Symptom Management In Palliative Care Research Articles

IJCM_200A: Symptom Burden Profile of individuals facing chronic life-limiting illnesses and barriers to effective management of symptoms in palliative care- Grounded theory qualitative study.

Background: Managing symptoms such as pain, breathlessness, and fatigue poses significant challenges in patients with advanced diseases. While palliative care has proven to enhance symptom control, there is a lack of exploration into the factors that contribute to successful symptom management in this specific context. This study was conducted to gain insight into the elements that support effective symptom management in palliative care within home settings and to explore the barriers that are encountered in this process. Objectives: To enumerate symptom burden profile of Patients facing chronic life limiting illness registered in Home based Palliative care program implemented by SVYM in Bengaluru and Hassan cities . Methodology: This is a Gounded theory study using qualitative semi- structured interviews. conducted between August 2023 to December 2023. Study participants are the primary caregivers of Patients with chronic life limiting illness in need of palliative care in Hassan and Bengaluru. 50 participants were interviewed through convenience sampling for the purpose of the study. Edmonton's Symptom assessment scale (ESAS) was used to assess the symptom burden of patient during the registration and 3 weeks post intervention. Conclusion: Effective symptom management relies on collaborative decision-making between patients and healthcare professionals, along with the coordinated efforts of a multidisciplinary team. Taking steps to address psychological distress and assessing the comprehension and expectations of patients and their families would enhance the overall effectiveness of symptom management in palliative care.

Drug Therapy Safety in Palliative Care-Pharmaceutical Analysis of Medication Processes in Palliative Care.

Pharmacotherapy plays a crucial role in symptom management in palliative care and is associated with risks potentially leading to drug-related problems (DRP). Pharmacists can identify DRPs and advise prescribers on optimizing drug therapy. The aim of this study was to identify DRP in a palliative care unit (PCU) and evaluate corresponding pharmaceutical interventions. A non-randomized before-and-after study in a PCU starts with a control phase, an interphase, and an intervention phase. Primary endpoint: DRP, including pharmaceutical interventions and their acceptance. The medication of all inpatients was recorded at set time points, assessed for potential and manifest DRP, and categorized. In the control phase, the ward pharmacist did not interfere with the clinical team. In the intervention phase, the pharmacist could intervene when a DRP was identified and give recommendations. During the 12-month period, 284 patients were included (control phase n = 138; intervention phase n = 146) and 1079 DRPs were identified (control phase n = 634; intervention phase n = 445). The number of DRPs/patient was significantly reduced by the pharmacist's interventions between the control and intervention phases (4 vs. 3 DRPs, p = 0.001). Overall acceptance of pharmaceutical interventions by prescribers was very high (227/256; 88%). DRPs are hardly preventable. With a clinical pharmacist as a member of the palliative care team, it is possible to reduce the number of DRPs and identify potential problems earlier.

Barriers and facilitators to multidimensional symptom management in palliative care: A focus group study among patient representatives and clinicians.

It is widely acknowledged that co-occurring symptoms in patients with a psychosocial and spiritual aspects should also be considered. However, this multidimensional approach is difficult to integrate into daily practice, especially for generalist clinicians not specialized in palliative care. We aimed to identify the barriers and facilitators to multidimensional symptom management. Focus group meetings were conducted with the following stakeholders: (1) patient representatives, (2) generalist community nurses, (3) generalist hospital nurses, (4) general practitioners, (5) generalist hospital physicians, and (6) palliative care specialists. Audiotapes were transcribed verbatim and thematically analyzed. Fifty-one participants (6-12 per group) reported barriers and facilitators with 3 main themes: multidimensional symptom assessment, initiating management of nonphysical problems, and multidisciplinary collaboration. As barriers, generalist clinicians and palliative care specialists reported that generalist clinicians often lack the communication skills to address nonphysical problems and are unaware of available resources for multidimensional symptom management. Palliative care specialists felt that generalist clinicians may be unaware that assessing nonphysical problems is important and focus on pharmacological interventions. Generalist nurses and palliative care specialists indicated that hierarchical difficulties between them and generalist physicians are barriers to multidisciplinary collaboration. Reported facilitators included using symptom assessment scales and standardized questions on nonphysical problems. Generalist clinicians can be supported by improving their communication skills, increasing their awareness of available resources for multidimensional symptom management, and by using a standardized approach to assess all 4 dimensions of palliative care.

