Symptoms In Palliative Care Patients Research Articles

Gastro-Intestinal Symptoms in Palliative Care Patients.

This review of the palliation of various gastro-intestinal (GI) symptoms encountered in cancer patients is by no means exhaustive. Frequent symptoms such as constipation, nausea and vomiting, bowel obstructions, ascites and bleeds will be discussed, focusing on their assessment and most importantly, how to control the associated symptoms. All of these symptoms and GI complications can significantly impact patients' quality of life (QOL) and should be treated as quickly and aggressively as possible.

The effects of virtual reality interventions on occupational participation and distress from symptoms in palliative care patients: A pilot study.

Virtual reality (VR) offers the prospect of a safe and effective adjunct therapeutic modality to promote mental health and reduce distress from symptoms in palliative care patients. Common physiological and psychological symptoms experienced at the end of life may impact the person's participation in day-to-day activities that bring them meaning. The purpose of this study was to examine the effect of VR interventions on occupational participation and distress from symptoms. To describe the stimulus, results, and learnings from a single-site pilot study of virtual reality therapy in a specialist palliative care setting. Participants engaged in a VR session lasting from 9 to 30 minutes related to coping with pain, inner peace and mindfulness, adventure, and bucket list. The pilot prospective quantitative observational cohort study was conducted from November 2021 through March 2022 using a pre-post VR intervention research design. Quantitative data was collected using patient-rated assessments and a wireless pulse oximeter. Occupational performance, satisfaction, and distress symptoms were measured using the Canadian Occupational Performance Measure and the Palliative Care Outcomes Collaboration Symptom Assessment Scale (PCOC SAS). The intervention and study design adhered to international guidelines. Ten participants engaged in the VR interventions. Data showed significantly improved occupational performance and satisfaction scores (p < .001), decreases in PCOC SAS distress from pain (p = .01), fatigue (p < .001), and heart rate (p = .018). No adverse side effects were observed. Outcomes included an analysis of virtual reality's effectiveness to alleviate symptom burden and increase occupational participation for palliative care patients. Of specific interest to the research team was the application of virtual reality in a community-based and inpatient palliative care context to supplement allied health services and its feasibility of integration into standard palliative care. VR therapy showed positive improvements in the participants' occupational performance, satisfaction, and distress from pain and fatigue.

Understanding Quality of Life for Palliative Patients With Dysphagia Using the Swallowing Quality of Life (SWAL-QOL) Questionnaire.

There are few studies concerning the differences in quality-of-life (QOL) between palliative care patients with and without dysphagia to date. We aimed to compare the QOL and symptoms in palliative patients with and without dysphagia using Swallowing Quality of Life (SWAL-QOL). Eighty-one palliative patients with and without dysphagia underwent the SWAL-QOL questionnaire. A series of Mann Whitney U tests were performed between non-dysphagic and dysphagic groups for the total SWAL-QOL score and the 11 SWAL-QOL domains. Dysphagia significantly impacted patients' QOL in the dysphagic group (mean, 69.5; SD 21.9) than non-dysphagic group (mean, 83.2; SD 14.8) (P = 0.006). Significant differences were observed between both groups for the domains of burden, eating desire, eating duration, symptoms, food selection, communication and mental health. The results also showed that the dysphagic group had lower symptom score across all symptoms, suggesting higher symptom burdens. This study is the first to examine QOL and swallow symptoms in palliative care patients with and without dysphagia. Dysphagia causes significantly worse QOL in palliative care patients. Screening for dysphagia and managing its impact on symptoms and QOL domains is important in palliative care.

The role of cannabinoids in the management of symptoms in palliative care patients

The endocannabinoid system (ECS) regulates body’s homeostasis and performs vital physiological functions. The thorough understanding of the role of endocannabinoids and the composition of cannabis containing phytocannabinoids and terpenoids play an important role in symptom management. Clinical effects of medical cannabis depend among others on the activity of the ECS in a given patient, the proportion of phytocannabinoids, and the doses used. Cannabinoids are used to treat symptoms in patients with cancer and chronic non-malignant diseases. Cannabinoids are usually not drugs of first choice and can be added to basic pharmacotherapy, which often improves the effectiveness of symptom treatment. Due to limited scientific evidence, experimental studies on the role of the ECS and clinical trials on the use of cannabinoids in the treatment of symptoms are recommended. In this article the role of the ECS and the use of cannabinoids in palliative care patients has been discussed.

