Abstract
Fisch MJ, Lee JW, Weiss M, et al.: Prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer. J Clin Oncol 2012;30:1980–1988.
Pain is prevalent among patients with cancer, yet pain management patterns in outpatient oncology are poorly understood and frequently, poorly managed. In this prospective study, a total of 3123 ambulatory patients with invasive cancer of the breast, prostate, colon/rectum, or lung were enrolled, regardless of phase of care or stage of disease. At initial assessment and four to five weeks later, patients completed a 25-item measure of pain, functional interference, and other symptoms. Providers recorded analgesic prescribing, and a pain management index was calculated to assess treatment adequacy. Results demonstrated that of the 3023 patients identified to be at risk for pain, 2026 (67%) reported having pain or requiring analgesics at initial assessment; of these 2026 patients, 670 (33%) were receiving inadequate analgesic prescribing. The authors found no difference in treatment adequacy between the initial and follow-up visits. Multivariable analysis revealed that the odds of a non-Hispanic white patient having inadequate pain treatment were approximately half those of a minority patient after adjusting for other explanatory variables (odds ratio 0.51; 95% CI, 0.37 to 0.70; P=.002). Other significant predictors of inadequate pain treatment were having a good performance status, being treated at a minority treatment site, and having non-advanced disease without concurrent treatment. The authors conclude that most outpatients with common solid tumors must confront issues related to pain and the use of analgesics. There is significant disparity in pain treatment adequacy, with the odds of undertreatment twice as high for minority patients, with findings persisting for over one month of follow-up.
Beckman HB, Wendland M, Mooney C, et al.: The impact of a program in mindful communication on primary care physicians. Acad Med 2012;87:815–819.
In addition to structural transformations, deeper changes are needed to enhance physicians' sense of meaning and satisfaction with their work and their ability to respond creatively to a dynamically changing practice environment. In this study, the authors attempted to understand what aspects of a successful continuing education program in mindful communication contributed to physicians' well-being and the care they provide. In 2008 the authors conducted in-depth, semistructured interviews with primary care physicians who had recently completed a 52-hour mindful communication program demonstrated to reduce psychological distress and burnout while improving empathy. Interviews with a random sample of 20 of the 46 physicians in the Rochester, New York, area who attended at least four of eight weekly sessions and four of eight monthly sessions were audiorecorded, transcribed, and analyzed qualitatively. The authors identified salient themes from the interviews. Results demonstrated that participants reported three main themes: (1) sharing personal experiences from medical practice with colleagues reduced professional isolation, (2) mindfulness skills improved the participants' ability to be attentive and listen deeply to patients' concerns, respond to patients more effectively, and develop adaptive reserve, and (3) developing greater self-awareness was positive and transformative, yet participants struggled to give themselves permission to attend to their own personal growth. The authors conclude that interventions to improve the quality of primary care practice and practitioner well-being should promote a sense of community, specific mindfulness skills, and permission and time devoted to personal growth.
Creutzfeldt CJ, Holloway RG, Walker M: Symptomatic and palliative care for stroke survivors. J Gen Intern Med 2012;27(7):853–860.
Stroke is the leading cause of disability and one of the most common causes of death worldwide. With more than 4,500,000 stroke survivors alive in the United States today, 15% to 30% are permanently disabled and 20% require institutional care at three months after stroke onset. Outside the setting of acute management, secondary prevention, and stroke rehabilitation, little has been written to address the ongoing symptomatic and palliative needs of these patients and their families. In this literature review the authors look beyond secondary prevention with the aim of providing evidence-informed management guidelines for the myriad and often underrecognized symptomatic and palliative care needs of stroke survivors. Some of the most common and disabling poststroke symptoms that are reviewed include central poststroke pain, hemiplegic shoulder pain, painful spasticity, fatigue, incontinence, poststroke seizures, sexual dysfunction, sleep-disordered breathing, depression, and emotionalism. The authors reviewed the role of caregivers and explore ways to support them and, lastly, remind clinicians to be perceptive to the patient's spiritual needs. They found the literature is most robust, including controlled trials, for central poststroke pain and depression. Synthesis and discussion outside these areas are frequently limited to smaller studies, case reports, and expert opinion. While some data exists to guide informed decision making, there is an urgent need to document best practice and identify appropriate clinical standards for the full spectrum of symptoms experienced by stroke survivors. The authors present the current and established data to aid health care providers in symptomatic and palliative management of stroke survivors.
