needs and responding to unforeseeable situations – as such, this unpredictability has historically challenged the collection of high-quality data in such settings. Through a feedback consensus approach, this pilot study sought to determine the feasibility of implementing a clinical trial aiming to understand the impact of a recorded music care intervention on quality of life (QoL) in HPC settings. Four participants with a palliative performance scale (PPS) score of ≥ 40 were recruited. Pre-developed music care albums designed for HPC were used as an intervention for a minimum duration of 30-minutes. The Edmonton Symptom Assessment Scale, Hospice Quality of Life Index, and State-Trait Anxiety Inventory were implemented to mirror a future randomised controlled trial (RCT) design but were not statistically interpreted in this pilot study. Data collectors also recorded participants’ and care providers’ perspectives. Through feedback from participants, healthcare professionals, and music care experts, the intervention duration was reduced to a minimum of 15-minutes, and the PPS inclusion criteria requirement was eliminated. The number of outcome measures was reduced from three to one to mitigate participant burnout. Finally, participants indicated that the recorded music intervention was therapeutic, therefore justifying further study of QoL outcome measures. Implementing a second pilot to validate the changes to the RCT study protocol will be a critical step in the research process, although the results of this study can be considered by researchers conducting RCTs in HPC to inform best practices.

Caregiver burden of patients with advanced cancer in Mexico.

181 Background: Caregivers of patients with advanced cancer often face significant physical, social, and emotional distress. In many Latin American cultures, family plays a particularly important role in the decision-making process of patients with cancer, and relatives often assume the role of unpaid caregivers. However, there is limited research about the burden associated with cancer unpaid caregiving among patients living in Latin America. We aimed to describe the profile of caregivers and to identify patient-related factors associated with caregiver burden in a third-level cancer center in Mexico City. Methods: We conducted a cross-sectional analysis of baseline data from patients with advanced cancer and their caregivers included in a multidisciplinary patient navigator-led supportive care program in Mexico City ( Te Acompañamos). At the time of enrollment in the program, caregivers completed a short version of the Zarit Burden scale and patients completed a series of screening questionnaires including assessments of quality of life (FACT-G), depression (PHQ-9), and anxiety (GAD-7). Life expectancy was calculated using the palliative performance scale (PPS). We used descriptive statistics, chi-square tests, and multivariate logistic regression analyses to understand which patient factors were associated with higher caregiver burden. Results: A total of 321 patients with advanced cancer (58% women; average age 63.3 +/- 14 years; 32.7 with hepatopancreatobiliary tumors) and 321 caregivers (67.1% women; 44% were the patient’s son/daughter; 29% were their spouses) were included. Sixty-four caregivers (20%) had a high caregiver burden (score &gt; 16 in the Zarit scale). Caregiver burden was more common among the patients’ spouses (24.1 %) followed by brothers/sisters (23.6%). On univariate analysis, moderate/severe levels of depression (p = 0.001), moderate/severe levels of anxiety (p = 0.02), and lower PPS scores (p = 0.002) were associated with a high caregiver´s burden. Multivariate analysis showed that only PPS &lt; 180 days was associated with increased odds of having caregiver burden (2.0; 95% CI 1.8-3.7); p = 0.02). Conclusions: A significant proportion of unpaid caregivers of Mexican patients with advanced cancer report high levels of caregiver burden, and the odds of having caregiver burden are increased when the patient has a calculated life expectancy of &lt;6 months. These results suggest targets for future supportive care interventions to improve caregiver wellbeing in Latin American and Hispanic populations.

Factors associated with access to palliative home care in palliative patients at Lampang Hospital.

