American Journal of Hospice and Palliative Medicine®

We examined determinants of symptom severity and response to treatment among 150 patients with cancer participating in a phase II trial of a palliative care team intervention. Patients completed a modified Edmonton Symptom Assessment Scale (ESAS) at baseline and 1 week. Women had a worse baseline ESAS Distress Score (EDS; P = .003) and Total Distress Score (TDS; P = .005); differences were particularly marked for anxiety and appetite. Performance status was inversely associated with EDS, TDS, well-being, appetite, and fatigue (Kruskal-Wallis, all P < .005). Multivariate analysis of covariance (ANCOVA) showed that symptom improvement was independently predicted by worse baseline EDS score and female gender. Performance status, gender, and baseline symptom severity should be accounted for in trials of palliative care interventions; inclusion criteria based on symptom severity should also be considered.

Aim: We report the characteristics of intermittent cancer pain. In addition, we propose a new clinically based classification. Methods: Consecutive patients with cancer referred to our palliative medicine service were consented and underwent a comprehensive pain evaluation including available laboratory and radiological studies, at the time of initial contact. Results and discussion: In total, 100 consecutive patients reported 158 different pain sites. Pain temporal pattern observed was 60% of patients had continuous (CP) plus intermittent pain (IP); 29% IP alone; and 11% CP alone. The etiology of IP was somatic (58%), visceral (24%), neuropathic (7%), and mixed (11%). Median duration of IP was 4 months with a median daily frequency of 4 episodes. Consequently, we propose that IP be classified into IP alone or nonbreakthrough pain (NBP; because there is no underlying CP or around-the-clock [ATC] opioids used) and breakthrough pain (BP; because there is underlying CP or/and ATC opioids used). We propose that both BP and NBP be each subclassified into 3 categories: (1) incident, (2) non-incident, and (3) mixed. In addition, a 4th category exclusive to BP: end-of-dose failure. Incident pains made up (N = 42, 47%) nearly half of all IP. According to our classification, incident pain was part of BP in 41% (N = 25) or NBP in 58% (N = 17). Incident NBP received less treatment than incident BP, and it was less controlled. Conclusion: (1) Intermittent pain is a major problem in patients with cancer, (2) NBP is a common but under-recognized form of cancer pain, (3) NBP is less defined and controlled than BP, (4) incident NBP accounts for 40% of all incident cancer pain, and (5) variable IP definitions and classifications make comparisons between studies difficult.

This article attempts to find a correlation between certain disease types and increased needs for bereavement services for survivors. Data were examined from those requesting increased bereavement services from a hospice provider in Kentucky, over a 2-year span. The survivors were then matched with the disease type of their loved one to see whether there was a connection between the two. Although limited in its scope and focus, the study revealed that patients surviving Alzheimer disease, lung cancer, and renal failure consistently (at least 50% of the time) required increased bereavement services after the death of their loved one. Other disease types indicated more erratic patterns for increased grief services.

A total of 22 family members, whose deceased loved ones had used the services of a hospice palliative care volunteer, responded to a brief survey designed to assess the importance of the different kinds of support offered to them (family members) by the volunteer, their impressions of the volunteers’ personal qualities/characteristics, their general experiences with the volunteer, and their overall satisfaction with the volunteer services. The kind of support that received the highest importance rating from family members was the opportunity to take a much-needed break from the demands of caring for their loved one, closely followed by emotional support, the volunteer spending time with them, and the volunteer providing them with information. Family members rated volunteers highly on a list of qualities/characteristics that exemplify individuals who are effective in this role. In all, 85% of the family members felt that their volunteer was well trained and 95% did not feel that their or their loved one’s privacy had been invaded by having a volunteer. Overall, family members were very satisfied with the volunteer support they received. Some limitations of the study are discussed.

After decades of disuse because of its teratogenic effects, thalidomide has had a resurgence of use as a promising therapeutic agent for multiple myeloma. Its mechanism of action involves activation of the immune system, antiangiogenic effects, and inhibition of cytokines. Thalidomide does not interact with the cytochrome oxidase system. It is not significantly metabolized, but it does undergo nonenzymatic hydrolysis in plasma. The resulting products are inactive. Despite the potential adverse effects of peripheral neuropathy, constipation, deep vein thrombosis, somnolence, rash, and orthostatic hypotension, thalidomide is an effective first-line agent for multiple myeloma in combination with dexamethasone or melphalan and prednisone. It has also been studied in the palliative care of patients with cytokine-based syndromes such as anorexia-cachexia syndrome. This review describes its use in oncology, hematology, and palliative care.

Published literature have not discerned end-of-life palliative versus life-shortening effects of pharmacologically maintaining continuous deep sedation until death (ie, dying in deep sleep) compared with common sedation practices relieving distress in the final conscious phase of dying. Continuous deep sedation predictably suppresses brainstem vital centers and shortens life. Continuous deep sedation remains controversial as palliation for existential suffering and in elective death requests by discontinuation of chronic ventilation or circulatory support with mechanical devices. Continuous deep sedation contravenes the double-effect principle because: (1) it induces permanent coma (intent of action) for the contingency relief of suffering and for social isolation (desired outcomes) and (2) because of its predictable and proportional life-shortening effect. Continuous deep sedation should be distinguished from common sedation practices for palliation and characterized instead as physician-assisted death.

The authors present a case report of an adult patient with sickle cell disease (SCD), who required frequent hospitalizations for sickle cell vaso-occlusive painful crisis as well as management of complications that resulted from treatment. The patient demonstrated clinical improvement after initiating palliative exchange transfusions of packed red blood cells (PRBCs) once every 4 weeks. They also promptly addressed their physical and psychosocial issues of care. The author described that because the patient was started on chronic exchange transfusions, there was a significant decrease in hospitalizations and emergency department (ED) visits. They saw a major improvement in the quality of life of this patient. The review of medical literature did not reveal any clear-cut guidelines for palliative chronic exchange transfusion for painful vaso-occlusive crisis in adult patients. This case review highlights the usefulness of this palliative model of care. The burden and benefits of chronic exchange transfusion always need to be weighed carefully.

Nausea and vomiting are relatively common in advanced cancer and is dreaded more than pain by patients. The history, pattern of nausea and vomiting, associated symptoms, and physical examination provides clues as to etiology and may guide therapy. Continuous severe nausea unrelieved by vomiting is usually caused by medications or metabolic abnormalities, while nausea relieved by vomiting or induced by eating is usually due to gastroparesis, gastric outlet obstruction, or small bowel obstruction. Drug choices are empiric or based on etiology. Metoclopramide has the greatest evidence for efficacy followed by phenothiazines and tropisetron. Corticosteroids have not been effective in randomized trials except in the case of bowel obstruction. Treatment of nausea unresponsive to first-line medications involves rotation to medications which bind to multiple receptors (broad-spectrum antiemetics), the addition of another antiemetic to a narrow-spectrum antiemetic (a serotonin receptor antagonist such as tropisetron to a phenothiazine), rotation to a different class of antiemetic (tropisetron for a phenothiazine), or in-class drug rotation. Venting gastrostomy, octreotide, and corticosteroids will reduce nausea and vomiting associated with malignant bowel obstruction.