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OBJECTIVES: The purpose of this multicenter study was to characterize the association between spirituality, religiosity, spiritual pain, symptom distress, coping, and quality of life (QOL) among Latin American advanced cancer patients. METHODS: Three hundred twenty-five advanced cancer patients from palliative care clinics in Chile, Guatemala, and the United States completed validated assessments: Faith, Importance and Influence, Community, and Address (FICA) (spirituality/religiosity), Edmonton Symptom Assessment Scale-Financial/Spiritual (ESAS-FS), including spiritual pain, Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Center for Epidemiologic Studies Depression Scale (CES-D), Brief-coping strategies (COPE) and Brief religious coping (RCOPE) and RCOPE, respectively, and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, Expanded version (FACIT-Sp-Ex). RESULTS: Median age: 58 years (range: 19–85); 60% female; and 62% Catholic and 30% Christian, but not Catholic. Three hundred fifteen patients (97%) considered themselves spiritual and 89% religious, with median intensities of 7 (interquartile range [IQR]: 5–10) and 7 (5–9), respectively (0–10 scale, 10 = “very much”). Median importance of spirituality/religiosity was 10 (IQR: 8–10). The frequency and associations between spirituality/religiosity and various items were as follows: helps to cope with illness (98%; r = 0.66303; p

Context Terminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear. Objective To determine the prevalence of TIP visiting the ED. Methods Systematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle–Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I2). Results We identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries, and none from low-income countries. Most were from 2015. We found that 45% of patients with cancer visited the ED in the last month of life [95% CI 37–54%] and 75% in the last six months of life [95% CI 62–83%]; I2 = 100%. Overall, 17% of patients who visited the ED had a terminal illness [95% CI 12–23%]; I2 = 98%. Few studies reported terminal nononcologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or nonresuscitation, or other criteria that could be used for grouping. Conclusions Patients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with nononcologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.

Objectives Advances in cancer treatments have allowed improved outcomes, even with advanced disease. However, this progress has resulted in a new toxic effect termed ‘financial toxicity.’ Financial toxicity severely impacts quality of life, even among those insured. The purpose of this article is to gain better understanding of this relatively new concept to better care for our patients, presented primarily from a US perspective. Data Sources These include medical databases (PubMed, Scopus) and researcher experience. Conclusion Financial toxicity is highly prevalent in patients with advanced cancer, and it is associated with multiple worsened outcomes. Those with advancing cancer are at accumulating risk of financial toxicity, exacerbated by other known risk factors. The effects of financial toxicity are debilitating, resulting in deleterious physical, psychological, spiritual, and social effects drastically affecting quality of life. Coping strategies such as taking less than prescribed therapy, delays seeking care, and poorly managed comorbid conditions potentially cause increased symptoms and worse outcomes. Implications for Nursing Practice Careful assessments by multidisciplinary health care teams could allow early intervention, timely referral to health professionals including social work or financial navigators, and provision of emotional support. Further studies are needed to explore solutions on an institutional and national level that can guide health policy and the creation of practice models that can reduce the harm of financial toxicity.

BACKGROUND. Financial distress (FD) is common among patients with advanced cancer. Our purpose was to compare the frequency and intensity of FD and its associations with symptom distress and quality of life (QOL) in these patients in France and the U.S. MATERIALS AND METHODS. In this secondary analysis of two cross‐sectional studies, we assessed data on 292 patients who received cancer care at a public hospital or a comprehensive cancer center in France (143 patients) or the U.S. (149 patients). Outpatients and hospitalized patients over 18 years of age with advanced lung or breast or colorectal or prostate cancer were included. Diagnosed cognitive disorder was considered a noninclusion criterion. Advanced cancer included relapse or metastasis or locally advanced cancer or at least a second‐line chemotherapy regimen. Patients self‐rated FD and assessed symptoms, psychosocial distress, and QOL on validated questionnaires. RESULTS. The average patient age was 59 years, and 144 (49%) were female. FD and high intensity were reported more frequently in U.S. patients than in French (respectively 129 [88%] vs. 74 [52%], p

BackgroundRecognizing and managing existential suffering remains challenging. We present two cases demonstrating how existential suffering manifests in patients and how to manage it to alleviate suffering.Case descriptionCase 1: A 69-year-old man with renal cell carcinoma receiving end-of-life care expressed fear of lying down “as he may not wake up.” He also expressed concerns of not being a good Christian. Supportive psychotherapy and chaplain support were provided, with anxiolytic medications as needed. He was able to express his fear of dying and concern about his family, and Edmonton Symptom Assessment System scores improved. He died peacefully with family at bedside. Case 2: A 71-year-old woman presented with follicular lymphoma and colonic obstruction requiring nasogastric drain of fecaloid matter. Initially, she felt that focusing on comfort rather than cure symbolized giving up but eventually felt at peace. Physical symptoms were well-controlled but emotionally she became more distressed, repeatedly asking angrily, “Why is it taking so long to die?.” She was supported by her family through Bible readings and prayers, but she was distressed about being a burden to them. An interdisciplinary approach involving expressive supportive counseling, spiritual care, and integrative medicine resulted in limited distress relief. Owing to increasing agitation, the patient and family agreed to titrate chlorpromazine to sedation. Her family was appreciative that she was restful until her death.ConclusionExistential suffering manifests through multiple domains in each patient. A combination of pharmacologic and non-pharmacologic techniques may be needed to relieve end-of-life suffering.