Safety and Utility of Chloroquine/ Hydroxychloroquine in Palliative Care Patients.

The coronavirus disease 2019 (COVID-19) pandemic represents a significant healthcare challenge for the world. Many drugs have therapeutic potential. The aminoquinolones, hydroxychloroquine, and chloroquine are undergoing evaluation as a potential therapy against COVID -19. In vitro and in vivo studies suggest that these drugs affect viral adherence and modify inflammatory responses, which may provide some impact on the symptoms associated with COVID. As palliative care specialists encounter more COVID positive patients, palliative care specialists need to know how these drugs work, and importantly how they interact with palliative care drugs used for symptom control. At the same time, there is a need to reduce polypharmacy in any seriously ill patient population. The goals of this paper are to identify whether or not hydroxychloroquine/chloroquine improves symptoms in palliative care patients and whether or not these drugs are safe to use in the advanced illness population who have COVID.

Acupuncture as a Treatment Within Integrative Health for Palliative Care: A Brief Narrative Review of Evidence and Recommendations.

Background: Acupuncture is one of the fastest developing evidence bases in Complementary Medicine and is one of the leading therapies included within integrative health care. This narrative review includes two separate parts: the first is about evaluation of the current evidence status in reviews on acupuncture and the second examines and gives examples of available recommendations on acupuncture in treatment guidelines from health care experts and public health organizations recommending acupuncture as a viable treatment in patients in palliative care. Methods: Electronic searches were performed in PubMed using the terms "acupuncture" + "palliative" and adding the term "safety" to find review articles documenting safety and evidence of effectiveness of acupuncture for treatment of symptoms in palliative care patients. Treatment guidelines that recommend use of acupuncture for symptom control in palliative care were found by searching through a database currently under construction by the lead author. Results: Acupuncture shows emerging evidence for 17 indications in palliative care. Examples were found and presented of publications recommending acupuncture for treatment of symptoms for patients in palliative care from Government, public health, oncology, and medical expert sources. The most publications are in oncology, but other conditions were found and a number were found in pediatric care. Conclusions: While the evidence for use of acupuncture to treat symptoms in palliative care patients is relatively weak, the evidence base is growing. Experts worldwide are also increasingly recommending acupuncture as a treatment for symptoms in palliative care. Since acupuncture is a safe, nonpharmacological treatment but with small, clinically significant effects, these recommended uses appear as pragmatic efforts to bridge the gap of treatment options available to this patient group.

Evaluating the effects of the pharmacological and nonpharmacological interventions to manage delirium symptoms in palliative care patients: systematic review

There is a high prevalence of delirium in palliative care patients. This review aims to evaluate the effects of the pharmacological and nonpharmacological interventions used to manage delirium symptoms in this patient group. A recent study has suggested there is no role for antipsychotic medication in the management of delirium in palliative care patients, which is a move away from previous expert opinion. In addition, recent findings suggest there may be a role for the use of antipsychotics in combination with benzodiazepines in the management of agitated delirium. It is too early to abandon the use of antipsychotic medication entirely in the management of delirium, however there remains inadequate evidence to support the routine use of either pharmacological or nonpharmacological interventions for delirium treatment. Clinicians should determine the delirium subtype and severity, using this to inform the most appropriate pharmacological treatment if required. Further rigorously designed research is needed to seek clarity over whether the alleviation of symptoms is dose dependent, and to determine whether there is a severity threshold over which pharmacological interventions are most effective. Future research is required to evaluate nonpharmacological interventions in this population.

Frequency, Outcomes, and Associated Factors for Opioid-Induced Neurotoxicity in Patients with Advanced Cancer Receiving Opioids in Inpatient Palliative Care.