Nurses' Views on Palliative Care and Death: A Qualitative Study

Giriş: Palyatif bakım yaşam kalitesini yükseltmeyi hedefleyen, çok boyutlu bir bakım yaklaşımıdır. Palyatif bakım sürecinde aktif rol alan hemşireler, bakım sürecinde pek çok güçlükle karşılaşmaktadır.Amaç: Bu araştırma ile, palyatif bakım kliniğinde çalışmakta olan hemşirelerin mesleki yaşam deneyimlerinin, palyatif bakım hemşirelik uygulamalarının ve ölüme bakış açılarının belirlenmesi amaçlanmıştır.Yöntem: Nitel çalışma deseninde yürütülen çalışmanın evrenini, bir eğitim araştırma hastanesinin palyatif bakım kliniğinde çalışmakta olan 13 hemşire oluşturmaktadır. Çalışma grubu seçilmemiş olup evrenin tamamına ulaşılmıştır. Çalışmanın verileri 15.01.2022- 15.02.2022 tarihleri arasında toplanmıştır. Toplanan veriler içerik analizi yöntemi ile değerlendirilip tematik kodlama yapılmıştır.Bulgular: Katılımcıların hepsinin kadın olduğu, yaş ortalamalarının 33,30±7,45 (min:23, max:47) olduğu belirlenmiştir. Hemşirelerin, meslekte çalışma yılı ortalamaları 10,92±7,80 (min:2, max:25), palyatif bakım kliniğinde çalışma süreleri 2,15±1,21 (min:1, max:5) yıl olarak belirlenmiştir. Verilerin betimleyici ve yorumlayıcı analizleri sonucunda 5 ana tema, 19 alt tema oluşturulmuştur. Belirlenen 5 ana tema başlıkları şu şekildedir: Palyatif bakım hemşirelik yaklaşımları, palyatif bakım veren hemşirelerin duygu ve düşünceleri, hemşirelerin ölüm algısı, ölmek üzere olan hastaya bakım veren hemşirelerin duygu ve düşünceleri ve hemşirelerin kişisel motivasyon kaynaklarıdır.Sonuç: Çalışmamızda hemşirelerin palyatif bakımda en çok hastaların yaşam kalitesini arttırmaya, öz bakım uygulamalarına ve semptom yönetimine odaklandıkları belirlenmiştir. Ayrıca hemşirelerin terminal dönemdeki hastaya bakım verme konusunda zorluk yaşadıkları belirlenmiştir. Bu kapsamda yaşamın son döneminde olan hastaya bakım verme ve sonrasında yas sürecinde aileye destek olma gibi konularda hemşirelere hizmet içi eğitimlerin verilmesi önerilmektedir.

Conceptualising effective symptom management in palliative care: a novel model derived from qualitative data

BackgroundPain, breathlessness and fatigue are some of the most challenging symptoms to manage in patients with advanced disease. Specialist palliative care leads to better symptom management, but factors contributing to successful symptom management in this context have not been explored. Our aim was to understand what facilitates effective symptom management in specialist palliative care within UK hospices and investigate what barriers are experienced.MethodsThis was a grounded theory study using qualitative semi-structured focus groups and interviews. Participants were recruited from multidisciplinary specialist palliative care teams (doctors, nurses, healthcare assistants, physiotherapists, occupational therapists, complementary therapists, social workers and chaplains) working in inpatient, outpatient and community services provided by five hospices in the United Kingdom.ResultsWe present a novel qualitative data-derived model of effective symptom management in specialist palliative care. We describe a co-ordinated, multi-faceted, sequential approach involving a process of engagement, partnership, decision-making, and delivery. Interventions to manage symptoms are less effective in psychologically distressed patients. Our data highlights that families of patients have a key role in determining effectiveness of symptom management interventions A holistic approach by a co-ordinated, multi-disciplinary team, including support to recognise and minimise psychological distress might facilitate more effective symptom management. Barriers to symptom management include team discordance and lack of understanding about symptom management by patient and families.ConclusionsShared decision-making between patients and professionals and co-ordination of care by a multi-disciplinary team are key components of effective symptom management. Actions to address psychological distress and evaluate the understanding and expectations of patients and their families would enable more effective symptom management. A more effective multi-disciplinary approach would be facilitated by discussion within teams about role competencies and boundaries.

Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus

ObjectivesDespite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and...

The Core Information Tools for Palliative Care Symptom Management in Patients with Cancer

The Core Information Tools for Palliative Care Symptom Management in Patients with Cancer

Chronic Obstructive Pulmonary Disease: A Palliative Medicine Review of the Disease, Its Therapies, and Drug Interactions

Despite significant advances in treatment, chronic obstructive pulmonary disease (COPD) remains a chronic and progressive disease that frequently leads to premature mortality. COPD is associated with a constellation of significant symptoms, including dyspnea, cough, wheezing, pain, fatigue, anxiety, depression, and insomnia, and is associated with increased morbidity. Palliative care is appropriate to support these patients. However, historically, palliative care has focused on supporting patients with malignant disease, rather than progressive chronic diseases such as COPD. Therapies for COPD often result in functional and symptomatic improvements, including health-related quality of life (HRQL), and palliative care may further improve symptoms and HRQL. Provision of usual palliative care therapies for this patient population requires understanding the pathogenesis of COPD and common disease-targeted pharmacotherapies, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes COPD and current targeted therapies and their effects on symptoms, exercise tolerance, HRQL, and survival. It is important to note that medications commonly used for symptom management in palliative care can interact with COPD medications resulting in increased risk of adverse effects, enhanced toxicity, or changes in clearance of medications. To address this, we review pharmacologic interactions with and precautions related to use of COPD therapies in conjunction with commonly used palliative care medications.

Is Dopamine the Golden Ticket for Symptom Management in Palliative Care? Role of Antipsychotics for Off-Label Uses (TH304)

Is Dopamine the Golden Ticket for Symptom Management in Palliative Care? Role of Antipsychotics for Off-Label Uses (TH304)

Virtual Reality Use for Symptom Management in Palliative Care: A Pilot Study to Assess User Perceptions.

In the past two decades, virtual reality (VR) technology has found use in a variety of clinical settings including pain management, physical medicine and rehabilitation, psychiatry, and neurology. However, little is known about the utility of VR in the palliative care setting. Moreover, previous investigations have not explored user perceptions of the VR experience in this population. Understanding user perceptions of the VR intervention will be critical for the development and delivery of effective VR therapies. To examine the utility of VR for palliative care patients, a pilot study of VR use was conducted with 12 adult patients diagnosed with life-limiting illness who were residents at a free-standing hospice facility. The intervention consisted of a one-time 30-minute VR experience. User perceptions were assessed through both quantitative and qualitative means, including participant responses to open-ended questions after the VR intervention. Acute changes in symptom burden were assessed using the revised Edmonton Symptom Assessment Scale. Participants found the VR experience to be both enjoyable and useful, and the intervention was well-tolerated overall. This study provides support for VR as a promising new therapeutic modality for patients undergoing palliative care.

Safe and effective prescribing for symptom management in palliative care.

Palliative and end of life care forms an important part of the role of any doctor in training, and an awareness of a structured approach to managing common symptoms and end of life care is essential. Common symptoms include pain, nausea and vomiting, constipation, and breathlessness. Anticipatory prescribing of the 4 A's (analgesic, anti-emetic, anxiolytic, and anti-secretory) is a proactive approach to ensure medication is available, if required, for common symptoms in the last hours to days of life, such as pain, upper airway secretions, anxiety, and agitation. Prescribing or medication errors in relation to symptom control in palliative care can relate to individual errors, poor communication, poor care coordination, equipment and care planning. There are some important key points relating to prescribing to consider, for example, using recognized conversions when changing between opioids and from the oral to syringe drivers route; that diamorphine and morphine are not equipotent; prescribing liquid opioids in milligrams not millilitres where there are multiple concentrations available; making the indication for steroids clear when used, as they are multiple possible indications (and also their intended duration, to avoid unintended longer term sequelae of steroid use); and avoiding the use of oxygen for symptomatic relief of breathlessness in the absence of hypoxia.