Background: Cancer patients frequently use complementary and alternative medicine (CAM), and spirituality has been associated with CAM use among patients. We evaluated how oncologists’ spirituality and religiosity are associated with personal use and patient recommendations for CAM. Methods: A survey was mailed to 1000 medical oncologists in the United States. The questionnaire asked about oncologists’ approaches to CAM use by patients, focusing on the use of herbs and supplement (HS), and about religiosity and spirituality. Results: Of 937 deliverable questionnaires, 392 were returned (response rate 42%). Respondents were mostly men (71%) and Caucasian (76%), with a median age of 48. Approximately 16% reported no religion, 19% Jewish, 24% Catholic, 28% Christian, and 13% other religions. Eighteen percent reported attending religious services at least once a week, including 15% who attend several times per week. Twenty-eight percent reported high theological pluralism (skepticism regarding whether one religion is comprehensively and uniquely true); 58% described themselves as moderately or very spiritual. Self-reported spirituality and religious service attendance were associated with using CAM personally and recommending HS to patients. In multivariate analyses, moderate-high spirituality and attending religious services less than monthly was positively associated with personal use of CAM: odds ratio (OR) = 3.10 (confidence interval [CI] = 1.5-6.5) and OR = 3.04 (CI = 1.5-6.6), respectively. Physicians with moderate to high spirituality were more likely to report recommending CAM in general (OR = 3.07, CI = 1.3-7.1), but less likely to report recommending HS (OR = 0.33, CI = 0.14-0.75). Conclusion: Self-reported spirituality is a significant factor among US oncologists’ decision to use CAM and recommend CAM to patients.

What a privilege it is to be able to touch those sacred spaces in the soul of each person that we encounter everyday. Patients with life-threatening illnesses can struggle with physical, emotional, and existential and spiritual concerns and the suffering of caregivers. A key goal of our supportive and palliative care teams is to alleviate patient and caregiver suffering. When caring for patients with advanced and terminal illness, the spirituality of each member of the palliative care team becomes a single collective spirituality or soul with common goals, values, and belonging, with a main goal of providing the best care for patients and caregivers in the alleviation of suffering. Embracing the spiritual care into our daily practice is a common effort and a service provided by each member of the team. Our role as members of the collective soul is to preserve human dignity and raise up the broken souls of patients living with life-threatening illness by creating healing environments.

Conversations about end-of-life (EOL) wishes are challenging for many clinicians. The Go Wish card game (GWG) was developed to facilitate these conversations. Little is known about the type and consistency of EOL wishes using the GWG in advanced cancer patients. We conducted a randomized controlled trial to assess the EOL wishes of 100 patients with advanced cancer treated at The University of Texas MD Anderson Cancer Center. The purpose of this study was to determine the EOL wishes of patients with advanced cancer and to compare patients’ preference between the GWG and List of wishes/statements (LOS) containing the same number of items. Patients were randomized into four groups and completed either the GWG or a checklist of 35 LOS and one opened statement found on the GWG cards; patients were asked to categorize these wishes as very, somewhat, or not important. After 4–24 h, the patients were asked to complete the same or other test. Group A (n = 25) received LOS-LOS, group B (n = 25) received GWG-GWG, group C (n = 26) received GWG-LOS, and group D (n = 24) received LOS-GWG. All patients completed the State-Trait Anxiety Inventory (STAI) for adults before and after the first test. Median age (interquartile range = IQR): 56 (27–83) years. Age, sex, ethnicity, marital status, religion, education, and cancer diagnosis did not differ significantly among the four groups. All patients were able to complete the GWG and/or LOS. The ten most common wishes identified as very important by patients in the first and second test were to be at peace with God (74 vs. 71 %); to pray (62 vs. 61 %); and to have family present (57 vs. 61 %). to be free from pain (54 vs. 60 %); not being a burden to my family (48 vs. 49 %); to trust my doctor (44 vs. 45 %); to keep my sense of humor (41 vs. 45 %); to say goodbye to important people in my life (41 vs. 37 %); to have my family prepared for my death (40 vs. 49 %); and to be able to help others (36 vs. 31 %). There was significant association among the frequency of responses of the study groups. Of the 50 patients exposed to both tests, 43 (86 %) agreed that the GWG instructions were clear, 45 (90 %) agreed that the GWG was easy to understand, 31 (62 %) preferred the GWG, 39 (78 %) agreed that the GWG did not increase their anxiety and 31 (62 %) agreed that having conversations about EOL priorities was beneficial. The median STAI score after GWG was 48 (interquartile range, 39–59) vs. 47 (interquartile range, 27–63) after LOS (p = 0.2952). Patients with advanced cancer assigned high importance to spirituality and the presence/relationships of family, and these wishes were consistent over the two tests. The GWG did not worsen anxiety.

Background: Patients with advanced cancer experience severe physical, psychosocial, and spiritual distress requiring palliative care (PC). There are limited literature regarding characteristics and outcomes of patients evaluated by PC services at public hospitals (PHs). Objective, Design, Setting/Subjects, and Measurements: To compare the outcomes of advanced cancer patients undergoing PC at a PH and those at a comprehensive cancer center (CCC). We reviewed 359 consecutive advanced cancer patients (PH, 180; CCC, 179) undergoing PC. Symptoms and outcomes at consultation and first follow-up visit were assessed. Summary statistics were used to describe patient characteristics and outcomes. Results: The PH and CCC patients differed significantly according to race: 23% white, 39% black, and 36% Hispanic patients at the PH versus 66% white, 17% black, and 11% Hispanic patients at the CCC (p