Ahluwalia SC, Levin JR, Lorenz KA, Gordon HS: Missed opportunities for advance care planning communication during outpatient clinic visits. J Gen Intern Med 2011;27:445–451.
Early provider–patient communication about future care is critical for patients with heart failure (HF); however, advance care planning (ACP) discussions are often avoided or occur too late to usefully inform care over the course of the disease. In this qualitative study of audiorecorded outpatient clinic visits, the authors attempted to identify opportunities for physicians to engage in ACP discussions and to characterize physicians' responses to these opportunities. Fifty-two patients ≥65 years recently hospitalized for HF with one or more postdischarge follow-up outpatient visits, and their physicians (n=44), at two Veterans Affairs Medical Centers were selected for the study. Using content analysis methods, the authors analyzed and coded transcripts of outpatient follow-up visits for (1) patient statements pertaining to their future health or their future physical, psychosocial, and spiritual/existential care needs, and (2) subsequent physician responses to patient statements, using an iterative consensus-based coding process. Results demonstrated that in 13 of 71 consultations patients expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians responded by terminating the conversation, hedging their responses, denying the patient's expressed emotion, or inadequately acknowledging the sentiment underlying the patient's statement. The authors conclude that physicians often missed the opportunity to engage in ACP despite openers patients provided that could have prompted such discussions. Communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses, in order to successfully leverage opportunities to engage in ACP discussions.
Newton PJ, Davidson P, Sanderson C, and the Improving Palliative Care through Clinical Trials group: An online survey of Australian physicians reported practice with the off-label use of nebulised frusemide. BMC Palliative Care 2012;11:6.
Off-label prescribing is common in palliative care, with many medications used for treatment of symptoms. Despite inconsistent reports of the benefit of nebulised frusemide for breathlessness, its use continues to be reported. In this study, an online survey was emailed to 249 members of the Australian and New Zealand Society of Palliative Medicine to estimate the use of nebulised frusemide for breathlessness by Australian physicians involved in palliative care in the previous 12 months. Results demonstrated that there were 52/249 (21%) respondents to the survey. The majority (44/52; 85%) had not prescribed nebulised frusemide in the previous 12 months. The most common (18/44; 43%) reason for not prescribing nebulised frusemide was a belief that there was not enough evidence to support its use. While only a few respondents (8/52; 15%) reported having used nebulised frusemide, all that had used it thought there was at least some benefit in relieving breathlessness. The authors conclude that their report adds to the series of case studies reporting some benefit from nebulised frusemide in relieving breathlessness.
Perkins HS, Cortez JD, Hazuda HP: Diversity of patients' beliefs about the soul after death and their importance in end-of-life care. South Med J 2012;105:266–272.
Because beliefs about the soul after death affect the dying experience, patients and survivors may want to discuss those beliefs with their health care provider; however, almost no medical research describes such beliefs, leaving health care professionals ill prepared to respond. In this exploratory study, the authors begin the descriptive process. Older adult Mexican American (MA), European American (EA), and African American (AA) inpatients were asked their beliefs about whether the soul lives on after physical death; if so, where; and what the ‘‘afterlife’’ is like. Results demonstrated some beliefs varied little across the sample. For example, most participants said that the soul lives on after physical death, leaves the body immediately at death, and eventually reaches heaven. Many participants also said death ends physical suffering; however, other beliefs varied distinctly by ethnic group or sex. More AAs than MAs or EAs said that they believed that the soul after physical death exists in the world (57% versus 35% and 33%) or interacts with the living (43% versus 31% and 28%). Furthermore, in every ethnic group, more women than men said they believed that the soul exists in the world (42% versus 29% for MAs, 45% versus 14% for EAs, and 71% versus 43% for AAs). The authors conclude that as death nears, patients or survivors may want to discuss beliefs about the soul after death with their health care provider. This preliminary study characterizes some of those beliefs. By suggesting questions to ask and responses to give, the study provides health care professionals a supportive, knowledgeable way to participate in such discussions.