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Fundamental to the quality of life is assisting patients in relieving pain including at the end of life. Compassionate, effective, evidence-based pain care for the dying improves the quality of life for patients and may reduce distress and complicated bereavement in the loved ones witnessing this death. However, efforts designed to mitigate the consequences of the opioid epidemic have seriously compromised pain care at the end of life. This has created an urgent need to focus on the barriers to relief, and solutions necessary to provide safe and effective pain and symptom management in this population. To that end, a committee of experts was convened by the American Society for Pain Management Nursing and the Hospice and Palliative Nursing Association. These experts reviewed the current literature, developed a draft position statement which underwent consecutive revisions. This statement was then endorsed by the respective organizations. Elucidation of barriers to effective pain control in advanced disease allows targeted interventions; including those related to clinical care, education, accessibility, and research. As nurses, we must continuously advocate for humane and dignified care, promoting ethical, effective pain and symptom management at the end of life for all. [ABSTRACT FROM AUTHOR]

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations. [ABSTRACT FROM AUTHOR]

Pain at the end of life continues to be of great concern as it may be unrecognized or untreated. Although nurses have an ethical obligation to reduce suffering, barriers remain regarding appropriate and adequate pain management at the end of life. This joint position statement from the American Society for Pain Management Nursing and Hospice and Palliative Nurses Association contains recommendations for nurses, prescribers, and institutions that would improve pain management for this vulnerable population. [ABSTRACT FROM AUTHOR]

Objectives To promote oncology nurse communication that is grounded on principles of ethics, individual care, and shared decision-making. Data Sources Articles and references in the communication, nursing and oncology nursing literature Conclusion Communication is essential to effectively advocate to meet the needs of cancer patients and their families, and other health care providers, particularly in the quality–of life domains. Implications for Nursing Practice Oncology nurses are in a prime position to facilitate quality communication. Nurses need education in communication to promote quality care and navigate critical junctures in the cancer continuum. [ABSTRACT FROM AUTHOR]

CONTEXT: The topical gel known as 'ABH gel,' comprising lorazepam (Ativan((R))), diphenhydramine (Benadryl((R))), and haloperidol (Haldol((R))), is frequently used to treat nausea because of its perceived efficacy, relatively low cost, and ease of use in the home setting. There are limited scientific data on this medication, however. Recent pilot studies showed no absorption of the active ingredients of the gel, prompting further prospective studies into the cause of the perceived efficacy in the clinical setting. OBJECTIVES: To determine any difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea. METHODS: A randomized, double-blind, placebo-controlled, crossover, noninferiority clinical trial was developed to test the hypothesis that there is no difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea. The primary outcome was the difference in nausea score (on a 0-10 scale) at baseline and at 60 minutes in each treatment group. The difference in the ABH gel-treated group compared with placebo was evaluated for noninferiority. Secondary outcomes included the number of vomiting episodes and side effects over time. RESULTS: The mean change in nausea score from baseline to 60 minutes after treatment in the ABH gel group was 1.7 ± 2.05 and 0.9 ± 2.45 for the placebo group (P = 0.42). The placebo group was found to be noninferior to the ABH gel group in reducing the nausea score. ABH gel also did not decrease vomiting events better than placebo (P = 0.34). Only one patient reported any side effects from the treatments in either arm of the study. CONCLUSION: ABH gel in its current formulation should not be used in cancer patients experiencing nausea. [ABSTRACT FROM AUTHOR]

Objectives To provide an overview of the four major palliative care delivery models: ambulatory clinics, home-based programs, inpatient palliative care units, and inpatient consultation services. The advantages and disadvantages of each model and the generalist and specialist roles in palliative care will be discussed. Data Sources Literature review. Conclusion The discipline of palliative care continues to experience growth in the number of programs and in types of delivery models. Ambulatory- and home-based models are the newest on the scene. Implications for Nursing Practice Nurses caring for oncology patients with life-limiting disease should be informed about these models for optimal impact on patient care outcomes. Oncology nurses should demonstrate generalist skills in the care of the seriously ill and access specialist palliative care providers as warranted by the patient's condition. [ABSTRACT FROM AUTHOR]