Objective:Regular assessments of spiritual distress/spiritual pain among patients in a supportive/palliative care clinic (SCPC) are limited or unavailable. We modified the Edmonton Symptom Assessment Scale (ESAS) by adding spiritual pain (SP) to the scale (0 = best, 10 = worst) to determine the frequency, intensity, and correlates of self-reported SP (≥1/10) (pain deep in your soul/being that is not physical) among these advanced cancer patients.Method:We reviewed 292 consecutive consults of advanced cancer patients (ACPs) who were evaluated at our SCPC between October of 2012 and January of 2013. Symptoms were assessed using the new instrument (termed the ESAS–FS).Results:The median age of patients was 61 (range = 22–92). Some 53% were male; 189 (65%) were white, 45 (15%) African American, and 34 (12%) Hispanic. Some 123 of 282 (44%) of ACPs had SP (mean (95% CI) = 4(3.5–4.4). Advanced cancer patients with SP had worse pain [mean (95% CI) = 5.3(4.8, 5.8) vs. 4.5(4.0, 5.0)] (p = 0.02); depression [4.2(3.7, 4.7) vs. 2.1(1.7, 2.6), p < 0.0001]; anxiety [4.2(3.6, 4.7) vs. 2.5(2.0, 3.0), p < 0.0001]; drowsiness [4.2(3.7, 4.7) vs. 2.8(2.3, 3.2), p < 0.0001]; well-being [5.4(4.9, 5.8) vs. 4.5(4.1, 4.9), p = 0.0136]; and financial distress (FD) [4.4(3.9, 5.0) vs. 2.2(1.8, 2.7), p < 0.0001]. Spiritual pain correlated (Spearman) with depression (r = 0.45, p < 0.0001), anxiety (r = 0.34, p < 0.0001), drowsiness (r = 0.26, p < 0.0001), and FD (r = 0.44, p < 0.0001). Multivariate analysis showed an association with FD [OR (95% Wald CI) = 1.204(1.104–1.313), p < 0.0001] and depression [1.218(1.110–1.336), p < 0.0001]. The odds that patients who had SP at baseline would also have SP at follow-up were 182% higher (OR = 2.82) than for patients who were SP-negative at baseline (p = 0.0029). SP at follow-up correlated with depression (r = 0.35, p < 0.0001), anxiety (r = 0.25, p = 0.001), well-being (r = 0.27, p = 0.0006), nausea (r = 0.29, p = 0.0002), and financial distress (r = 0.42, p < 0.0001).Significance of results:Spiritual pain, which is correlated with physical and psychological distress, was reported in more than 40% of ACPs. Employment of the ESAS–FS allows ACPs with SP to be identified and evaluated in an SCPC. More research is needed.

Objective:The potential influence of patient religious and spiritual beliefs on the approach to end-of-life care and resuscitation status preferences is not well understood. The aim of this study was to assess the association between religiosity and resuscitation preferences in advanced-cancer patients.Method:We performed a secondary analysis of a randomized controlled trial that evaluated the influence of physician communication style on patient resuscitation preferences. All patients completed the Santa Clara Strength of Religious Faith Questionnaire–Short Form (SCSRFQ–SF) and expressed their resuscitation preferences. We determined the frequency of resuscitation preferences and its association with intensity of religiosity.Results:A total of 78 patients completed the study. The median age was 54 years, with a range of 18–78. Some 46 (59%) were women; 57 patients (73%) were Caucasian, 15 (19%) African American, and 5 (7%) Hispanic. A total of 46 patients (56%) were Protestant and 13 (17%) Catholic. Some 53 of 60 patients who chose Do Not Resuscitate status (DNR) (88%) and 16 of 18 patients who refused DNR (89%) for a video-simulated patient were highly religious (p = 0.64). When asked about a DNR for themselves after watching the videos, 43 of 48 who refused DNR (90%) and 26 of 30 patients who chose DNR (87%) were highly religious (p = 0.08). The Spearman correlation coefficient for patients choosing DNR for themselves and intensity of religiosity was r = –0.16 (p = 0.16). Some 30 patients (38%) who chose DNR for the video patient refused DNR for themselves, and 42 who chose DNR for both the video patient and themselves (54%) were highly religious (p = NS).Significance of Results:There was no significant association between intensity of patient religiosity and DNR preference for either the video patient or the patients themselves. Other beliefs and demographic factors likely impact end-of-life discussions and resuscitation status preferences.

To provide an updated overview about the role of spirituality and religiosity in the way patients with life-threatening illnesses cope, and the importance of providing a comprehensive spiritual assessment and spiritual care in an interdisciplinary team work setting, such as supportive and palliative care.Spirituality is a lifelong developmental task, lasting until death. Spirituality and religion continue to play an important role across cultures globally. Spirituality is seen as a vital element connected to seeking meaning, purpose, and transcendence in life. Many individuals recognize their life-threatening illness as an opportunity for spiritual growth; therefore, these individuals who have access to spirituality through meaning, purpose, connections with others, or connections with a higher power will have the spiritual resources necessary to adjust to adverse circumstances. It is extremely important to pay attention to patients' and caregivers' cultural and spiritual identity and spiritual needs.The interdisciplinary supportive and palliative care model of spiritual care proposes inclusion of the spiritual domain in the overall screening and history-taking process and spiritual care by all members of the team, including a full spiritual assessment by a professional chaplain. Research in this extremely important field needs to continue growing.

Understanding cancer patients' preferences in decisional roles is important in providing quality care and ensuring patient satisfaction. There is a lack of evidence on decisional control preferences (DCPs) of Hispanic Americans, the fastest growing population in the U.S.The primary aims of this study were to describe DCPs of Hispanics with advanced cancer in the U.S. (HUSs) and compare the frequency of passive DCPs in this population with that of Hispanics with advanced cancer in Latin America (HLAs).We conducted a prospective survey of patients with advanced cancer referred to outpatient palliative care clinics in the U.S., Chile, Argentina, and Guatemala. Information was collected on sociodemographic variables, Karnofsky Performance Scale scores, acculturation (Marin Acculturation Assessment Tool), and DCP (Control Preference Scale). Chi-square tests were used to determine the differences in DCPs between HUSs and HLAs.A total of 387 patients were surveyed: 91 in the U.S., 100 in Chile, 94 in Guatemala, and 99 in Argentina. The median age of HUSs was 56 years, 59% were female, and the median Karnofsky Performance Scale score was 60; the corresponding values for HLAs were 60 years, 60%, and 80. HLAs used passive DCP strategies significantly more frequently than HUSs did with regard to the involvement of the family (24% vs. 10%; P=0.009) or the physician (35% vs. 16%; P0.001), even after age and education were controlled for. Eighty-three percent of HUSs and 82% of HLAs preferred family involvement in decision making (P=non-significant). No significant differences were found in DCPs between poorly and highly acculturated HUSs (P=0.91).HUSs had more active DCPs than HLAs did. Among HUSs, acculturation did not seem to play a role in DCP determination. Our findings confirm the importance of family participation for both HUSs and HLAs. However, HUSs were less likely to want family members to make decisions on their behalf.