Editorial introductions

Editorial introductions

HSR19-087: Intensity of Symptom Management After Palliative Care Referral Not Associated With Reduced Imaging Intensity for Cancer Patients During the End-of-Life Period

Purpose: For patients with advanced cancer, palliative care (PC) referral itself results in improved quality of life and lower total health care costs. While our earlier research suggests that PC referral alone does not appear to affect imaging utilization, the effect of the intensity of services for PC symptom management on utilization of imaging services is unknown. We sought to evaluate whether an association exists between the intensity of PC symptom management services and utilization of high-cost imaging at the end-of-life. Methods/Materials: Adult cancer patients who died between January 1, 2012–May 31, 2015 were identified. A PC symptom management intensity score was determined for each patient during the last year of life based upon the number of inpatient and outpatient PC service visits and the number of problems addressed within the 8 defined domains for palliative care. Frequency of utilization of nonemergent oncologic imaging was determined for the last 3 months and the last month of life. Using chi-square and Wilcoxon-rank sum tests, effects of low (<20th percentile) and high (>80th percentile) PC symptom management intensity score on the proportion of patients imaged and mean number of studies per patient (mean imaging intensity [MII]) were compared for the last 3 months and last month of life. Results: 3,772 decedents were included, with 3,523 (93.4%) never referred to PC and 249 (6.6%) referred to PC, largely before the last month of life (70.3%). Within the last 3 months and last month of life, the proportion of patients imaged was significantly greater (P<.001) in patients with high PC symptom management intensity scores when compared to those with low PC symptom management intensity scores. There was no significant difference in the mean number of imaging studies received by either group in the last 1 month or 3 months of life. (P>.05). Conclusions: The intensity of PC symptom management in end-of-life oncologic care was not associated with decreased use of nonemergent, high-cost cancer imaging in our cohort. This may suggest an opportunity for reduced high-cost imaging through further clarification of the goals of care with both patients and oncologists, although the role of imaging in the setting of PC during the end-of-life period warrants further study as well.

Subcutaneous administration at home for symptom management in palliative care.

49 Background: Patients who require home-based palliative care have advanced complex illnesses with functional limitations and decline. Subcutaneous administration of drugs and hydration is a possible alternative when oral intake is hampered. This observational study characterized the use of subcutaneous catheters at a home based palliative care program in Bogotá, Colombia. Methods: Consecutive medical records from September 1, 2017 to February 28, 2018 were reviewed for 272 patients at a home based palliative care program who received subcutaneous administration of drugs and/ or hydration. Statistical analysis was performed to describe the characteristics of the population and its relation to the use of subcutaneous catheters using SPSS tool. Results: The mean age was 72 years (SD: 18), 163 (60%) were females, with a mean in Barthel Index 20 (SD:22), Karnofsky Performance Status Scale 36 (SD: 9.6), PPS of 36 (SD: 11), and PPI 6 (SD: 3.4). The mean time for subcutaneous use was of 34 days (SD: 52). The main indication for the subcutaneous route was poor symptom control in 162 (60%), and because of reduced oral intake in 107 (39%). The administration of drugs was done by a family member in 207 (76%), all trained by a nurse (spouse 14%, offspring 52%, others 34%). The mean number of drugs used per catheter was 3,7 (SD: 1,7). The most common opioid was hydromorphone (57%) followed by morphine (35%). Other medications used were haloperidol (59%) and midazolam (23%). The most common site of application was the upper right extremity. The change of the catheter due to dysfunction was made in 98 (36%) subjects, due to infection in 9 (3.3%) of the 272 patients and 1.5% of 594 catheter insertions. An association with catheter dysfunction was found after multivariate analysis of the time of catheter use and the number of medications. 240 patients (88.2%) died with the catheter in place. Conclusions: Subcutaneous administration of hydration and drugs when used with proper education, training, and followed up by home care programs is a useful strategy for delivering care at home for optimal symptom control for patients receiving palliative care.