Context: Opioid-induced neurotoxicity (OIN) is an underdiagnosed yet distressing symptom in palliative care patients receiving opioids. However, there have been only a limited number of studies on OIN. Objectives: Our aim was to determine the frequency of and risk factors for OIN in patients receiving opioids during inpatient palliative care. Methods: We randomly selected 390 of 3014 eligible patients who had undergone palliative care consultations from January 2014 to December 2014. Delirium, drowsiness, hallucinations, myoclonus, seizures, and hyperalgesia were defined as OIN and were recorded. The other 10 common symptoms in cancer patients were assessed using the Edmonton Symptom Assessment Scale (ESAS). Patient demographics, morphine equivalent daily dose (MEDD), comorbidities, OIN management, and overall survival (OS) duration were also assessed. The associations between the incidence of OIN and MEDD, the other 10 symptoms, and OS were analyzed. Results: Fifty-seven (15%) patients had OIN. The most common symptom was delirium (n = 27). On multivariate analysis, a high MEDD (p = 0.020), high ESAS pain score (p = 0.043), drowsiness (p = 0.007), and a poor appetite (p = 0.014) were significantly associated with OIN. OIN was not significantly associated with a shorter OS duration (p = 0.80). Conclusions: OIN was seen in 15% of patients receiving opioids as part of inpatient palliative care. Although OIN was not associated with OS, routine monitoring is especially needed in cancer patients.

Neurological Symptoms in Palliative Care Patients.

Neurological expertise in palliative care may be required not only for patients with primary neurological disorders but also for patients with non-neurological diseases suffering from burdensome neurological symptoms. The aim of this study was to determine the prevalence of neurological diagnoses and symptoms in palliative care patients, as well as the related burden and impact on everyday life. We analyzed retrospectively the medical records of 255 consecutive patients from a tertiary medical center, at the time point of referral to an inpatient palliative care consultation service. In addition, 100 patients prospectively answered a questionnaire which included the assessment of neurological symptoms, as well as numeric rating scales for quality of life, symptom-specific burden, and restrictions in everyday life. Forty-one patients (16%) suffered from a primary neurological disease. Most decisions regarding the termination of life-sustaining measures concerned this group (20/22, 91%). Neurological symptoms (excluding pain) were documented in 122 patients (48%) with an underlying non-neurological disease. In the questionnaire study, 98/100 patients reported at least one neurological or neuropsychiatric symptom, most frequently sleeping problems (N = 63), difficulty concentrating (N = 55), and sensory symptoms (N = 50). Vertigo/dizziness (N = 19) had the greatest impact on everyday life (7.57/10 ± 2.17) and the highest symptom-specific burden (7.14 ± 2.51). Difficulty concentrating (restrictions in everyday life/burden) and pain intensity were the only symptoms significantly correlated with quality of life (r = -0.36, p = 0.009/r = -0.32; p = 0.04; r = -0.327, p = 0.003). Neurological diseases and symptoms are frequent among palliative care patients and are often associated with a high symptom burden, which may severely affect the patients' lives. It is thus of paramount importance to implement neurological expertise in palliative care.

In Vivo CYP3A Activity in Palliative Care Patients: Study Protocol for a Single Arm Prospective Trial.

Drug interactions are a common cause for escalation of debilitating symptoms in palliative care patients. CYP3A is the most relevant CYP enzyme in humans involved in metabolism of about half of all available pharmaceuticals. To increase knowledge about the CYP3A enzyme and the impact of drug interactions on its activity to improve dosing in palliative care patients. The prospective clinical trial uses a secure method of analyzing CYP3A activity in humans: Administration of a marker substance followed by the determination of its blood concentrations as well as the concentrations of its metabolite at certain points of time and corresponding metabolic clearance calculations. The ongoing trial is carried out at a palliative care unit under real-life clinical conditions. A four-hour pharmacokinetic profile after oral administration of the marker substance (microdose of midazolam) will be obtained from each enrolled patient. Plasma concentrations of midazolam and its primary metabolite will be quantified by mass spectrometry techniques. CYP3A activity will be calculated as partial metabolic clearance from a limited sampling area under the curve. All other drugs taken by the participating patients will be considered as well as recent blood test results and the patients' diagnoses. This is the first prospective study dealing with drug metabolism in patients on a palliative care unit. The trial is based on reliable and established methods aiming to provide improved dosing regimens and thus optimize pharmacological therapies in this specialty.