Background: Understanding family caregivers’ decisional role preferences is important for communication, quality of care, and patient and family satisfaction. The family caregiver has an important role in a patient’s decisional role preferences. There are limited studies on family caregivers’ preferences of the patient’s decision control at the end of life among Hispanics. Aims: To identify Hispanic caregivers’ preferences of the decision control of patients with advanced cancer and to compare the preferences of caregivers in Hispanic Latin American and Hispanic American caregivers. Design: We surveyed patients and their family caregivers referred to outpatient palliative care clinics in the United States, Chile, Argentina, and Guatemala. Caregiver preferences of patient’s decision control were evaluated using the Control Preference Scale. Caregivers’ and patients’ sociodemographic variables, patient performance status, and Hispanic American patient acculturation level were also collected. Participants: A total of 387 caregivers were surveyed: 100 (26%) in Chile, 99 (26%) in Argentina, 97 (25%) in Guatemala, and 91 (24%) in the United States. The median age was 56 years, and 59% were female. Results: Caregiver preference of patient’s decision control was passive, shared, and active for 10 (11%), 45 (52%), and 32 (37%) Hispanic American caregivers and 54 (19%), 178 (62%), and 55 (19%) Hispanic Latin American caregivers ( p = 0.0023), respectively. Caregiver acculturation level did not affect the preferences of the Hispanic American sample ( p = 0.60). Conclusions: Most Hispanic family caregivers preferred the patient to make shared decisions. Hispanic Latin American caregivers more frequently preferred patients to assume a passive decisional role. Acculturation did not influence the preferences of Hispanic American caregivers.

Spirituality, religiosity, and spiritual pain may affect advanced cancer patients' symptom expression, coping strategies, and quality of life.To examine the prevalence and intensity of spirituality, religiosity, and spiritual pain, and how spiritual pain was associated with symptom expression, coping, and spiritual quality of life.We interviewed 100 advanced cancer patients at the M.D. Anderson palliative care outpatient clinic in Houston, TX. Self-rated spirituality, religiosity, and spiritual pain were assessed using numeric rating scales (0=lowest, 10=highest). Patients also completed validated questionnaires assessing symptoms (Edmonton Symptom Assessment Scale [ESAS] and Hospital Anxiety and Depression Scale), coping (Brief COPE and Brief R-COPE), the value attributed by the patient to spirituality/religiosity in coping with cancer (Systems of Belief Inventory-15R), and spiritual quality of life (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being-Expanded [FACIT-Sp-Ex]).The median age was 53 years (range 21-85) and 88% were Christians. Almost all patients considered themselves spiritual (98%) and religious (98%), with a median intensity of 9 (interquartile range 7-10) of 10 and 9 (range 5-10) of 10, respectively. Spiritual pain was reported in 40 (44%) of 91 patients, with a median score of 3 (1-6) among those with spiritual pain. Spiritual pain was significantly associated with lower self-perceived religiosity (7 vs. 10, P=0.002) and spiritual quality of life (FACIT-Sp-Ex 68 vs. 81, P=0.001). Patients with spiritual pain reported that it contributed adversely to their physical/emotional symptoms (P0.001). There was a trend toward increased depression, anxiety, anorexia, and drowsiness, as measured by the ESAS, among patients with spiritual pain (P0.05), although this was not significant after Bonferroni correction.A vast majority of advanced cancer patients receiving palliative care considered themselves spiritual and religious. Spiritual pain was common and was associated with lower self-perceived religiosity and spiritual quality of life.

BACKGROUND: Refusal of appropriately indicated do-not-resuscitate (DNR) orders may cause harm and distress for patients, families, and the medical team. We conducted a retrospective study to determine the frequency and predictors of refusals of DNR in advanced cancer patients admitted to an acute palliative care unit. METHODS: A total of 2538 consecutive admissions were reviewed. Demographic and clinical characteristics from 200 consecutive patients with DNR orders and 100 consecutive patients who refused DNR were collected, and differences between the groups were determined by multivariate regression and recursive partitioning analysis. RESULTS: Of 2538 admissions, 2530 (99%) were appropriate for DNR discussion. Of the 2530 admissions, 2374 were unique patients, and 100 (4%) of 2374 refused DNR. Refusers had median (interquartile range, IQR) pain of 7 (4-9) versus 5 (3-8, P = .0005), nausea of 2 (0-7) versus 1 (0-4, P = .05), and dyspnea of 1 (0-5) versus 4 (0-7, P = .002) as compared with DNR nonrefusers, respectively. Patients with hematological malignancies and advance directives had a lower DNR refusal risk (odds ratio [OR], 0.38; P = .02, and OR, 0.36; P < .0001, respectively). Multivariate regression analysis revealed that patients with moderate-severe pain (OR, 3.19; P = .002) and with no advance directives (OR, 2.94; P ≤ .001) had higher DNR refusal risk. There were more inpatient deaths among DNR nonrefusers (87 of 200 vs 1 of 100, P < .0001). Median (IQR) time from discharge to death was 18 (8-35) days for those with DNR orders and 85 (25-206) days for DNR refusers (P ≤ .0001). CONCLUSIONS: DNR refusal in patients admitted to the acute palliative care unit is low, more frequent in patients with more pain and nausea and no advance directives, and associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions. Cancer 2010. © 2010 American Cancer Society.