Existing literature has shown the importance of palliative home care to improve quality of life among end-stage patients. However, access to palliative home care remains an issue. This study explores factors associated with successful delivery of palliative home care in palliative patients. A retrospective study was conducted among patients who were referred to the palliative care team for consultation at Lampang Hospital from April 2020 to March 2021. Data from electronic medical records, including successful delivery of palliative home care, age, gender, public health insurance, admission department, primary disease (cancer, non-cancer), presenting symptoms (pain, dyspnea), palliative performance scale score and morphine use, were retrieved. Multiple logistic regression analysis was applied to explore the association, adjusting for covariates. A total of 370 patients were identified, with 88 (23.8%) receiving palliative home care. Results showed that being female, having low palliative performance scale score, morphine use, and having Civil Servant Medical Benefit Scheme insurance are associated with a higher chance of having access to palliative home care, compared with their counterparts. Results of this study pointed out health disparities among palliative patients who required palliative home care. This information can be in part used to redesign palliative home care system with the aim of improving access to care and patients' and caregivers' quality of life as a consequence.

Benzodiazepine Use and Morbidity-Mortality Outcomes in a Geriatric Palliative Care Unit: A Retrospective Review

Introduction: Patients often experience delirium at the end of life. Benzodiazepine use may be associated with an increased risk of developing delirium. Alternate medications used in conjunction with benzodiazepines may serve as an independent precipitant of delirium. The aim is to understand the role of benzodiazepines in precipitating delirium and advanced mortality in palliative care population at the end of life. Methods: A retrospective medical chart review was conducted at a hospice and palliative care inpatient unit between the periods of June 2017–December 2017 and October 2017–November 2018. It included patients in hospice and palliative care inpatient units who received a benzodiazepine and those who did not. Patient characteristics, as well as Palliative Performance Scale score, diagnosis, and occurrence of admission, terminal, and/or recurrent delirium, were collected and analyzed. Results: Use of a benzodiazepine was not significantly associated with overall mortality nor cause-specific death without terminal delirium rate. However, it was significantly associated with higher cause-specific death with terminal delirium rate and a higher recurrent delirium rate. Discussion: This retrospective chart review suggests an association between benzodiazepine use and specific states of delirium and cause-specific death. However, it does not provide strong evidence on the use of this drug, especially at the end of life, as it pertains to the overall mortality rate. Suggested is a contextual approach to the use of benzodiazepines and the need to consider Palliative Performance Scale score and goals of care in the administration of this drug at varying periods during patient length of stay.

Treatment of Positive Urine Cultures at End-of-Life and the Effect on Terminal Delirium Management.

Background: The decision to initiate antibiotics in hospice patients that are very near end-of-life is a complex ethical and stewardship decision. Antibiotics may be ordered to improve urinary tract infection-related symptoms, such as delirium. However, infection symptoms may be managed using antipsychotics, antipyretics, antispasmodics, and analgesics instead. Currently, there are no studies that compare symptom management between those who receive antibiotics and those who do not. Methods: A retrospective chart review was conducted for patients admitted to a hospice inpatient unit. Charts were included if the patient was admitted for delirium and had a Palliative Performance Scale score ≤40%, the urine culture was positive for organism growth, and the patient died while in the HIU. Clinical and demographic data was collected. Medication use was tallied for the 5 days prior to the date of death. Results: Sixty-one charts met the inclusion criteria. Thirty-five patients received antibiotics (ABX+) and 26 did not (ABX-). There was no difference in any medication consumption between groups during the 5 days prior to death. The ABX+ group died 8.2 days after obtaining the urine sample vs 6 days (P =0.046). The ABX+ group had more documented urinary tract-specific infection symptoms (66% vs 38%, P =0.042). More than half of antibiotic courses were discontinued prematurely. Conclusion: The results of this study do not show a difference in overall medication consumption between groups, which suggests that antibiotics may not help improve terminal delirium symptoms in those with a suspected urinary tract infection at end-of-life.

Validity and reliability of the Turkish version of the Patient Dignity Inventory.

