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Background Chronic musculoskeletal pain (CMP) may lead to reduced physical function and is the most common cause of chronic non-cancer pain. Currently, the pharmacotherapeutic options against CMP are limited and frequently consist of pain management with non-steroidal anti-inflammatories, gabapentinoids, or opioids, which carry major adverse effects. Although the effectiveness of medical cannabis (MC) for CMP still lacks solid evidence, several patients suffering from it are exploring this therapeutic option with their physicians. Objectives Little is known about patients’ perceptions of their MC treatment for CMP. We aimed to increase this knowledge, useful for healthcare professionals and patients considering this treatment, by conducting a scoping literature review, following guidance by Arksey and O’Malley, to describe the views and perceptions of adult patients who had consumed MC to relieve chronic CMP. Methods Databases (PUBMED, EMBASE, Web of Science) and websites were searched using combinations of controlled and free vocabulary. All studies and study designs reporting on patients’ perceptions regarding MC against CMP were considered. Studies had to include adult patients reporting qualitatively or quantitatively, i.e., through questionnaires, on MC use to treat CMP or other non-cancer pain, since studies reporting exclusively on perceptions regarding CMP were very rare. Study characteristics were extracted and limitations of the study quality were assessed. The review includes patients’ demographic characteristics, patterns of MC use, perceived positive and negative effects, use of alcohol or other drugs, reported barriers to CM use, and funding sources of the studies. Results Participants of the 49 included studies reported that MC use helped them to reduce CMP and other chronic non-cancer pain, with only minor adverse effects, and some reported improved psychological well-being. In the included studies, men represent between 18 and 88% of the subjects. The mean age of participants in these studies (42/49) varied between 28.4 and 62.8 years old. The most common route of administration is inhalation. Conclusion MC users suffering from CMP or other chronic non-cancer pain perceived more benefits than harms. However, the information from these studies has several methodological limitations and results are exploratory. These user-reported experiences must thus be examined by well-designed and methodologically sound clinical or observational studies, particularly regarding CMP, where reports are very scarce.

ObjectivesDiagnosis of cancer is emotionally threatening not only for patients but also for their family caregivers (FC) who witness and share much of the illness experience. This study compares distress experienced by lung cancer patients and their FC during the year following the diagnosis.MethodsA prospective cohort study of 206 patients recently diagnosed with inoperable lung cancer (participation rate 79.5%) and 131 FC (participation rate 63.6%) was conducted in an ambulatory oncology clinic in Quebec City (Canada). They completed validated questionnaires regarding their personal and psychological characteristics (Hospital and Anxiety Depression Scale—HADS), in the first months after the diagnosis of lung cancer and after 6 and 12 months. Univariate, bivariate, and linear mixed models were conducted to compare patient and FC distress.ResultsAt baseline, 7.8% of patients reported distress (HADS total score >15) and their mean distress score was 7.0 ± 4.9 (range 0–42). In contrast, 33.6% of FC presented significant distress and their mean distress score was 12.0 ± 7.2 (P < 0.0001). Proportions of patients and FC with distress remained relatively stable at 6 and 12 months, and at every time point, FC reported higher levels of distress compared to their relative with cancer (P < 0.0001). Comparable trends were found when looking at the mean scores of distress, anxiety, and depression throughout the study.Significance of resultsBeing diagnosed with lung cancer and going through its different phases seems to affect more FC than patients. The psychological impact of such diagnosis appears early after the diagnosis and does not significantly change over time. These findings reinforce the importance for oncology teams, to include FC in their systematic distress screening program, in order to help them cope with their own feelings and be able to play their role in patient support and care throughout the cancer journey.

