Abstract
Moksanes K, Dale O, Rosland JH, et al: How to switch from morphine or oxycodone to methadone in cancer patients? A randomised clinical phase II trial. Eur J Cancer (published online ahead of print publication)
Rotating opioids is utilized in cancer patients with unacceptable pain and/or adverse effects (AEs). In this prospective, open, parallel-group, multicenter study, the authors investigated whether patients switched to methadone by the stop-and-go (SAG) strategy have lower pain intensity (PI) than patients switched over 3 days (3DS), and whether the SAG strategy is as safe as the 3DS strategy. Forty-two patients were enrolled, with 21 patients randomized to each group. The methadone dose was calculated using a dose-dependent ratio. PI, AEs and serious adverse events (SAEs) were recorded daily for 14 days. Primary outcome was average PI day 3, and secondary outcomes were PI now and AEs day 3 and 14 and number of SAEs. Results demonstrated that the mean pre-switch morphine doses were 900 mg/d in SAG and 1330 mg/d in 3DS. No differences between groups were found in mean average PI day 3 (mean difference 0.5 [confidence interval {CI} −1.2–2.2); SAG 4.1 (CI 2.3–5.9), and 3DS 3.6 (CI 2.9–4.3) or in PI now. The SAG group had more dropouts and three SAEs (two deaths and one severe sedation). No SAEs were observed in the 3DS group. The authors conclude that the SAG patients reported a trend of more pain, had significantly more dropouts and three SAEs, which indicate that the SAG strategy should not replace the 3DS when switching from high doses of morphine or oxycodone to methadone.
Billings JA, Krakauer EL: On patient autonomy and physician responsibility in end-of-life care. Arch Intern Med 2011;171:849–853.
In current medical practice, excessive or reflexive deference to an unreflective concept of patient autonomy may unintentionally compromise patient autonomy by placing unwanted and unreasonable responsibility for technical medical decisions on patients or their surrogate decision makers rather than on their physicians. Such practices can harm patients by depriving them of the expert, professional advice they both need and deserve to make important decisions about their health care. In this article, the authors describe how the patient–physician relationship has evolved in recent decades as more life-sustaining and life-saving treatments such as cardiopulmonary resuscitation have become available. They then examine respect for patient autonomy and describe how patient autonomy can be promoted while the physician's responsibility for technical medical decisions is simultaneously affirmed. The patient is the expert on his or her values, goals, and preferences, while the physician is the expert on the medical means for honoring the patient's perspective. The authors conclude that an intervention, such as cardiopulmonary resuscitation, should not be offered when, based on the patient's own criteria, it promises no physical or psychosocial benefit or would be far more harmful than beneficial.
Back AL, Trinidad SB, Hopley EK, et al: What patients value when oncologists give news of cancer recurrence: commentary on specific moments in audio-recorded conversations. Oncologist 2011;16:342–350.
Communicating bad or serious news is difficult for many clinicians, with recommendation for communicating such news on limited evidence. In this study, the authors attempted to understand patient perspectives on what patient's value when oncologists communicate news of cancer recurrence. Participants were 23 patients treated for a gastrointestinal cancer at a tertiary U.S. cancer center within the past 2 years, who had semistructured qualitative interviews in which they listened to audio recordings of an oncology fellow discussing news of cancer recurrence with a standardized patient. Participants paused the audio recording to comment on what they liked or disliked about the oncologist's communication. Results identified three themes that refine existing approaches to discussing serious news. The first theme, recognition, described how the oncologist responded to the gravity of the news of cancer recurrence for the patient. Participants saw the need for recognition throughout the encounter and not just after the news was given. The second theme, guiding, describes what participants wanted after hearing the news, which was for the oncologist to draw on her biomedical expertise to frame the news and plan next steps. The third theme, responsiveness, referred to the oncologist's ability to sense the need for recognition or guidance and to move fluidly between them. The authors conclude that this study suggests that oncologists giving news of cancer recurrence could think of the communication as going back and forth between recognition and guidance and could ask themselves: “Have I demonstrated that I recognize the patient's experience hearing the news?” and “Have I provided guidance to the next steps?”