Abstract: Therapeutic hypothermia (ARCTIC, or Advanced Resuscitation Cooling Therapeutics and Intensive Care protocol) is a widely recommended intervention to improve mortality and neurologic outcomes after cardiac arrest. However, neurologic outcomes are difficult to predict soon after cardiac arrest in the setting of hypothermia, as illustrated by this case report. A 60-year-old man had witnessed cardiac arrest at home. He was defibrillated twice, with return of spontaneous circulation, and cooled to 33°C for 24 hours. Neurologic exam on Day 6 revealed limited brainstem reflexes, and the intensive care unit team discussed with the patient’s family that his prognosis for neurologic recovery was poor. Palliative care was consulted to participate in a goals-of-care meeting. Just prior to the meeting on Day 7, the patient awoke. He fully recovered and walked out of the hospital on Day 18. Prior to induced hypothermia, indicators of poor outcome included lack of one or more brainstem reflexes (pupillary or corneal reflex), absence of motor response at 72 hours, myoclonus, status epilepticus, electroencephalogram with generalized suppression, and absent bilateral cortical N20 response to somatosensory-evoked potentials. However, several studies have found these indicators to be unreliable after hypothermia. This may be the result of sedatives, which can affect physical examination and electroencephalogram results, and delayed clearance. Because of the unreliability of prognostication tests within the first 72 hours of hypothermic protocols in the setting of sedation, it appears prudent in some cases to delay final prognosis discussions until at least six days postcardiac arrest and after neurologic evaluation is done with patients sedative-free. [Copyright &y& Elsevier]

Abstract: Context: Chemotherapy-induced peripheral neuropathy (CIPN) is a major dose-limiting and persistent consequence of numerous classes of antineoplastic agents, affecting up to 30%–40% of patients. To date, there is no effective prevention or therapy. An evolving hypothesis for reducing CIPN pain involves direct nerve stimulation to reduce the pain impulse. Objectives: To evaluate the impact on CIPN associated with the MC5-A Calmare® therapy device. Methods: The MC5-A Calmare® therapy device is designed to generate a patient-specific cutaneous electrostimulation to reduce the abnormal pain intensity. Sixteen patients from one center received one-hour interventions daily over 10 working days. Results: Of 18 patients, 16 were evaluable. The mean age of the patients was 58.6 years—four men and 14 women—and the duration of CIPN was three months to eight years. The most common drugs were taxanes, platinums, and bortezomib (Velcade, Millenium Pharmaceuticals, Cambridge MA). At the end of the study (Day 10), a 20% reduction in numeric pain scores was achieved in 15 of 16 patients. The pain score fell 59% from 5.81±1.11 before treatment to 2.38±1.82 at the end of 10 days (P <0.0001 by paired t-test). A daily treatment benefit was seen with a strong statistically significant difference between the pre- and post-daily pain scores (P <0.001). Four patients had their CIPN reduced to zero. A repeated-measures analysis using the scores from all 10 days confirmed these results. No toxicity was seen. Some responses have been durable without maintenance. Conclusion: Patient-specific cutaneous electrostimulation with the MC5-A Calmare® device appears to dramatically reduce pain in refractory CIPN patients with no toxicity. Further studies are underway to define the benefit, mechanisms of action, and optimal schedule. [ABSTRACT FROM AUTHOR]