Pain is a very common symptom in patients with advanced cancer, with a prevalence as high as 80%. The vast majority of patients with cancer pain require opioids for its treatment.1,2 Most patients will require alternatives to the oral route for analgesic administration during the course of their disease, due to a variety of factors such as nausea, vomiting, sedation, delirium, bowel obstruction, and swallowing impairment.3 Patients who need parenteral opioids for severe cancer pain usually are managed with intravenous (IV) continuous infusions to maintain stable blood levels due to the short half life of the drugs.4 In order to maintain a continuous opioid infusion, patients managed by palliative care and hospice teams in acute care hospitals, inpatient hospices or at home need to use expensive portable or nonportable pumps, with the added costs of maintenance of a central or peripheral intravenous line and the management of rescue analgesic boluses.2,4 Intermittent IV opioid delivery results in significant sedation and short duration of effect, due to the short half-life of these drugs.4 One alternative is the subcutaneous (SC) route, which offers the possibility of maintaining efficacious pain control with intermittent injections, due to the slower rate of absorption of opioid analgesics.5–7 Intermittent subcutaneous opioid administration with an indwelling subcutaneous butterfly needle is a painless and inexpensive way of achieving pain control in those patients.7–10 The Edmonton Injector is a portable, simple, safe, and inexpensive mechanical device for delivering subcutaneous drugs.11 The purpose of this study is to review the results of intermittent SC opioids in a consecutive series of patients with cancer.

Mood disorders are among the most distressing psychiatric conditions experienced by patients with advanced cancer; however, studies have not shown a direct association of physical symptoms with depression and anxiety. The purpose of this study is to determine the relationship between the frequency and intensity of patients’ physical symptoms and their expressions of depression and anxiety. We retrospectively reviewed the records of 216 patients who had participated in three previous clinical trials conducted by our group. We assessed patients’ demographic data using descriptive statistics. We analyzed physical symptom frequency and intensity using the Edmonton Symptom Assessment System (ESAS) and anxiety and depression using the respective subscales of the Hospital Anxiety and Depression Scale (HADS-A and HADS-D). Sixty-two percent were male; the median age was 59 years (range 20–91 years). Seventy nine (37%) of the patients had depressive mood (HADS-D ≥ 8), and 94 (44%) had anxiety (HADS-A ≥ 8). Patients with depressive mood expressed higher frequency of drowsiness (68/78, 64%; p = 0.0002), nausea (52/79, 66%; p = 0.0003), pain (74/79, 94%; p = 0.0101), dyspnea (68/79, 86%; p = 0.0196), worse appetite (72/79, 91%; p = 0.0051), and worse well-being (78/79, 99%; p = 0.0014) and expressed higher intensity of symptoms (ESAS ≥ 1) [median (Q1–Q3)] including drowsiness [4 (3–7), p = 0.0174], fatigue [7 (5–8), p

Patients with advanced cancer may be referred for a palliative care consultation (PC) from a hospital emergency center (EC) or as inpatients. However, research about symptoms and outcomes in patients with advanced cancer who receive PC at the EC is limited. We reviewed demographic variables, frequency and intensity of symptoms (using the Edmonton Symptom Assessment Scale (ESAS)), PC interventions, time from admission to PC consultation, hospitalization duration, and discharge destination of 200 advanced cancer patients referred to PC services from the EC (“EC patients”) and 200 matched advanced cancer inpatients referred to PC services (“inpatients”) from January 1, 2010, through December 31, 2011. The median age for all patients was 56 years (range, 48–64 years); 222 (56 %) patients were female, and 243 (61 %) were white. There were no significant demographic differences between the EC patients and inpatients. The median time from admission to PC was 12 h (range, 7–23 h) for the EC patients and 24 h (24–96 h) for the inpatients (p

Background. Delirium is a common neuropsychiatric condition seen in patients with severe illness, such as advanced cancer. Few published studies are available of the frequency, course, and outcomes of standardized management of delirium in advanced cancer patients admitted to acute palliative care unit (APCU). In this study, we examined the frequency,characteristics,andoutcomesofdeliriuminpatients with advanced canceradmitted to an APCU. Methods. Medical records of 609 consecutive patients admitted to the APCU from January 2011 through December 2011 were reviewed. Data on patients’ demographics; Memorial Delirium Assessment Scale (MDAS) score; palliative care specialist (PCS) diagnosis of delirium; delirium etiology, subtype, and reversibility; late development of delirium; and discharge outcome were collected. Delirium was diagnosed with MDAS score $7 and by a PCS using Diagnostic and Statistical Manual, 4th edition, Text Revision criteria. All patients admitted to the APCU received standardized assessments and management of delirium per best practice guidelines in delirium management. Results. Of556patientsintheAPCU,323(58%)hadadiagnosis of delirium. Of these, 229 (71%) had a delirium diagnosis on admissionand94(29%)developeddeliriumafteradmissionto the APCU.Delirium reversedin 85 of 323episodes (26%). Half of patients with delirium (n 5 162) died. Patients with the diagnosisofdeliriumhada lowermedianoverallsurvival than thosewithoutdelirium.Patientswhodevelopeddeliriumafter admission to the APCU had poorer survival (p # .0001) and alowerrateofdeliriumreversal(p5.03)comparedwiththose admitted with delirium. Conclusion. More than half of the patients admitted to the APCU had delirium. Reversibility occurred in almost one-third of cases. Diagnosis of delirium was associated with poorer survival.The Oncologist 2015;20:1425–1431 ImplicationsforPractice:Deliriumisthemostcommonneuropsychiatricconditioninpatientswithseveremedicalillnessandthose at the end of life. It can be a source of distress for patients, their families, and the medical team.When missed, or if symptoms are misinterpreted, delirium may also lead to unnecessary interventions.This underlines the importance of diagnosis and detection of deliriumin populationsthatare atincreasedrisk.This study hasimportantimplications inpractice,asitcan assistclinicians inmaking decisions regarding other medical interventions, advance care planning, and communicating with families relating to end-of-life issues.