Palyatif Bakım Hastalarına Müziğin Etkisi: Türk Müziği ile Tedavinin Tarihsel Gelişimi

Music is a universal language, and is the best way of cultural interaction, communication and share feelings. Different musical melodies have different influences on mind states of individuals. Musical therapy is a special type of therapy in which verbal communication is coupled with musical interaction and communication styles. Selection of person specific and therapeutic music styles will result in the alleviation of several symptoms in patients under palliative care. Musical therapy is a significant supportive tool for the treatment of cognitive, physical, social, environmental and spiritual needs of palliative care patients of all ages. Furthermore, it prevents the disturbances caused by cancer treatment. The use of musical therapy in Turkish history has first been mentioned in Uyghur rock inscriptions. Ottoman music is a sophisticated and developed synthesis of the makam music. Ottomans would use different instrumental and vocal musical pieces to cure certain medical and psychological conditions. In more recent times however, ethnomusicology was not included in the curriculum as a teaching or means of therapy in Turkish medicine, that is why it did not become a routine treatment modality, the applications were limited to the disciplines of psychiatry, anesthesiology, intensive care, surgery and pediatric medicine as well as to the academic studies of the physicians who had an interest in this field. Despite the fact that it is a significant contributor to the control of symptoms in palliative care patients, there have not been studies emphasizing the importance of its use in such patients until recently. Together with reentry into agenda of the treatment efficacy of music in Turkey and worldwide, Ministry of Health of Turkey initiated a ''Musical Therapy Training Certificate Program'' For health professionals in 2016. In addition to this intervention, professional musicians should also have an interest in this topic and should collaborate with the physicians academically in the treatment process. This review emphasizes the need for initiating routine clinical applications, academic studies and trainings with cultural, ethnic and individualized Turkish music therapy on palliative care patients as a means of efficient palliation.

Music therapy for palliative care: A realist review.

Music therapy has experienced a rising demand as an adjunct therapy for symptom management among palliative care patients. We conducted a realist review of the literature to develop a greater understanding of how music therapy might benefit palliative care patients and the contextual mechanisms that promote or inhibit its successful implementation. We searched electronic databases (CINAHL, Embase, Medline, and PsychINFO) for literature containing information on music therapy for palliative care. In keeping with the realist approach, we examined all relevant literature to develop theories that could explain how music therapy works. A total of 51 articles were included in the review. Music therapy was found to have a therapeutic effect on the physical, psychological, emotional, and spiritual suffering of palliative care patients. We also identified program mechanisms that help explain music therapy's therapeutic effects, along with facilitating contexts for implementation. Music therapy may be an effective nonpharmacological approach to managing distressing symptoms in palliative care patients. The findings also suggest that group music therapy may be a cost-efficient and effective way to support staff caring for palliative care patients. We encourage others to continue developing the evidence base in order to expand our understanding of how music therapy works, with the aim of informing and improving the provision of music therapy for palliative care patients.

Identifying Factors That Predict Worse Constipation Symptoms in Palliative Care Patients: A Secondary Analysis.

The aim of this work was to investigate whether variables identified as likely to impact the experience of constipation in other clinical settings similarly affected the experiences of constipated palliative care patients. The majority of palliative care patients with cancer are likely to be bothered by constipation symptoms at some point in their disease trajectory. Despite this, it remains unclear as to which factors predict more severe problems. This study was conducted in a sample of 94 constipated palliative care patients who were asked to voluntarily complete a series of questions regarding their demographic and other characteristics, including whether they had chronic constipation symptoms, that is, constipation symptoms for 12 months. Other variables included age, body mass index, sex, performance status, and regular opioids and their doses. At the same time, they were asked to complete the Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. Descriptive statistics summarized baseline data. Unadjusted associations between the selected variables on PAC-SYM were examined by using bi-variate analyses. Significant variables identified on bi-variate analyses were included in a multivariate analysis. The final results identified that only the chronicity of constipation symptoms predicted more severe symptoms. This relationship persisted when this single variable was retained in the final model, illustrating that PAC-SYM scores are 0.41 higher in patients with chronic constipation compared with those without it (p = 0.02). In contrast, regular opioid use was not identified as a significant factor (p = 0.56). This study suggests that the factor most likely to predict worse constipation symptoms was the duration that people had experienced problems. Further, those who perceived their constipation symptoms to be more severe had a poorer quality of life. More work is required to better define constipation risk factors and ways to best modify a patient's experiences.