The aim of this study was to investigate the validity and reliability of the Patient Dignity Inventory (PDI) in the Turkish society, which was developed to evaluate dignity-related distress in palliative care patients. One hundred and twenty-seven adults with advanced cancer hospitalized in several clinics of two university hospitals were included in the study. The patients whose Palliative Performance Scale score was at least 40% were recruited to study. The data were collected with a patient demographic form, the Turkish version of Hospital Anxiety and Depression Scale (HADS-TR), and the Turkish version of the PDI (PDI-TR). The PDI-TR was finalized and back-translated after translating into Turkish and obtaining 10 expert opinions. Exploratory and confirmatory factor analysis, internal consistency, concurrent validity, and test-retest reliability analysis were performed. The Cronbach's α coefficient of PDI-TR was 0.94. Factor analysis resulted in a five-factor solution, and all items were loaded on factors. Factors were labeled as symptom distress, existential distress, self-confidence, dependency, and supportive care needs and accounted for 68.70% of the overall variance. The model's normed fit index, comparative fit index, and X2/SD were found between acceptable range (0.90, 0.93, and 2.64, respectively). A positive and strong correlation was found between subdimension scores of HADS-TR and the total score of PDI-TR (r = 0.70 for anxiety subdimension; r = 0.73 for depression subdimension). The test-retest reliability was conducted with 32 patients within the sample two weeks after the first application, and no significant difference was found between the two application scores as the result of paired-sample t-test (p > 0.05). An intraclass correlation coefficient of test-retest reliability was r = 0.855. PDI-TR was found to be a valid and reliable tool in palliative care patients in Turkish society.

Topical cannabis-based medicines - A novel adjuvant treatment for venous leg ulcers: An open-label trial.

Venous leg ulcers are highly prevalent lower limb integumentary wounds that remain challenging to heal despite the use of evidence-based compression therapies. A multitude of adjuvant treatments has been studied but none have demonstrated enough efficacy to gain adoption into treatment guidelines. Global attention on Cannabis-Based Therapies is increasing and has been driven by quantum scientific advancements in the understanding of the endocannabinoid signalling system. Topical Cannabis-Based Medicines represent a novel treatment paradigm for venous leg ulcers in terms of promoting wound closure. Fourteen complex patients with sixteen recalcitrant leg ulcers were treated with Topical Cannabis-Based Medicines in conjunction with compression bandaging, every second day, to both wound bed and peri-wound tissues. The cohort had a mean age of 75.8years and was medically complex as reflected by a mean M3 multimorbidity index score of 2.94 and a mean Palliative Performance Scale score of 67.1%. Complete wound closure, defined as being fully epithelialized, was achieved among 11 patients (79%) and 13 wounds (81%) within a median of 34days. All three remaining patients demonstrated progressive healing trends but were lost to follow-up. The treatments were well tolerated, and no significant adverse reactions were experienced. The rapid wound closure of previously non-healing venous leg ulcers among elderly and highly complex patients suggests that Topical Cannabis-Based Medicines may become effective adjuvants in conjunction with compression therapy. This may also indicate that they may have an even broader role within integumentary and wound management. Therefore, this treatment paradigm warrants being subjected to controlled trials.

The PROVIEW+ tool: Developing and validating a tool to predict risk of poor performance status and severe symptoms in cancer patients over time.