The use of benzodiazepines to control agitation in delirium in the last days of life is controversial.To compare the effect of lorazepam vs placebo as an adjuvant to haloperidol for persistent agitation in patients with delirium in the setting of advanced cancer.Single-center, double-blind, parallel-group, randomized clinical trial conducted at an acute palliative care unit at MD Anderson Cancer Center, Texas, enrolling 93 patients with advanced cancer and agitated delirium despite scheduled haloperidol from February 11, 2014, to June 30, 2016, with data collection completed in October 2016.Lorazepam (3 mg) intravenously (n = 47) or placebo (n = 43) in addition to haloperidol (2 mg) intravenously upon the onset of an agitation episode.The primary outcome was change in Richmond Agitation-Sedation Scale (RASS) score (range, -5 [unarousable] to 4 [very agitated or combative]) from baseline to 8 hours after treatment administration. Secondary end points were rescue neuroleptic use, delirium recall, comfort (perceived by caregivers and nurses), communication capacity, delirium severity, adverse effects, discharge outcomes, and overall survival.Among 90 randomized patients (mean age, 62 years; women, 42 [47%]), 58 (64%) received the study medication and 52 (90%) completed the trial. Lorazepam + haloperidol resulted in a significantly greater reduction of RASS score at 8 hours (-4.1 points) than placebo + haloperidol (-2.3 points) (mean difference, -1.9 points [95% CI, -2.8 to -0.9]; P .001). The lorazepam + haloperidol group required less median rescue neuroleptics (2.0 mg) than the placebo + haloperidol group (4.0 mg) (median difference, -1.0 mg [95% CI, -2.0 to 0]; P = .009) and was perceived to be more comfortable by both blinded caregivers and nurses (caregivers: 84% for the lorazepam + haloperidol group vs 37% for the placebo + haloperidol group; mean difference, 47% [95% CI, 14% to 73%], P = .007; nurses: 77% for the lorazepam + haloperidol group vs 30% for the placebo + haloperidol group; mean difference, 47% [95% CI, 17% to 71%], P = .005). No significant between-group differences were found in delirium-related distress and survival. The most common adverse effect was hypokinesia (3 patients in the lorazepam + haloperidol group [19%] and 4 patients in the placebo + haloperidol group [27%]).In this preliminary trial of hospitalized patients with agitated delirium in the setting of advanced cancer, the addition of lorazepam to haloperidol compared with haloperidol alone resulted in a significantly greater reduction in agitation at 8 hours. Further research is needed to assess generalizability and adverse effects.clinicaltrials.gov Identifier: NCT01949662.

Purpose We examined the frequency and severity of financial distress (FD) and its association with quality of life (QOL) and symptoms among patients with advanced cancer in France. Design In this cross-sectional study, 143 patients with advanced cancer were enrolled. QOL was assessed using the Functional Assessment of Cancer General (FACT-G) and symptoms assessed using Edmonton Assessment System (ESAS) and Hospital Anxiety and Depression Scale (HADS). FD was assessed using a self-rated numeric scale from 0 to 10. Results Seventy-three (51%) patients reported having FD. Patients reported having FD were most likely to be younger (53.8 (16,7SD) versus 62 (10.5SD), p

Admissions to the emergency department (ED) can be distressing to patients with advanced cancer receiving palliative care. There is limited research about the clinical characteristics of these patients and whether these ED visits can be categorized as avoidable or unavoidable.To determine the frequency of potentially avoidable ED visits (AvEDs) for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center, identify the clinical characteristics of the patients receiving palliative care who visited the ED, and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs).We randomly selected 200 advanced cancer patients receiving treatment in the outpatient palliative care clinic of a tertiary cancer center who visited the ED between January 2010 and December 2011. Visits were classified as AvED (if the problem could have been managed in the outpatient clinic or by telephone) or UnAvED.Forty-six (23%) of 200 ED visits were classified as AvED, and 154 (77%) of 200 ED visits were classified as UnAvED. Pain (71/200, 36%) was the most common chief complaint in both groups. Altered mental status, dyspnea, fever, and bleeding were present in the UnAvED group only. Infection, neurologic events, and cancer-related dyspnea were significantly more frequent in the UnAvED group, whereas constipation and running out of pain medications were significantly more frequent in the AvED group (P0.001). In a multivariate analysis, AvED was associated with nonwhite ethnicity (odds ratio [OR] 2.66; 95% CI 1.26, 5.59) and constipation (OR 17.08; 95% CI 3.76, 77.67), whereas UnAvED was associated with ED referral from the outpatient oncology or palliative care clinic (OR 0.24; 95% CI 0.06, 0.88) and the presence of baseline dyspnea (OR 0.46; 95% CI 0.21, 0.99).Nearly one-fourth of ED visits by patients with advanced cancer receiving palliative care were potentially avoidable. Proactive efforts to improve communication and support between scheduled appointments are needed.

Oncologists need excellent communication skills to effectively handle challenging conversations regarding prognosis, transition to palliative care, code status, and other sensitive topics. Foundational skills include: 1) posing open-ended, exploratory questions, 2) allowing for appropriate silence in the conversation, 3) listening actively, 4) recognizing emotions, 5) responding to emotions with empathy rather than biomedical information, and 6) speaking with clarity by avoiding technical jargon and offering small chunks of information. Conversations about sensitive topics can be particularly challenging with geriatric patients, who experience functional and sensory limitations. The risk-benefit ratio of diagnostic and therapeutic interventions tips precariously in older patients as many develop geriatric syndromes. Older cancer patients have the unique perspective of looking back on a long life and looking forward to impending death. Higher order skills can be very powerful in helping geriatric cancer patients find meaning and dignity at the end of life. These skills include exploring spirituality and coping strategies and engaging the patient in conversation and reflection about their legacy.