Drug Treatments for Pruritus in Adult Palliative Care

Pruritus is a rare but troublesome symptom in palliative-care patients with a variety of underlying diseases. The pharmacotherapy of pruritus is often off-label, and an evidence-based evaluation is needed. A Cochrane Review published in 2013 was updated with a systematic literature search up to January 2014. Randomized and controlled trials (RCTs) with adult palliative-care patients were included. In the 43 RCTs that were analyzed, three of which were more recent than the Cochrane Review, 8 clinically relevant active substances were investigated in a total of 19 RCTs. Effective drugs for pruritus in palliative-care patients included paroxetine for pruritus of diverse origins (1 RCT; strong effect) and indomethacin for HIV-induced prutitus (1 RCT; median effect = moderate reduction). Effective drugs for pruritus in uremia were gabapentin (2 RCTs; strong effect), nalfurafin (3 RCTs; moderate effect), naltrexone (3 RCTs; heterogeneous effects, ranging from weak to strong), and cromoglicic acid (2 RCTs; moderate to strong effect). Effective drugs for cholestatic pruritus were rifampicin (3 RCTs; moderate effect), flumecinol (2 RCTs; weak to moderate effect), and naltrexone (2 RCTs; moderate to strong effect). Undesired effects were most common with naltrexone (dizziness: 0% -50% , nausea: 0% -50% ) and nalfurafin (nasopharyngitis: 8% -12% , insomnia: 7% -15%). In view of the diverse etiologies of pruritus in palliative-care patients, careful consideration should be given to the choice of drug used to treat it. The substances listed here have moderate to strong antipruritic effects and merit further study in RCTs of high methodological quality.

Self-report measurement of pain &amp; symptoms in palliative care patients: a comparison of verbal, visual and hand scoring methods in Sub-Saharan Africa

BackgroundDespite a high incidence of life-limiting disease, there is a deficit of palliative care outcome evidence in sub-Saharan Africa. Providers of end of life care call for appropriate measurement tools. The objective is to compare four approaches to self-report pain and symptom measurement among African palliative care patients completing the African Palliative Care Association African Palliative Outcome Scale (APCA African POS).MethodsPatients were recruited from five services (4 in South Africa and 1 in Uganda). Research nurses cross-sectionally administered POS pain and symptom items in local languages. Both questions were scored from 0 to 5 using 4 methods: verbal rating, demonstrating the score using the hand (H), selecting a face on a visual scale (F), and indicating a point on the Jerrycan visual scale (J). H, F and J scores were correlated with verbal scores as reference using Spearman’s rank and weighted Kappa. A Receiver Operating Characteristic (ROC) analysis was performed.Results315 patients participated (mean age 43.5 years, 69.8% female), 71.1% were HIV positive and 35.6% had cancer, 49.2% lived in rural areas. Spearman’s rank correlations for pain scores were: H: 0.879, F: 0.823, J: 0.728 (all p < 0.001); for symptoms H: 0.876, F: 0.808, J: 0.721 (all p < 0.001). Weighted Kappa for pain was H: 0.798, F: 0.719 J: 0.548 and for symptoms: H: 0.818, F: 0.718, J: 0.571. There was lower agreement between verbal and both hand and face scoring methods in the Ugandan sample. Compared to the verbal scale the accuracy of predicting high pain/symptoms was H > F > J (0.96–0.89) in ROC analysis.ConclusionsHands and faces scoring methods correlate highly with verbal scoring. The Jerrycan method had only moderate weighted Kappa. POS scores can be reliably measured using hand or face score.

Constipation in palliative care: treatment options and considerations for individual patient management

Constipation is an all too common symptom in palliative care patients and may be associated with a range of severe issues and experiences. Its effects on patients contribute to both physical and psychological scarring during a very distressing stage of life not only for the patient but also for their caregivers. It is during this time that, too often, the complexity of managing the condition moves the locus of control away from the patient toward the health professionals. This article considers a number of different treatment options and facets of individual management that may enable patients to move the locus of control back to a position of joint management by patients, caregivers, and health professionals.