12095 Background: There are numerous predictive cancer tools that focus on survival. However, no tools predict risk of low performance status or severe symptoms, which are important for patient decision-making and early integration of palliative care. The aim of this study was to develop and validate a model for all cancer types that predicts the risk for having low performance status and severe symptoms. Methods: A retrospective, population-based, predictive study using linked administrative data from cancer patients from 2008-2015 in Ontario, Canada. Patients were randomly selected for model derivation (60%) and validation (40%). The derivation cohort was used to develop a multivariable logistic regression model to predict the risk of having the reported outcomes in the subsequent 6 months. Model performance was assessed using discrimination and calibration plots. The main outcome was low performance status using the Palliative Performance Scale. Secondary outcomes included severe pain, dyspnea, well-being, and depression using the Edmonton Symptom Assessment System. Outcomes were recalculated after each of 4 annual survivor marks. Results: We identified 255,494 cancer patients (57% female; median age of 64; common cancers were breast (24%) and lung (13%)). At diagnosis, the risk of having low performance status, severe pain, well-being, dyspnea, and depression in 6-months is 1%, 3%, 6%, 13% and 4%, respectively for the reference case (i.e. male, lung cancer, stage I, no symptoms). Generally these covariates increased the outcome risk by &gt; 10% across all models: obstructive lung disease, dementia, diabetes; radiation treatment; hospital admission; high pain; depression; Palliative Performance Scale score of 60-10; issues with appetite; or homecare. Model discrimination was high across all models. Conclusions: The model accurately predicted changing cancer risk for low performance status and severe symptoms over time. Providing accurate predictions of future performance status and symptom severity can support decision-making and earlier initiation of palliative care, even alongside disease modifying therapies.

The impact of a standardised ketamine step protocol for cancer neuropathic pain

Context Ketamine at sub-anesthetic doses is a potent analgesia. Its use in cancer pain remains equivocal with protocols varying in patient selection, starting dose, titration, duration of use and adjustment of co-analgesics. Objective To study the impact of a standardised Ketamine Step Protocol on cancer pain in a Palliative Care Unit (PCU). Methodology This is a prospective cohort study of a standardised Ketamine Step Protocol which was developed in a PCU for use in cancer pain. The subcutaneous ketamine infusion was standardised at a starting dose of 75 mg over 24 hours with Haloperidol 5 mg as prophylaxis against psycho-mimetic side effects. Incremental doses of ketamine followed the daily stepwise protocol. Result Of the 48 patients analysed, 41 (85.4%) had neuropathic cancer pain. The median Palliative Performance Scale score (PPSv2) was 40%. Mean Numerical Rating Score (NRS) improved from 6.74 to 2.61 (P < 0.0001) with a mean percentage reduction of 58.05%. The final mean daily ketamine dose needed to achieve stable pain control was 137.50 mg/day (±81.54). 31(62.5%) patients achieved pain control by day 3. The mean Morphine Equivalent Daily Dose (MEDD) reduction was from 130.34 mg to 107.33 mg (P < 0.002) with a percentage reduction of 18.85%. More than half of our patients completed the 5 d protocol with mild to moderate side effects not warranting urgent medical intervention nor termination of the ketamine protocol. Conclusion Use of a standardised Ketamine Step Protocol showed a statistically significant reduction in pain and MEDD in patients with predominantly neuropathic cancer pain. It also demonstrated a safe and effective method for opioid reduction after commencement of parenteral ketamine. Key Message How can a standardised ketamine protocol impact on cancer pain control? Our study shows that: Parenteral ketamine is a potent analgesic which significantly reduced pain in patients with cancer neuropathic pain. This study also demonstrated a safe and effective method for titration of opioids after parenteral ketamine is started. Concurrent use of psychotropics also helps to reduce psycho-mimetic side effects, increasing tolerability to ketamine.

Integrating Palliative Care Assessment Tools to Enhance Understanding of Illness Trajectory in Post-Acute Care and Long-Term Care

To determine whether education and integration of the Gold Standard Framework Proactive Identification Guidance (GSF-PIG) and the Palliative Performance Scale (PPS) into care rounds, in post-acute care settings, can facilitate communication between the interprofessional care team to enhance understanding of illness trajectories, identifying those who would benefit from a palliative approach to care. Interprofessional care teams received training on the GSF-PIG and PPS which were integrated into weekly care rounds and completed a post-evaluation survey. A chart review was conducted for the 40 patients and residents reviewed with the GSF-PIG and PPS. Data analysis included descriptive statistics and comparisons of characteristics between patients and residents who were grouped as positive or negative on the GFS-PIG surprise question using chi square analyzes and t-tests. The GSF-PIG and PPS were found to enhance communication within care teams and enhance understanding of patient and resident's illness burden. The chart review revealed that patients and residents whom the team would not be surprised if they died within 1 year were older (p = .002), had a lower PPS score (p = .002) and had more indicators of decline (p < .001) compared to patients and residents the team would be surprised if they died within the year. Training interprofessional care teams on the utilization and integration of the GSF-PIG and PPS during weekly care rounds helped increase the understanding of patient and resident illness burden and illness trajectory to identify those who may benefit from a palliative approach to care.