Background: Caregivers of patients with advanced cancer often face physical, social, and emotional distress as well as spiritual pain. Limited research has focused on the spiritual aspects of caregivers’ suffering in the palliative care setting. Methods: We interviewed 43 caregivers of patients with advanced cancer in our palliative care outpatient clinic. We determined demographic characteristics, religious affiliation, and relationship to the patient. Levels of spirituality, religiosity, and spiritual pain were self-reported using numeric rating scales (0 = lowest; 10 = highest). The participants completed various validated questionnaires to assess sleep disturbances, psychosocial distress, coping skills, and quality of life (QOL). Results: The median age was 52 years(range, 21-83); 29 (67%) were women, 34 (78%) were white, 7 (17%) were African American, and 2 (5%) were Hispanic; 39 (91%) were Christian, 1 (2%) was Jewish, and 1 (2%) was agnostic; 37(86%) were married; 18 (42%) were working full time; and 25(58%) were spouses. All considered themselves spiritual, and 98% considered themselves religious, with median scores of 8 (interquartile range, 6-10) and 8 (interquartile range, 4-9), respectively. All the caregivers reported that spirituality and religiosity helped them cope with their loved one’s illness, and many reported that spirituality and religiosity had a positive impact on their loved one’s physical (58%) and emotional (76%) symptoms. Spiritual pain was reported by 23 (58%), with a median score of 5 (interquartile range, 2-8). Caregivers with spiritual pain had higher levels of anxiety (median 10 vs 4; P = .002), depression (6 vs 2; P = .006), and denial (3 vs 2; P = .01); more behavioral disengagement (3 vs 2; P = 0.011) more dysfunctional coping strategies (19 vs 16; P < .001) and worse QOL (70 vs 51; P < .001) than those who did not have spiritual pain. Conclusions: The majority of caregivers of patients with advanced cancer considered themselves spiritual and religious. Despite this, there is high prevalence of spiritual pain in this population. Caregivers with spiritual pain experienced worse psychological distress and worse QOL. These findings support the importance of spiritual assessment of and spiritual support for caregivers in this setting.

Sleep disturbance (SD) is a significant source of distress for patients with cancer. Studies of patients with advanced cancer receiving palliative care to identify symptoms associated with the severity of SD are limited.In this study, we sought to identify the symptoms measured by the Edmonton Symptom Assessment Scale (ESAS) that are associated with SD, as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary aims of the study were to determine the association between occurrences of SD with occurrences of other symptoms and screening performance of the ESAS-Sleep item against the PSQI.We reviewed the completed ESAS and PSQI assessments of 101 patients with advanced cancer who were receiving palliative care and had been admitted to prospective clinical trials previously initiated by us. Patients with a PSQI score of ≥ 5 were considered to have an SD. The frequency and severity of the ESAS symptoms items, their correlation with each other, the PSQI score, and the screening performance of the ESAS-Sleep item were calculated.The median age of patients was 60 years. Most were white non-Hispanic (73%), had lung or breast cancer (41%), and were diagnosed with SD (85%). The PSQI score was correlated with the ESAS items of pain (r=0.27, P=0.006), dyspnea (r=0.25, P0.001), well-being (r=0.35, P0.0001), and sleep (r=0.44, P0.0001). Compared with patients without SD, those with SD were more likely to report pain (P=0.0132), depression (P=0.019), anxiety (P=0.01), and a poorer sense of well-being (P=0.035). An ESAS-Sleep item cutoff score of ≥ 3 (of 10) resulted in a sensitivity of 74% and a specificity of 73%.SD is associated with increased frequency of pain, depression, anxiety, and a worse sense of well-being. These four symptoms should be assessed in all patients with advanced cancer with a complaint of SD. The ideal cutoff point of the ESAS-Sleep item for screening for SD is a score of ≥ 3. More research is needed to better characterize this frequent and distressing syndrome.

BACKGROUND: The symptom burden of intensive care unit (ICU) patients who are referred to a palliative care team (PCT) has not been characterized to the authors' knowledge, and the response of these symptoms to the palliative care intervention has not been reported. METHODS: The authors retrospectively reviewed PCT consults for ICU patients who were seen between July 2006 and October 2007. To characterize symptom distress and outcomes in ICU patients who were referred to PCT in a cancer center, information and descriptive statistics about patients' demographics, comorbidities, PCT findings, interventions, and outcomes were obtained. The chi-square test was used to analyze ICU and PCT mortality, and the signed-rank test was used to analyze PCT interventions. RESULTS: Of 1637 PCT consults, 88 consults (5%) were from the ICU. The median patient age was 60 years (range, 22-87 years), and 41 patients (46%) were women. The types of cancers were hematologic (19 patients; 22%), gastrointestinal (19 patients; 22%), lung (18 patients; 20%), and others (24 patients; 26%). Nineteen patients were on mechanical ventilation (MV), and 24 patients were on bilevel positive airway pressure (BIPAP). The findings were delirium (71 patients; 81%), dyspnea (67 patients; 76%), pain (74patients; 84%), fatigue (84 patients; 95%), and anxiety (57 patients; 65%). The interventions used were opioid management (99%), steroids (70%), antipsychotics (76%), and counseling (100%), do not resuscitate conversion (62 of 88 patients; 70%), withdrawal of MV (15 of 19 patients; 79%), and withdrawal of BIPAP (26 of 26 patients; 100%). Improvement was reported in pain (67 patients; 90%), dyspnea (60 patients; 90%), anxiety (51 patients; 80%), and delirium (31 patients; 44%). Thirty-five patients (40%) were transferred to the palliative care unit (PCU). Fifty-one ICU/PCT patients (58%) died during admission versus 130 of 1549 (8%) non-ICU PCT patients (P < .0001). Twenty-three of 35 patients who were transferred to the PCU (66%) died there versus 212 of 629 patients (34%) who were admitted to the PCU from another service (P < .0001). Thirty-seven of 88 ICU/PCT patients (42%) were discharged alive. CONCLUSIONS: ICU patients who are referred to the PCT have severe symptom distress. The PCT was able to identify multiple problems and make numerous pharmacologic and nonpharmacologic recommendations that improved these symptoms, including the participation in do not resuscitate conversion and withdrawal of MV and BIPAP. Although many patients in this population died, a significant subset, including those who were transferred to the PCU, survived to discharge. Cancer 2009. © 2009 American Cancer Society.