Purpose: More than 50 million people die each year around the world. Nurses are crucial in providing care to these individuals and their families as they spend the most time at the bedside with patients and families. Yet many nurses have received little or no education about palliative care. Methods/Sample: The Open Society Institute (OSI) and the Open Medical Institute (OMI) partnered with End-of-Life Nursing Education Consortium (ELNEC) to develop an international nursing palliative care curriculum. This international curriculum was implemented with two training courses held in Salzburg, Austria in October 2006 (n =38) and April 2008 (n =39) representing 22 Eastern European/Central Asian countries. Participants were asked to establish goals in disseminating the palliative care information when they returned to their country. The participants were mentored/followed for a 12-month period to evaluate their palliative care knowledge as well as challenges encountered. Key Results: The participants provided excellent ratings for the training courses indicating that the courses were stimulating and met their expectations. The 12-month follow-up demonstrated many challenges (i.e., lack of funds, institutional support, fear of death), in advancing palliative care within each participant''s setting/country as well as many examples of successful implementation. Conclusions: There is an urgent need for improved palliative care throughout the world. The ELNEC-International curriculum is designed to address the need for increased palliative care education in nursing. In order to improve the quality of life for those facing life-threatening illnesses around the world, ongoing support is needed for world-wide palliative care educational efforts. [Copyright &y& Elsevier]

Abstract: The article presents the position statement and clinical practice recommendations for pain assessment in the nonverbal patient developed by an appointed Task Force and approved by the ASPMN Board of Directors. [Copyright &y& Elsevier]

Increasing numbers of patients with refractory pain are receiving intrathecal drug delivery systems (IDDS). We describe a case to illustrate the clinical manifestations and management implications of inadvertent overdose with drugs used in IDDS, including opioids, clonidine, baclofen, and local anesthetics. An IDDS patient received a bimonthly dose of intrathecal hydromorphone subcutaneously. The patient received a total of 540 mg hydromorphone into the subcutaneous pocket around the intrathecal pump. She was treated with naloxone intravenously over 12 hours, and had no major adverse sequelae. Such occurrences may happen more frequently with the expanded use of IDDS and clinicians should be prepared to take quick action. Counteracting an opioid with naloxone until the opioid is metabolized and excreted can be done safely. Inadvertent subcutaneous administration of other types of drugs could be more difficult to manage. [Copyright &y& Elsevier]

Dyspnea, a subjective symptom of impaired breathing, occurs in 70% of terminally ill cancer patients. Current treatments are suboptimal and little is known about the patient''s perception of effect. We tested nebulized inhaled fentanyl citrate on patient perceptions, respiratory rate, and oxygen saturation. The study was conducted using a convenience sample of 35 cancer patients on a dedicated oncology unit. We assessed patient perception (did breathing stay the same, worsen, or improve), respiratory rate, and oxygen saturation by pulse oximetry at baseline, 5 minutes, and 60 minutes. Twenty-six of 32 (81%) patients reported improvement in breathing, 3 (9%) were unsure, and 3 (9%) reported no improvement. Oxygen saturation improved from 94.6% at baseline to 96.8% at 5 minutes and 96.7% at 60 minutes (P = 0.0069 compared to baseline). Respiratory rates improved from a baseline of 28.4/min to 25.9/min at 5 minutes and 24.1/min at 60 minutes (P = 0.0251 compared to baseline). No side effects were observed. Inhaled nebulized fentanyl citrate significantly improved patient perception of breathing, respiratory rate, and oxygen saturation. This inexpensive and readily available treatment may offer substantial relief of end-of-life dyspnea. Randomized trials, dose, and length of effect trials are underway. [Copyright &y& Elsevier]

Managing pain in those vulnerable populations who are unable to self-report or communicate is challenging due to difficulty recognizing pain presence and severity. As no valid and reliable objective measure of pain exists, the ASPMN supports assessment practice recommendations that gather relevant information to infer presence of pain and evaluate response to intervention. Nurses and other healthcare professionals must be advocates for those who are unable to speak for themselves regarding their pain experience. [ABSTRACT FROM AUTHOR]

Abstract: Pain management in a hospital setting remains a challenge today. Many health care providers remain anxious and uninformed regarding analgesic titration within a hospital setting. Overcoming the potential risks to obtain the benefits of opiate titration is a challenge within any health care setting. Virginia Commonwealth University, a tertiary medical center which houses schools of medicine, nursing, and pharmacy, evaluated the use of algorithms for managing acute pain. This article describes the Pain Committee's efforts and offers one potential intervention for safe analgesic opioid titration, an algorithm for acute pain management. [Copyright &y& Elsevier]