PurposeIn the absence of treatments for chemotherapy-induced peripheral neuropathy (CIPN), dose reductions (DR) and premature discontinuation (PD) are primary management strategies. However, decision-making guidance is insufficient and knowledge of factors associated with DR/PD is limited. We examined biopsychosocial factors associated with CIPN-related DR/PD in women undergoing taxane-based chemotherapy for early-stage breast cancer.Patients and methodsAs part of a longitudinal study of CIPN measurement, women completed assessments before the first taxane infusion and at the final infusion or within the originally expected timeframe for the final infusion. Participants completed self-report measures of CIPN, pain, and physical and psychosocial wellbeing, and underwent physical testing of lower limb disability and Quantitative Sensory Testing for sensation and pain threshold to thermal, vibration, and touch stimuli in the feet and hands. Sociodemographic and clinical data were collected. Logistic regression was used to identify factors associated with neuropathy-related DR/PD.ResultsAmong 121 participants, 66 (54.5%) received taxane-as-prescribed, 46 (38.0%) had neuropathy-related DR/PD, and 9 (7.4%) had DR/PD for other reasons. Factors associated with neuropathy-related DR/PD were receipt of paclitaxel (Odds Ratio [OR]=75.05, 95% Confidence Interval [CI] 2.56-2197.96]), lower pre-treatment pain catastrophizing (OR=0.72, 95% CI: 0.54 – 0.95), and higher post-treatment neuropathic pain (OR=10.77, 95% CI: 1.99 – 58.15) and sensitivity to cold pain in the hand (OR=1.64, 95% CI: 1.05 – 2.56).ConclusionCIPN-related DR/PD is associated with paclitaxel treatment and post-treatment neuropathic pain and cold pain sensitivity in the hands. CIPN communication to healthcare providers may be influenced by pain catastrophizing, suggesting symptom appraisal may be an important factor in communication. Findings could contribute to clinical practice recommendations to facilitate treatment decision-making.Lay summaryWe studied pre- and post-treatment factors associated with reduced taxane dose or early cessation due to chemotherapy-induced peripheral neuropathy in women undergoing chemotherapy for early-stage breast cancer. Reduced taxane dose or early cessation is associated with paclitaxel treatment, and high post-treatment neuropathic pain and sensitivity to cold pain stimuli in the hands. Communication of these experiences to healthcare providers may be influenced by pre-treatment thoughts and feelings about symptoms.Precis for use in the Table of Contentstwo concise sentences that state the significant conclusion(s) or message of the manuscript; Chemotherapy-induced peripheral neuropathy-related reduced taxane dose or premature discontinuation is associated with paclitaxel treatment and high post-treatment neuropathic pain and cold pain sensitivity in the upper limbs. Reporting of these experiences may be influenced by pre-treatment symptom appraisal and communication style.

Nous avons examine la qualite des soins fournis aux personnes âgees fragiles dans cinq provinces canadiennes a partir de donnees administratives sur la sante. Dans chaque province, nous avons considere les personnes âgees fragiles en fonction de deux cohortes : les personnes decedees et les personnes vivantes. Des regles de decision ont ete utilisees pour determiner quelles personnes etaient freles, soit celles residant en etablissement de soins de longue duree, qui etaient en phase terminale ou dont le profil correspondait a deux des sept domaines identifies. Ces domaines etaient fondes sur des echelles de fragilite, des discussions avec des geriatres et des indicateurs d'utilisation des services de sante. Nous avons evalue la qualite des soins a l'aide des indicateurs de qualite suivants : diminution de la duree de l'hospitalisation, diminution du nombre de readmissions a l'hopital, diminution du nombre de visites a l'urgence, augmentation de la continuite des soins fournis par un medecin de famille, diminution de l'utilisation de la ventilation mecanique et diminution du nombre d'admissions aux soins intensifs. A l'aide d'analyses de regression, nous avons egalement constate que le sexe masculin et l'âge avance etaient associes a une moins bonne qualite de soins dans les deux cohortes. Cette etude fournit des donnees de base qui permettront d'evaluer les futurs efforts visant a ameliorer la qualite des soins offerts aux personnes âgees fragiles. We examined the quality of care provided to older persons with frailty in five Canadian provinces, using administrative health data. In each province, we identified two cohorts of older persons with frailty: decedents and living persons. Using decision rules, we considered individuals to be frail if they were long-term care residents, terminally ill, or met at least two of seven domains, which were based on frailty scales, geriatrician discussions, and health service utilization indicators. We assessed quality of care using selected quality indicators: decrease in length of hospital stay, decrease in the number of in-patient readmissions, decrease in the number of emergency department visits, increase in the level of family physician continuity of care, decrease in the use of mechanical ventilation, and decrease in the number of admissions to intensive care. Using regression analyses, we also found male sex and older age were associated with poorer quality of care in both cohorts. This study provides baseline data for evaluating future efforts to improve the quality of care provided to older persons with frailty.

PURPOSE: Collaboration between family physicians (FPs) and oncologists can be challenging. We present the results of a randomized clinical trial of an intervention designed to improve continuity of care and interprofessional collaboration, as perceived by patients with lung cancer and their FPs. METHODS: The intervention included (1) supplying FPs with standardized summaries related to each patient, (2) recommending that patients see their FP after receiving the cancer diagnosis, (3) supplying the oncology team with patient information resulting from FP visits, and (4) providing patients with priority access to FPs as needed. A total of 206 patients with newly diagnosed lung cancer were randomly assigned to the intervention (n = 104) or control group (n = 102), and 86.4% of involved FPs participated. Perceptions of continuity of care and interprofessional collaboration were assessed every 3 months for patients and at baseline and at the end of the study for FPs. Patient distress and health service utilization were also assessed. RESULTS: Patients and FPs in the intervention group perceived better interprofessional collaboration (patients: P

