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Background: A universal consensus regarding standardized pain outcomes does not exist. The personalized pain goal has been suggested as a clinically relevant outcome measure. Aim: To assess the feasibility of obtaining a personalized pain goal and to compare a clinically based personalized pain goal definition versus a research-based study definition for stable pain. Design: Prospective longitudinal descriptive study. Measures: The attending physician completed routine assessments, including a personalized pain goal and the Edmonton Classification System for Cancer Pain, and followed patients daily until stable pain control, death, or discharge. Stable pain for cognitively intact patients was defined as pain intensity less than or equal to desired pain intensity goal (personalized pain goal definition) or pain intensity ⩽3 (Edmonton Classification System for Cancer Pain study definition) for three consecutive days with Setting/participants: A total of 300 consecutive advanced cancer patients were recruited from two acute care hospitals and a tertiary palliative care unit. Results: In all, 231/300 patients (77%) had a pain syndrome; 169/231 (73%) provided a personalized pain goal, with 113/169 (67%) reporting a personalized pain goal ⩽3 (median = 3, range = 0–10). Using the personalized pain goal definition as the gold standard, sensitivity and specificity of the Edmonton Classification System for Cancer Pain definition were 71.3% and 98.5%, respectively. For mild (0–3), moderate (4–6), and severe (7–10) pain, the highest sensitivity was for moderate pain (90.5%), with high specificity across all three categories (95%–100%). Conclusion: The personalized pain goal is a feasible outcome measure for cognitively intact patients. The Edmonton Classification System for Cancer Pain definition closely resembles patient-reported personalized pain goals for stable pain and would be appropriate for research purposes. For clinical pain management, it would be important to include the personalized pain goal as standard practice.

Background: Ascites secondary to cancer has a dramatic effect on all aspects of patients’ lives. Healthcare professional surveys have shown that there is considerable variation in the management of ascites. Aim: To explore patients’ experiences of living with ascites and its management. Design: Qualitative research study using digitally recorded semi-structured interviews. Setting/participants: Twelve adult patients with ascites who, between them, had undergone 47 paracentesis procedures in hospitals and/or specialist palliative care units in Southern England. Results: Symptoms were pain, discomfort and effects on appetite, digestion, breathing and mobility. All participants had experienced paracentesis in hospital or a specialist palliative care unit, and these experiences differed. They had views on what constituted a good procedure: setting, competence and pain control. They reported rapid improvement of symptoms after paracentesis. While some did not like the idea of a semi-permanent drain, those with them appreciated the convenience and not having to wait for repeated admissions or the recurrence of symptoms. The interval between ascitic taps was seen as a useful guide as to when a semi-permanent drain should be offered. Participants had mixed views on participation in a hypothetical randomised controlled trial of repeated ascitic taps versus semi-permanent drains. Conclusion: Patients’ experiences of ascites management are variable and could be improved. These experiences can inform healthcare professionals. They have views on when semi-permanent drains should be offered and future research.

Background: Different opioids for use in the control of moderate to severe cancer pain have become widely available. More recently, sophisticated formulations such as transdermal patches have been developed. One example, transdermal fentanyl (TF), has characteristic pharmacokinetics and along with the other opioids, equivalency conversions are often made when changing from or to other opioids. Aim of study: To explore the knowledge of general practitioners (GPs), hospital consultants and oncologists about the pharmacology and use of TF in the management of moderate/severe cancer pain. Method: During 2001 and 2002 a questionnaire survey was carried out. A randomized selection of GPs, hospital consultants and oncologists (n-1167) from the UK and Ireland were sent a questionnaire and 576 (49%) were returned and evaluated. Results: The results show doctors who had previously prescribed TF are more confident and knowledgeable about the indications and pharmacology of TF than doctors who had never prescribed TF. Overall knowledge and confidence in using TF was poor.

Introduction: The effective management of pain requires a multidisciplinary approach. Previous studies have suggested that around 8% of cancer patients will require interventional techniques from an anaesthetist with special interest in pain management to maximize pain control, although this percentage may increase in the cohort of patients with difficult pain syndromes under the care of specialist palliative care services. We wished to determine the experiences and views of other palliative care physicians with regard to input from specialists in pain management. Method: A postal questionnaire was sent to the consultant members of the Association of Palliative Medicine. Results: Most respondents had access to ‘as-required’ anaesthetist consultations with 72% of respondents feeling that the frequency of consultation was adequate. However, over half of the respondents had used the services of a pain management specialist less than four times in the past year and a quarter of respondents had not been involved in a joint consultation with an anaesthetist in the past year. All respondents felt that the pain management specialist's role included advice on technical procedures but less than 25% felt that their role should extend to advice on prescribing analgesics. Discussion: There are likely to be several reasons for this apparent underutilization of specialist anaesthetist/pain management services. This survey has identified possible factors including lack of formal arrangements, lack of suitable experience and the attitudes of palliative medicine consultants.