End-of-life hospital referrals by out-of-hours general practitioners: a retrospective chart study

BackgroundMany patients are transferred from home to hospital during the final phase of life and the majority die in hospital. The aim of the study is to explore hospital referrals of palliative care patients for whom an out-of-hours general practitioner was called.MethodsA retrospective descriptive chart study was conducted covering a one-year period (1/Nov/2005 to 1/Nov/2006) in all eight out-of-hours GP co-operatives in the Amsterdam region (Netherlands). All symptoms, sociodemographic and medical characteristics were recorded in 529 charts for palliative care patients. Multivariate logistic regression analysis was performed to identify the variables associated with hospital referrals at the end of life.ResultsIn all, 13% of all palliative care patients for whom an out-of-hours general practitioner was called were referred to hospital. Palliative care patients with cancer (OR 5,1), cardiovascular problems (OR 8,3), digestive problems (OR 2,5) and endocrine, metabolic and nutritional (EMN) problems (OR 2,5) had a significantly higher chance of being referred. Patients receiving professional nursing care (OR 0,2) and patients for whom their own general practitioner had transferred information to the out-of-hours cooperative (OR 0,4) had a significantly lower chance of hospital referral. The most frequent reasons for hospital referral, as noted by the out-of-hours general practitioner, were digestive (30%), EMN (19%) and respiratory (17%) problems.ConclusionWhilst acknowledging that an out-of-hours hospital referral can be the most desirable option in some situations, this study provides suggestions for avoiding undesirable hospital referrals by out-of-hours general practitioners at the end of life. These include anticipating digestive, EMN, respiratory and cardiovascular symptoms in palliative care patients.

Constipation management in palliative care: treatments and the potential of independent nurse prescribing

Constipation is a common symptom in palliative care patients that can generate considerable suffering owing to both the inherent physical discomfort and the attendant psychological issues such as embarrassment. This article considers the management of constipation for palliative care patients, including the importance of the patient's own definition of their problem, the need for thorough and frequent assessment, established treatment options, and the challenges that nurses may face. It provides a simple algorithm to assist in the management process, and also looks at the current strength of the evidence base for two more recent therapies. Finally, it examines the potential of the independent nurse prescriber (INP) for constipation management in the UK, using a brief case study to illustrate a commonly experienced constipation management scenario for the INP in the community setting.

Reversible delirium in an advanced cancer patient

Delirium is still one of the most common and distressing symptoms in palliative care patients. Causes and pathophysiology of this neuropsychiatric dysfunction are multifactorial. Recent studies indicate that the interaction of special triggers facilitates development of delirium. Some of them are reversible. This case report presents a reversible delirium in an advanced cancer patient and offers a list of possible delirogen medications. This list might be useful to prevent delirium, particularly in older people.

The Art and Science of Palliative Nursing

As noted by the editors of this comprehensive textbook, this edition “comes at a time when palliative nursing has truly come of age” (p. ix). This textbook, which now carries the official designation of the Oxford University Press, is the definitive treatise on palliative nursing. The textbook contains a total of 78 chapters that are written by teams of interdisciplinary experts, which exemplifies the collaboration that is needed to achieve both compassionate and competent palliative care. The scope and breadth of the content of the chapters are far reaching and highly relevant to all aspects of pain and symptom management for palliative care patients. Part I provides an excellent introduction to the general principles of palliative nursing. Part II, which appropriately so, is one of the largest portions of the textbook, focuses on the assessment and management of symptoms in palliative care patients. Part III focuses on psychosocial support of patients and family caregivers. Part IV provides information on spiritual care. The fifth section of the textbook discusses the palliative care needs of special patient populations, including the poor, homeless and underserved, as well as elderly patients and patients with substance abuse disorders. Additional sections of the textbook are devoted to end-of-life issues across settings, pediatric palliative care, special issues for the nurse in end-of-life care, and international models of palliative care. The final chapter is entitled “A Good Death,” which is the ultimate goal that all palliative care nurses strive to ensure for all patients. One of the most attractive features of this textbook is its “user-friendly” format. Each chapter contains a set of key points that summarize the major conclusions in each chapter. Each chapter contains the perfect balance of science and art. The theoretical and scientific underpinnings of each chapter are clearly articulated. These provide the foundation on which is built the assessment and management principles that can be integrated into routine care of palliative care patients. Each chapter is filled with tables and figures that enhance the content of the chapter. This textbook is designed to provide clinicians and educators with the information that they need to provide care to patients across the continuum of palliative care. The writing style is clear and concise. In my opinion, this textbook should be on the bookshelf of every palliative care clinician. Christine Miaskowski, RN, PhD, FAAN, is Professor and Associate Dean for Academic Affairs, American Cancer Society Clinical Research Professor, and Sharon A. Lamb Endowed Chair in Symptom Management Research, University of California, San Francisco, CA, USA.