A critical realist evaluation of a music therapy intervention in palliative care

BackgroundMusic therapy is increasingly used as an adjunct therapy to support symptom management in palliative care. However, studies to date have paid little attention to the processes that lead to changes in patient outcomes. To fill this gap, we examined the processes and experiences involved in the introduction of music therapy as an adjunct complementary therapy to palliative care in a hospice setting in the United Kingdom (UK).MethodsUsing a realistic evaluation approach, we conducted a qualitative study using a variety of approaches. These consisted of open text answers from patients (n = 16) on how music therapy helped meet their needs within one hospice in Northern Ireland, UK. We also conducted three focus groups with a range of palliative care practitioners (seven physicians, seven nursing staff, two social workers and three allied health professionals) to help understand their perspectives on music therapy’s impact on their work setting, and what influences its successful implementation. This was supplemented with an interview with the music therapist delivering the intervention.ResultsMusic therapy contains multiple mechanisms that can provide physical, psychological, emotional, expressive, existential and social support. There is also evidence that the hospice context, animated by a holistic approach to healthcare, is an important facilitator of the effects of music therapy. Examination of patients’ responses helped identify specific benefits for different types of patients.ConclusionsThere is a synergy between the therapeutic aims of music therapy and those of palliative care, which appealed to a significant proportion of participants, who perceived it as effective.

Palliative Care Symptom Management in The Emergency Department: The ABC's of Symptom Management for The Emergency Physician

BackgroundPalliative care is a rapidly evolving area of emergency medicine. With an estimated 5,000 to 10,000 baby boomers per day reaching retirement age, emergency departments (EDs) are treating more patients with chronic and serious disease. Palliative care offers comprehensive care for patients with advanced medical illness, aims to alleviate suffering and improve quality of life, and plays an important role in caring for these patients in the ED. ObjectivesWe sought to increase the emergency physician's knowledge of and comfort with symptom control in palliative and hospice patients. DiscussionHaving the skills to deliver efficient and appropriate palliative and hospice care is imperative for emergency physicians. Palliative care should be considered in any patient suffering from symptoms of a life-limiting illness, whereas hospice care should be considered in the patient with likely <6 months left to live. Palliative care is appropriate earlier in the course of disease, and is appropriate when the practitioner would not be surprised if the patient died in the next 2 years (“The Surprise Question”). This article discusses management in the ED of pain, nausea, dyspnea, agitation, and oral secretions in patients appropriate for hospice and palliative care. ConclusionThe need for palliative and hospice care in the ED is increasing, requiring that emergency physicians be familiar with palliative and hospice care and competent in the delivery of rapid symptom management in patients with severe and life-limiting disease.

Effect of Opioids and Benzodiazepines on Clinical Outcomes in Patients Receiving Palliative Care: An Exploratory Analysis.

Medications for symptom management in palliative care have associated, but poorly understood, harms. Drug-related harms have important clinical implications, may impact on patients' compliance and contribute to symptoms. To explore the longitudinal relationship between oral morphine equivalent daily dose (MEDD) and oral diazepam equivalent daily dose (DEDD) with functional, cognitive, and symptom outcomes in patients receiving palliative care. Secondary longitudinal analysis of cancer decedents (n = 235) was carried out from a palliative care randomized controlled trial with multiple outcome measures. At each time point, MEDD and DEDD were calculated. Multilevel modeling was used to investigate independent associations between MEDD and DEDD, and cognitive and gastrointestinal symptoms, quality of life (QoL), performance status, and survival. Participants were recruited from a specialist palliative care program in southern Adelaide, were expected to live ≥48 hours, had pain in the previous 3 months, and a baseline Folstein Mini-Mental Status Examination score ≥25. Cognitive and gastrointestinal symptoms, performance status, and QoL worsened over time. In the adjusted multilevel analysis, statistically significant relationships remained between MEDD/DEDD and worsening performance status (p = 0.001), DEDD and gastrointestinal effects (p < 0.001), MEDD and QoL (p < 0.022). Commonly used palliative medications were associated with deteriorating performance status. The lack of association between MEDD with gastrointestinal or cognitive symptoms underlines that these associations are not inevitable with close attention. This analysis highlights the importance of including other medications as confounders when exploring medication-related harms. An understanding of the risk-benefit balance of medications is needed to maximize net benefits for patients.