Alcoholism is a devastating disease that can cause patient and family suffering and is frequently underdiagnosed. Preliminary studies suggest that it is associated with increased symptom expression and opioid dose escalation. The CAGE questionnaire is a widely used tool for alcoholism screening. The purpose of this study was to determine the frequency and characteristics of patients who screen positive for alcoholism in a palliative care outpatient clinic (PCOC).We reviewed 665 consecutive charts of patients referred to the PCOC and collected data regarding age, gender, and type of cancer. For the first 100 consecutive CAGE positive (CAGE+) and 100 consecutive CAGE negative (CAGE-) patients, time from advanced cancer diagnosis (AC) to PCOC was calculated, and symptoms (Edmonton Symptom Assessment Scale, ESAS) and Morphine Equivalent Daily Dose (MEDD) were collected.CAGE was available for 598 of 665 (90%) patients. Of 598 patients, 100 (17%) were CAGE+. CAGE+ patients were younger (58 versus 60 years, p0.05), predominantly male (68% versus 47%, p0.0001), and with head/neck malignancies (24% versus 9%, p0.05). CAGE+ patients were referred earlier (5 +/- 27 months after AC, p0.0001). At baseline, pain, sleep, dyspnea, well-being, and total symptom distress were significantly worse among CAGE+ patients. Both groups showed similar improvement in symptoms. CAGE+ patients were more frequently on opioids upon referral (47/100 versus 29/100, p0.05) and follow-up (27/65 versus 16/68, p0.05). At follow-up, opioid doses did not show significant changes.Seventeen percent of the patients were CAGE+. These patients were referred earlier to palliative care, had more symptom expression, and were more frequently on opioids. The palliative care team successfully improved symptom control in both groups without opioid dose escalation.

Predicting inpatient mortality has clinical and financial implications and helps improve the care of patients with advanced cancer and their families. Models with excellent validity and reliability are available for mortality prediction in intensive care units. The purpose of the current study was to determine factors associated with increased likelihood of mortality in an acute palliative care unit (APCU). We retrospectively reviewed the medical records of 500 patients admitted to the APCU. Basic characteristics and information on symptom intensity, vital signs, relevant laboratory tests, and the presence or absence of delirium were obtained from the records of the consultation that preceded the APCU admission. Univariate and multivariate analyses were conducted to compare characteristics of patients who died in the APCU with characteristics of those who were discharged alive. Of the 500 patients admitted to the APCU, 124 (25%) died. Factors that were jointly prognostic for death, using multivariate analysis were younger age (odds ratio [OR] for older patients [≥65] 0.43, 95% confidence interval [CI], 0.25−0.73, p

Pain in older cancer patients is a common event, and many times it is undertreated. Barriers to cancer pain management in the elderly include concerns about the use of medications, the atypical manifestations of pain in the elderly, and side effects related to opioid and other analgesic drugs. The care of older cancer patients experiencing pain involves a comprehensive assessment, which includes evaluation for conditions that may exacerbate or be exacerbated by pain, affecting its expression, such as emotional and spiritual distress, disability, and comorbid conditions. It is important to use appropriate tools to evaluate pain and other symptoms that can be related to it. Pain in older cancer patients should be managed in an interdisciplinary environment using pharmacologic and nonpharmacologic interventions whose main goals are decreasing suffering and improving quality of life. In this two-part article, the authors present a review of the management of pain in older cancer patients, emphasizing the roles of adequate assessment and a multidisciplinary team approach.

Pain in older cancer patients is a common event, and many times it is undertreated. Barriers to cancer pain management in the elderly include concerns about the use of medications, the atypical manifestations of pain in the elderly, and side effects related to opioid and other analgesic drugs. The care of older cancer patients experiencing pain involves a comprehensive assessment, which includes evaluation for conditions that may exacerbate or be exacerbated by pain, affecting its expression, such as emotional and spiritual distress, disability, and comorbid conditions. It is important to use appropriate tools to evaluate pain and other symptoms that can be related to it. Pain in older cancer patients should be managed in an interdisciplinary environment using pharmacologic and nonpharmacologic interventions whose main goals are decreasing suffering and improving quality of life. In this two-part article, the authors present a review of the management of pain in older cancer patients, emphasizing the roles of adequate assessment and a multidisciplinary team approach.

Delirium is considered to be multifactorial, especially in elderly patients and those with advanced cancer, and can cause significant distress. High baseline vulnerability at the end of life, combined with cachexia, hepatic impairment, general comorbidities, and impaired functional status, can make delirium difficult to correct. Nonetheless, approximately 50% of delirium episodes are potentially reversible and reversible causes should be investigated. Hypercalcemia is one of the reversible metabolic causes of delirium in patients with advanced cancer. Here, we present the case of a patient with metastatic small cell prostate carcinoma who presented to our palliative care clinic with uncontrolled symptoms. A thorough evaluation using appropriate assessment tools revealed that he had delirium, and hypercalcemia was found to be the major etiologic factor. An interdisciplinary team approach (including a nutritionist, pharmacist, counselor, social worker, chaplain, and case manager) was provided. With aggressive symptom management and correction of hypercalcemia and other reversible causes of delirium, the delirium was resolved and the symptoms were controlled. This case illustrates the importance of screening for delirium in patients with severe symptom distress and how the interdisciplinary management of reversible causes of delirium, including hypercalcemia, can improve patients' symptoms and quality of life.