Outcomes 1. Identify strategies to integrate palliative care concepts into healthcare education to best prepare providers and healthcare workers to meet the current needs of people with serious illness and facing end of life 2. Discuss steps taken to embed palliative care concepts into undergraduate and graduate programs at a southeastern college of nursing 3. Discuss how to develop and implement a specialty graduate palliative care nursing program to help meet the urgent need for providers with advanced specialty skills in palliative care Palliative care education is vital in answering the call to increase both primary and specialty palliative care access for patients with serious illness and their families. At the Medical University of South Carolina (MUSC) in Charleston, South Carolina, experienced faculty and providers in the field of palliative care have led the way in palliative care education integration by prioritizing palliative care across all domains, including in areas of education, practice, and research. This session will focus on the palliative care initiatives taken specifically at the College of Nursing at MUSC over the last 5 years. Presenters will discuss steps taken to fully integrate palliative care content into the undergraduate and graduate nursing curriculums. This includes the commitment for every student and faculty member to be prepared in End-of-Life Nursing Education Consortium (ELNEC) training. Through an online curriculum designed specifically for nursing students, each year over 200 undergraduate students and 100 graduate students are graduating fully trained in palliative care, and this number is climbing. In addition, presenters will review the development and implementation of the first Doctor of Nursing Practice program in palliative care in the United States, established in 2020. In addition to receiving ELNEC training in this program, all graduate students receive training in Vital Talk, learning the skills to communicate effectively with patients living with serious illness and, upon completion, are eligible to sit for the Advanced Certified Hospice and Palliative Nurse examination. Faculty will present the challenges and the successes of this model of palliative care education. In addition, during an interactive session learners will review primary and specialty palliative care competencies that provide a framework for educators to teach palliative care content and review other important foundational documents, including the NCP Clinical Practice Guidelines. [ABSTRACT FROM AUTHOR]

This paper reports revisions in formulation and new features of the Hybrid-Maize model (released as HM2016), to better simulate yields in harsh rainfed environments. Revisions include updated subroutines for root growth and distribution within the soil profile, greater sensitivity of canopy expansion and senescence to water deficits, an expanded kernel setting period, and soil evaporation as influenced by surface cover with crop residues. The updated model also includes routines for simulating surface runoff and estimating soil water content at sowing based on simulation of soil water balance during the preceding fallow period. Revisions of model functions were based on recent advances in understanding and quantification of maize response to environmental factors and management practices, as well as characteristics of new maize hybrids. More robust simulation of maize yield was obtained with the updated model under rainfed conditions, especially in years and locations with severe drought or on soils with limited water holding capacity. Capability to quantify soil water content at sowing and to perform batch simulations makes HM2016 more useful for pre-season yield projections in years with below-normal soil water recharge and for in-season yield forecasting across a wide range of environments. Revisions to routines governing root distribution and kernel setting make HM2016 a more powerful tool for evaluating hybrid-specific traits and crop management practices for ability to mitigate yield loss from water deficits and for identifying management options for individual production fields. [ABSTRACT FROM AUTHOR]

Abstract: Background: Lorazepam (Ativan®), diphenhydramine (Benadryl®), haloperidol (Haldol®) (ABH) topical gel is currently widely used for nausea in hospice because of perceived efficacy and low cost and has been suggested for cancer chemotherapy. However, there are no studies of absorption, a prerequisite for effectiveness. We completed this study to establish whether ABH gel drugs are absorbed, as a prerequisite to effectiveness. Intervention: Ten healthy volunteers, aged 25 to 58 years (mean 37 years), two African Americans and eight Caucasian Americans, applied the standard 1.0mL dose (2mg of lorazepam, 25mg of diphenhydramine, and 2mg of haloperidol in a pluronic lecithin organogel), rubbed on the volar surface of the wrists by the subject. Measures: Blood samples were obtained at 0, 30, 60, 90, 120, 180, and 240 minutes. Plasma concentrations were analyzed by liquid chromatography-tandem mass spectrometry using deuterated internal standards for each drug. Outcomes: No lorazepam or haloperidol was detected in any sample from any of the 10 volunteers down to a level of 0.05ng/mL. Diphenhydramine was found in multiple plasma samples at concentrations >0.05ng/mL in three patients, with the highest concentration of 0.30ng/mL in one person at 240 minutes. Overall, five of 10 patients exhibited detectable diphenhydramine in one or more samples, supporting limited absorption. No subject noted any side effects. Conclusions/Lessons Learned: As commonly used, none of the lorazepam, haloperidol, or diphenhydramine in ABH gel is absorbed in sufficient quantities to be effective in the treatment of nausea and vomiting. Diphenhydramine is erratically absorbed at subtherapeutic levels. The efficacy of ABH gel should be confirmed in randomized trials before its use is recommended. [Copyright &y& Elsevier]