This study set out to systematically review the research evidence about the impact of alternative models of specialist palliative care on the quality of life of patients. Eighty-six relevant papers were identified and reviewed, including 22 descriptive and 27 comparative studies. We found few comparative trials of reasonable quality. There was some evidence that in-patient palliative care provided better pain control than home care or conventional hospital care, but this research was dated and open to criticism. Research on palliative home care teams and co-ordinating nurses has demonstrated limited impact on quality of life over conventional care for patients dying at home. These negative findings may be due to the limitations of the assessment tools used. There is a need for larger studies to provide clear evidence as to whether specialist palliative care services provide improvements in patients' quality of life. This review does not exclude the possibility that models of care might be justifiable on other grounds such as patient preference or cost-effectiveness.

Background: Opioid switching to methadone is reported frequently to improve pain control in patients with an unacceptable balance between pain control and side effects during treatment with first line opioids, but carries a risk of drug accumulation and respiratory depression. To justify this risk it is required that less risky treatments are tried beforehand and that a sufficiently large proportion of patients experience a long-lasting improvement in pain control. Research questions: How large was the proportion of patients remaining on long term methadone treatment after a switch from a strong opioid to methadone? How long had the patients been treated with opioids before the switch to methadone? Methods: Longitudinal pharmacoepidemiological study from the complete national Norwegian Prescription Database. Results: One hundred and thirty (77%) cancer patients received more than one dispensed prescription of methadone. Forty-nine (40%) chronic non-malignant pain (CNMP) patients continued to have methadone prescriptions dispensed more than 6 months after the switch. Of 168 cancer patients, 48 (29%) had tried two strong opioids prior to the switch to methadone whereas 21 (12.5%) had tried three or more strong opioids. Similar numbers for 124 CNMP patients were 26 (21%) and 34 (27%), respectively. Interpretation: Opioid switching to methadone appears to provide a long lasting improvement in pain control in a significant proportion of patients. However, the study raises concerns that treatment options with less risk are not being exhausted prior to switching to methadone.

Patient attitudes and knowledge regarding cancer pain and strong opioid analgesia can sometimes be a barrier to good pain control. Educational interventions that address these barriers are effective in oncology outpatients but have not been evaluated in patients with more advanced disease. We assessed the feasibility of a randomized, controlled clinical trial evaluating a brief DVD-based educational intervention for cancer pain in palliative care patients. Participants were shown DVD at baseline (V1) and at 1 week (V2). Outcomes were assessed using Brief Pain Inventory (BPI) and Patient Pain Questionnaire (PPQ) before intervention, and at V2 and V3 (4 weeks later). Fifteen patients and 10 carers were recruited. Between V1 and V2, total BPI and PPQ scores improved significantly by 9.6% ( p = 0.02) and 17% ( p = 0.04) respectively with no further improvements at V3. Our findings suggest that this intervention is feasible and potentially effective between 7—30 days follow up. A multicentre clinical trial is now needed to evaluate this intervention further.

The increasing public and professional interest in the United States concerning effective cancer pain control, has led to the development of state cancer pain initiatives. However, the understandable pressure to reduce drug abuse has paradoxically made effective pain control more difficult. It is hoped that the combined impetus of state initiatives and various national groups will lead to improved pain management. Achieving better relief of cancer pain goes some way to meeting the current debate on euthanasia.

The aim of the study was to investigate the extent to which an information leaflet on controlled-release morphine (MST) and complementary methods of pain control can increase knowledge and thus increase pain relief for cancer patients taking MST at home. An information leaflet on MSTwas adapted and extended to include complementary methods of pain control. Pre- and postleaflet tape-recorded interviews and a pain diary were then used to monitor the effect of the leaflet on a sample of 15 patients. The results indicated that knowledge regarding pain control was significantly increased by the administration of the leaflet (p = 0.01). Pain control also appeared to increase for some patients as a result of the leaflet, and this seemed to be due to the increased knowledge and subsequent use of complementary methods of pain control (p = 0.05). The patients who benefited most from the study were those with moderate pain, because they needed the information and were able to actively use it. It is concluded that this information leaflet is beneficial to patients and should be used as an adjunct to verbal instructions.

The principles of pain control in cancer have not changed over the past four years, but our understanding of opioids has increased in many areas. This update reviews recent developments and new knowledge in morphine pharmacokinetics, new and established opioids, opioid actions and routes of opioid administration, including spinal routes.