ObjectiveFamily caregivers (FCs) of cancer patients often experience high distress. This randomized clinical trial assessed the feasibility and preliminary effects of an intervention to improve FC supportive care.MethodA pragmatic and minimal intervention to improve FC supportive care was developed and pretested with FCs, oncology team, and family physicians to assess its relevance and acceptability. Then, FCs of lung cancer patients were randomized to the intervention or the control group. The intervention included (1) systematic FC distress screening and problem assessment in the first months after their relative cancer diagnosis, and every 2 months after; (2) privileged contact with an oncology nurse to address FC problems, provide emotional support and skills to play their caregiving role; (3) liaison with the family physician of FCs reporting high distress (distress thermometer score ≥4/10) to involve them in the provision of supportive care. Distress, the primary outcome, was measured every 3 months, for 9 months. Secondary outcomes included quality of life, caregiving preparedness, and perceived burden. At the end of their participation, a purposive sample of FC from the experimental group was individually interviewed to assess the intervention usefulness. Content analysis was performed.ResultsA total of 109 FCs participated in the trial. FC distress decreased over time, but this reduction was observed in both groups. Similar results were found for secondary outcomes. However, FCs who received the intervention felt better prepared in caregiving than controls (p= 0.05). All 10 interviewed FCs valued the intervention, even though they clearly underused it. Knowing they could contact the oncology nurse served as a security net.Significance of resultsAlthough the intervention was not found effective, some of its aspects were positively perceived by FCs. As many of them experience high distress, an improved intervention should be developed to better support them.

Background Chronic musculoskeletal pain (CMP) may lead to reduced physical function and is the most common cause of chronic non cancer pain. Currently, the pharmacotherapeutic options against CMP are limited and mainly consist of pain management with gabapentinoids or opioids, which carry major adverse effects. Although the effectiveness of medical cannabis (MC) for CMP still lacks solid evidence, several patients suffering from it are exploring this therapeutic option.Objectives Little is known about MC users suffering from CMP. We aimed to increase this knowledge, useful for health care professionals and policy makers considering this treatment, as well as for researchers planning rigorous randomized clinical trials on the effectiveness of MC.Methods We conducted a scoping literature review, according to the methods developed by Arksey and O’Malley, to describe the views and perceptions of patients who had consumed MC to relieve chronic CMP and other non-cancer pain, as well as their demographic characteristics, patterns of MC use, and perceived positive and negative effects.Conclusion Our review shows that MC users are frequently young or middle-aged men, and that the preferred form of use was smoking. Participants of the included studies reported that MC use was helpful in reducing CMP and other chronic non-cancer pain with only minor adverse effects; in addition, they reported improved psychological well-being. Discussion The information from the included studies has several methodological limitations and is exploratory. MC use might, from the perspective of persistent users suffering from CMP and other chronic non-cancer pain, produce more benefits than harms. However, specific results for CMP are very scarce.

Objective:Prevalence rates of sleep difficulties in advanced cancer patients have varied widely across studies (12 to 96%), and none of these employed a diagnostic interview to distinguish different types of sleep–wake disorders. Moreover, very limited information is available on subjective and objective sleep parameters in this population. Our study was conducted in palliative cancer patients and aimed to assess rates of sleep–wake disorders and subsyndromal symptoms and to document subjective and objective sleep–wake parameters across various types of sleep–wake difficulties.Method:The sample was composed of 51 community-dwelling cancer patients receiving palliative care and having an Eastern Cooperative Oncology Group score of 2 or 3. Relevant sections of the Duke Interview for Sleep Disorders were administered over the phone. An actigraphic recording and a daily sleep diary were completed for 7 consecutive days.Results:Overall, 68.6% of the sample had at least one type of sleep–wake difficulty (disorder or symptoms): 31.4% had insomnia and 29.4% had hypersomnolence as their main sleep–wake problem. Participants with insomnia as their main sleep difficulty had greater disruptions of subjective sleep parameters, while objectively-assessed sleep was more disrupted in patients with hypersomnolence comorbid with another sleep–wake difficulty.Significance of the Results:The high rates of sleep–wake difficulties found in this study indicate a need to screen more systematically for sleep–wake disorders, including insomnia and hypersomnolence, in both palliative care research and clinical practice, and to develop effective nonpharmacological interventions specifically adapted to this population.