Caraceni A, Pigni A, Brunelli C: Is oral morphine still the first choice opioid for moderate to severe cancer pain? A systematic review within the European Palliative Care Research Collaborative guidelines project. Palliat Med 2011;25:402–409.
The authors' purpose of this systematic review was to evaluate the evidence that oral morphine can be recommended as the first choice opioid in the treatment of moderate to severe cancer pain in updating the European Association for Palliative Care opioid recommendations. A systematic literature review was performed to update the 2007 Cochrane review “Oral morphine for cancer pain.” The literature search was conducted on MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases. The search strategy, limited in time (from July 1, 2006 to October 31, 2009), was aimed to be as extensive as possible using both text words and MeSH/EMTREE terms; a hand search of the reference lists of identified articles was also performed. Randomized clinical trials, containing data on efficacy and/or side effects of morphine, were identified. Among the papers retrieved from the cited databases and the Cochrane review, 17 eligible studies, for a total of 2053 patients, and a meta-analysis were selected. These studies did not add significant information to the previous Cochrane review confirming the limitation of efficacy and tolerability data on opioid-naïve and non-selected populations of cancer patients treated with morphine and suggesting that oral morphine, oxycodone, and hydromorphone have similar efficacy and toxicity in this patient population.
Campos MP, Hassan BJ, Reichelmann R, Del Giglio A: Cancer-related fatigue: A practical review. Ann Oncol 2011;22:1272–1279.
Fatigue is an exceedingly common yet often treatable problem in cancer patients that profoundly affects all aspects of quality of life, with prevalence estimates suggesting 50% to 90% of cancer patients are affected. After addressing reversible or treatable contributing factors, such as hypothyroidism, anemia, sleep disturbance, pain, emotional distress, climacterium, medication adverse events, metabolic disturbances, or organ dysfunction such as heart failure, myopathy, and pulmonary fibrosis, patients may be screened with a brief fatigue self-assessment tool. In fact, the authors recommend that all cancer patients should be screened regularly for fatigue. Those with moderate or severe fatigue may benefit from both pharmacologic and nonpharmacologic interventions, while mild fatigue that does not interfere with quality of life can be treated with nonpharmacologic measures alone. Physicians often have insufficient knowledge about fatigue and its treatments or underestimate the impact of fatigue on quality of life, while patients may consider it an unavoidable and untreatable side-effect and fear that reporting it may incite a change toward less aggressive cancer treatment. A practical review may therefore be useful to health care professionals in order to avoid the common barriers to its treatment that exist on the sides of both physicians and patients.
Bailey C, Murphy R, Porock D: Trajectories of end-of-life care in the emergency department. Ann Emerg Med 2011;57:362–369.
The emergency department is the gateway to the hospital setting and far-too-often a primary care setting for many underserved patients. Despite the intentions from the end-of-life care strategy in the United Kingdom to improve care provision, the emergency department has increasingly become the access site for end-of-life support. Little attention has been given to this aspect of the work of the emergency department, even as the quality of end-of-life care in hospitals has become the subject of increasing concerns. In this study, the authors explored end-of-life care in the emergency department and provided an understanding of how care is delivered to the dying, deceased, and bereaved in the emergency setting. Observation was carried out in a large urban emergency department during a 12-month period. Observation was complemented by detailed interviews with emergency department staff, patients diagnosed with a terminal condition who had visited the emergency department in the previous 6 months, and their family members. Data were analyzed thematically, following the normal conventions of ethnographic research. Results demonstrated two distinct trajectories of end-of-life care in the emergency department; the spectacular and the subtacular. Patients and family members experiencing end-of-life care in the emergency department have distinctly different care because of the nature of these two trajectories, frequently resulting in dissatisfaction for staff and distress and frustration for patients and their relatives. The authors conclude that the emergency department is priority driven, and focused on resuscitation and the prolongation of life. As a result of the consuming nature of the spectacular death, a reluctance to build relationships with the dying, and a lack of educational support, the care needs of patients in the subtacular trajectory are somewhat neglected. These trajectories can be used to identify the shortfalls in end-of-life care in the emergency department and raise serious concerns for policy in regard to staffing, resources, and professional development.