Context: Chemotherapy-induced peripheral neuropathy (CIPN) is a major dose-limiting and persistent consequence of numerous classes of antineoplastic agents, affecting up to 30%-40% of patients. To date, there is no effective prevention or therapy. An evolving hypothesis for reducing CIPN pain involves direct nerve stimulation to reduce the pain impulse.Objectives: To evaluate the impact on CIPN associated with the MC5-A Calmare® therapy device.Methods: The MC5-A Calmare® therapy device is designed to generate a patient-specific cutaneous electrostimulation to reduce the abnormal pain intensity. Sixteen patients from one center received one-hour interventions daily over 10 working days.Results: Of 18 patients, 16 were evaluable. The mean age of the patients was 58.6 years-four men and 14 women-and the duration of CIPN was three months to eight years. The most common drugs were taxanes, platinums, and bortezomib (Velcade, Millenium Pharmaceuticals, Cambridge MA). At the end of the study (Day 10), a 20% reduction in numeric pain scores was achieved in 15 of 16 patients. The pain score fell 59% from 5.81±1.11 before treatment to 2.38±1.82 at the end of 10 days (P<0.0001 by paired t-test). A daily treatment benefit was seen with a strong statistically significant difference between the pre- and post-daily pain scores (P<0.001). Four patients had their CIPN reduced to zero. A repeated-measures analysis using the scores from all 10 days confirmed these results. No toxicity was seen. Some responses have been durable without maintenance.Conclusion: Patient-specific cutaneous electrostimulation with the MC5-A Calmare® device appears to dramatically reduce pain in refractory CIPN patients with no toxicity. Further studies are underway to define the benefit, mechanisms of action, and optimal schedule. [ABSTRACT FROM AUTHOR]

Dyspnea, a subjective symptom of impaired breathing, occurs in 70% of terminally ill cancer patients. Current treatments are suboptimal and little is known about the patient's perception of effect. We tested nebulized inhaled fentanyl citrate on patient perceptions, respiratory rate, and oxygen saturation. The study was conducted using a convenience sample of 35 cancer patients on a dedicated oncology unit. We assessed patient perception (did breathing stay the same, worsen, or improve), respiratory rate, and oxygen saturation by pulse oximetry at baseline, 5 minutes, and 60 minutes. Twenty-six of 32 (81%) patients reported improvement in breathing, 3 (9%) were unsure, and 3 (9%) reported no improvement. Oxygen saturation improved from 94.6% at baseline to 96.8% at 5 minutes and 96.7% at 60 minutes (P = 0.0069 compared to baseline). Respiratory rates improved from a baseline of 28.4/min to 25.9/min at 5 minutes and 24.1/min at 60 minutes (P = 0.0251 compared to baseline). No side effects were observed. Inhaled nebulized fentanyl citrate significantly improved patient perception of breathing, respiratory rate, and oxygen saturation. This inexpensive and readily available treatment may offer substantial relief of end-of-life dyspnea. Randomized trials, dose, and length of effect trials are underway. [ABSTRACT FROM AUTHOR]

A letter to the editor and a reply are presented in response to an article on the need for cautious use of opioids in patients with advanced liver disease.