This paper describes the questionnaire component of a two-stage study to examine the research priorities of palliative care patients. In the first stage focus groups were conducted to determine a list of priorities for future research: a questionnaire created from these themes was then used in five hospices across East Anglia. Patients thought that the focus group priorities were important and scored research into emergency care, pain control and helping doctors to understand what patients were saying as most important. Differences in priority were associated with gender, age and in-patient versus day therapy patients. Palliative Medicine 2008;22: 7—12

Four cases are reported where pain control was achieved with epidural morphine after failure with oral morphine. The indications were unacceptable adverse effects with oral morphine or morphine resistant pain. The rationale for the use of the epidural route is discussed. We believe that there is a place for epidural analgesia in selected patients at palliative care centres. Nurses need training in epidural drug administration to enable them to be involved in this form of treatment.

Fifty junior residents completed a six-month training period. An anonymous postal questionnaire was sent to collect the residents' opinions on improvements in their knowledge, perception of priorities and usefulness of training. Responses were rated from 5 (a great deal) to 1 (not at all improved). A total of 33 (66%) questionnaires were returned. A mean score of 4.48 was obtained on general improvement of knowledge, 4.91 ± 0.29 on pain control, 4.17 ± 0.58 on neurological symptoms, 4.09 ± 0.77 on psychological symptoms, 4.64 ± 0.60 on communication skills and 4.4 ± 0.91 on physician attitudes. Some 58% of residents began the training with apprehension, 85% outlined their priorities and 76% reached these objectives. A total of 70% were fully satisfied with the tuition and support received and 98% recommended such clinical rotation. Data suggest that a six-month rotation in palliative care results in high levels of perception of improvement in knowledge and satisfaction. Exposure to palliative care patients during clinical rotations in specialized centres must be encouraged.

This paper presents a qualitative analysis of a subsample of data from a larger investigation into general practitioner referrals to specialist palliative care services (SPCS). The aim was to identify the expectations and perceptions of patients with advanced cancer and their relatives. Twenty-nine individuals were interviewed (18 patients, 11 relatives). Qualitative analysis of the interview transcripts was undertaken using an approach based on interpretative phenomenological analysis. The results indicated that SPCS were perceived as providing psychosocial services, characterized as ‘support’ and ‘someone to talk to’. SPCS were expected to have ‘expertise in symptom control’, particularly in relation to pain management. The study demonstrated that patients' and relatives' expectations of a referral to SPCS were of psychosocial support and symptom control. It is argued that the implications of this restricted view of SPCS may mean that other salient concerns are not raised by patients and relatives.

Seventy-eight cancer patients who were being treated for pain-related problems underwent a semistructured interview concerning the influence of cancer and cancer pain on existential issues. Pain intensity was assessed with visual analogue scales in order to quantify the overall mean pain intensity as well as pain intensity during the best and worst periods. Patients with a higher overall mean pain score (i.e. insufficient pain control) or higher mean worst pain score expressed significantly more fear about the future (P < 0.01), worries about pain progression (P < 0.05) and general anxiety that hampered their daily living (P < 0.05). Younger patients expressed more fear of pain progression and of the future in general and they were much more concerned about the future of their families (P < 0.05). The fear of future pain problems was related to the duration of the pain (P < 0.01). In conclusion, partly unrelieved pain contributes to the 'total pain' experience, not only by causing immediate physical suffering, but also by increasing the anxiety level and the fear about the future and future problems. The study underlines that effective symptom control is a prerequisite for a good quality of life: pain control is a matter of the highest priority.

Morphine is the mainstay of pain control in cancer patients. We describe three patients in whom adequate analgesia was not obtained with morphine, and discuss the role of morphine metabolites and the use of methadone as an alternative strong opioid analgesic.

This study aimed to assess the validity of the Support Team Assessment Schedule (STAS), a measure of the outcome of palliative care, through comparisons with the views of patients and family members. STAS ratings completed by two support teams were compared with (1) patients' ratings and (2) family member/carer ratings of seven (of the total 17 STAS) items, collected by independent interviewers. Of 183 patients referred to the teams, 84 (46%) were interviewed and 99 (54%) could not be contacted. Sixty-seven patients had family members or carers, all of whom were interviewed. Tests for agreement between team and patient were high for four items, and showed moderate correlations (Spearman's rho ranged 0.45-0.66) for five items, excepting two items including family needs. The summed scores for seven items were correlated, rho = 0.66, p < 0.0001. Where differences were found, team members identified more problems than patients' self-ratings, except for one item, 'pain control', where team members identified fewer problems. Team ratings were usually closer to those of the patients than to those of the family member; a team rating often lay between the patient's and family member's rating. The STAS is a measure of professional assessment which is independent from, although based on, the patient and family. The results support the validity of STAS as a measure of the outcome of palliative care from the perspective of a palliative care team.