Kanser hastalarında sağkalım Palyatif Performans Skalası ile doğru olarak tahmin edilebilir mi?

Introduction: Palliative Performance Scale (PPS), Karnofsky Performance Scale (KPS) and the Edmonton Symptom Assessment Scale (ESAS) are widely used prognostic scales in palliative care unit. Institutionalized palliative care services in our country are quite new compared to the practices in many countries. We do not have concrete data on the compatibility of these scales, which are developed with patient data from other countries, in our own palliative care practices with real cases. In this study, we aimed to evaluate the convenience of the Turkish versions of these scales on the first days of hospitalization of terminal cancer patients who were followed up in the palliative clinic of our hospital. We also questioned whether the initial estimated survival and actual survival were compatible. Methods: PPS, KPS and ESAS on the first days of hospitalization of terminal cancer patients, hospitalized in the palliative clinic of our hospital between November 14, 2016 and November 14, 2017, were retrospectively evaluated one year later (n = 222). The survivors and those who lost their lives were determined. The survival estimates with PPS of the patients who died were compared with their actual survival.Results: The average age of 222 patients (18% female, 82% male) participating in the study was 64.49 ± 11.62, and the range was 26-91. PPS, KPS, ESAS were determined as a mean value of 34.40±18.00 (min. 10-max. 90), 32.90±17.50 (min. 10-max. 90), 56.10±15.65 (min. 2-max. 90), respectively. The AUC of PPS is 0.83 (p&amp;lt;0.001) and the AUC of KPS is 0.78 (p&amp;lt;0.001) suggesting that KPS and PPS has at least one tie between alive and dead patients, which is 45%. Median survival time was found 14.00, 95% C.I. [10.87–17.13]. Conclusion: In our study, it was found that as the KPS and PPS scores decrease, the survival time of terminal cancer patients decrease. Patients with PPS &amp;lt;45% had a higher risk of death (sensitivity 71%, specificity 80%), patients with KPS &amp;lt;45% had a higher risk of death (sensitivity 60%, specificity 81%), and patients with ESAS&amp;gt; 60.50 had a higher risk of death (sensitivity 93%, specificity 45%). PPS is a useful assessment scale for predicting survival of terminal cancer patients in the palliative care unit. We think it is important in determining our patient-specific palliative approach and treatments.

El papel del conocimiento de diagnóstico y pronostico sobre la resiliencia y el apoyo social en pacientes paliativos

Objective: To study how awareness of diagnosis and prognosis may help develop resilient coping and promote social support seeking. Also, to study the relationships between information variables and both sociodemographic and clinical variables. Methods: Analyzed variables include resilience (BRCS), social support (MOS), and informational variables. Our sample was made up of 192 patients admitted to a palliative care unit, with a mean age of 69.05 years (SD = 15.106). A total of 50.5 % were men, of which 82.8 % had a cancer diagnosis, 52.6 % had a low education level, and 45.3 % were married. Their average Palliative Performance Scale (PPS) score was 49.11. Results: There is a relationship between emotional support, prognosis awareness (0.151; p = 0.036) and perceived proximity of death (0.186; p = 0.010). Resilience was also positively correlated with prognosis awareness (0.258; p = 0.000) and perceived proximity of death (0.146; p = 0.044). Conclusion: The significance of emotional support highlights the role of health professionals as providers of information, adapting their communication style to the information needs of patients and their families. Also, resilient coping helps in the management of information and its subsequent adjustment to the end-of-life situation.