Development of research priorities in paediatric pain and palliative care.

Priority setting for healthcare research is as important as conducting the research itself because rigorous and systematic processes of priority setting can make an important contribution to the quality of research. This project aimed to prioritise clinical therapeutic uncertainties in paediatric pain and palliative care in order to encourage and inform the future research agenda and raise the profile of paediatric pain and palliative care in the United Kingdom. Clinical therapeutic uncertainties were identified and transformed into patient, intervention, comparison and outcome (PICO) format and prioritised using a modified Nominal Group Technique. Members of the Clinical Studies Group in Pain and Palliative Care within National Institute for Health Research (NIHR) Clinical Research Network (CRN)-Children took part in the prioritisation exercise. There were 11 clinically active professionals spanning across a wide range of paediatric disciplines and one parent representative. The top three research priorities related to establishing the safety and efficacy of (1) gabapentin in the management of chronic pain with neuropathic characteristics, (2) intravenous non-steroidal anti-inflammatory drugs in the management of post-operative pain in pre-schoolers and (3) different opioid formulations in the management of acute pain in children while at home. Questions about the long-term effect of psychological interventions in the management of chronic pain and various pharmacological interventions to improve pain and symptom management in palliative care were among the 'top 10' priorities. The results of prioritisation were included in the UK Database of Uncertainties about the Effects of Treatments (DUETS) database. Increased awareness of priorities and priority-setting processes should encourage clinicians and other stakeholders to engage in such exercises in the future.

Applying palliative care principles and practice to emergency medicine.

Only recently has the potential (unmet) palliative care (PC) workload in the ED been recognised. While confident in PC symptom management, we underestimate the role of a palliative approach in non-cancer diagnoses and seek education in areas such as individual patient care pathways, ethical and legal issues and difficult conversations at the end of life. PC is best introduced early for a range of life-limiting cancer and non-cancer diagnoses. Allowing patients time to tell their story with active listening, acknowledgement of suffering and a compassionate presence leads to treatment 'success' that is not defined by cure. This patient-centred, rather than disease-centred approach, is the essence of PC, and one that is easily incorporated into emergency practice. PC and disease-specific treatments can comfortably coexist, and with meticulous symptom management, may actually prolong life. PC is everyone's business, and emergency medicine needs to be part of it.

Staff perceptions of palliative care in a public Australian, metropolitan emergency department.

The primary aim was to investigate staff experiences and attitudes towards palliative care provision in a public metropolitan ED. Using a previously validated survey tool, data were collected from ED clinical staff using Likert-type, open-ended and dichotomous items asking about perceptions of palliative care and education needs. Comparisons were made between nursing and medical staff. Medical staff and nurses' perceptions of palliative care were similar, differing on only 10 of 37 (Likert) items. All staff reported confidence with symptom management, whereas medical staff felt more confident with decision-oriented communication and nurses were more supportive of nasogastric feeding. Staff were moderately accurate in determining the five most common causes of death. Four out of five conditions selected as appropriate for palliative care were cancer diagnoses. End-of-life communication and ethical issues were the two most frequently requested areas for further education. Our study suggests that overall ED staff were confident regarding symptom management in palliative care. Cancer diagnoses were overrepresented in both the top five causes of death and conditions most appropriate for a palliative approach, suggesting that staff might underestimate the role of a palliative approach in non-cancer diagnoses. Areas suggested for further education include communication and ethical issues surrounding end-of-life care.