Contexte: En 2014, le Continuum des pratiques de collaboration interprofessionnelle en sante et services sociaux, un cadre de reference novateur, a ete developpe au Quebec afin d’habiliter les intervenants de differentes disciplines a ajuster leurs intentions de collaboration et leurs interactions avec leurs partenaires. Or, le developpement de leur capacite a utiliser cet outil avec aisance n’est pas sans embuche. Objectifs: Cet article presente la demarche systematique ayant conduit a la creation de la trousse Schem@CIP pour soutenir l’appropriation et l’utilisation des notions conceptuelles et theoriques du Continuum. Deux objectifs principaux etaient poursuivis : 1) Identifier les defis relatifs a l’appropriation du Continuum; 2) Developper des activites pedagogiques pour repondre aux defis identifies, integrees au sein d’une trousse pedagogique utile a la formation interprofessionnelle des futurs intervenants (milieux universitaires) et de ceux deja actifs dans les milieux cliniques. Methode: Les objectifs ont ete atteints a travers une demarche systematique et collaborative. D’abord un comite d’experts a identifie trois principaux defis pedagogiques rencontres dans les cours universitaires/formations faisant usage du Continuum. En lien avec ces defis, des activites pedagogiques incluant des scenarios cliniques ont ensuite ete elaborees. Resultats: Ce developpement a mene a la creation de la trousse pedagogique Schem@CIP pour les apprenants en formation initiale, pratique et continue. Conclusion: Reunir des partenaires d’expertises complementaires, engages et ouverts constitue une condition essentielle au developpement de contenus de formation interprofessionnelle adaptes aux clienteles apprenantes.

Introduction Chronic musculoskeletal pain (CMP) is one of the most common causes of chronic pain that leads to reduced physical function. Currently, the pharmacotherapeutic options against CMP are ...

BackgroundAt cancer diagnosis, it is unclear whether continuity of care (COC) between the patient and GP is safeguarded.AimTo identify patient–GP loss of COC around the time of, and in the year after, a cancer diagnosis, together with its determinants.Design and settingA post-hoc analysis of data from a prospective cohort of GPs in France, taken from a survey by the Observatoire de la Médecine Générale.MethodA prospective GP cohort (n = 96) filed data on patients who were diagnosed with incident cancer between 1 January 2000 and 31 December 2010. COC was assessed by ascertaining the frequency of consultations and the maximal interval between them. (In France, patients see their referring/named GP in most cases.) A loss of COC was measured during the trimester before and the year after the cancer diagnosis, and the results compared with those from a 1-year baseline period before cancer had been diagnosed. A loss of COC was defined as a longer interval (that is, the maximum number of days) between consultations in the measurement periods than at baseline. Determinants of the loss in COC were assessed with univariate and multivariate logistic regression models.ResultsIn total, 2853 patients were included; the mean age was 66.1 years. Of these, 1440 (50.5%) were women, 389 (13.6%) had metastatic cancer, and 769 (27.0%) had a comorbidity. The mean number of consultations increased up to, and including, the first trimester after diagnosis. Overall, 26.9% (95% confidence interval [CI] = 25.3 to 28.6) of patients had a loss of COC in the trimester before the diagnosis, and 22.3% (95% CI = 20.7 to 23.9) in the year after. Increasing comorbidity score was independently associated with a reduction in the loss of COC during the year after diagnosis (adjusted odds ratio [OR] comorbidity versus no comorbidity 0.61, 95% CI = 0.48 to 0.79); the same was true for metastatic status (adjusted OR metastasis versus no metastasis 0.49, 95% CI = 0.35 to 0.70).ConclusionAs COC is a core value for GPs and for most patients, special care should be taken to prevent a loss of COC around the time of a cancer diagnosis, and in the year after.

BackgroundGeneral practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. In order to maximise the impact of GPs and GPNs, the impact of different models of care that have been developed to support their practice of EoLC needs to be understood.ObjectiveTo examine published models of EoLC that incorporate or support GP and GPN practice, and their impact on patients, families and the health system.MethodSystematic literature review. Data included papers (2000 to 2017) sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 13 papers reported models of care supporting the GP and GPN’s role in EoLC or PC practice. Services and guidelines for clinical issues have mixed impact on improving symptoms, but improved adherence to clinical guidelines. National Frameworks facilitated patients being able to die in their preferred place. A single specialist PC-GP case conference reduced hospitalisations, better maintained functional capacity and improved quality of life parameters in both patients with cancer and without cancer. No studies examined models of care aimed at supporting GPNs.ConclusionsPrimary care practitioners have a natural role to play in EoLC, and most patient and health system outcomes are substantially improved with their involvement. Successful integrative models need to be tested, particularly in non-malignant diseases. Such models need to be explored further. More work is required on the role of GPNs and how to support them in this role.

BackgroundGeneral practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. To enhance primary EoLC, the facilitators and barriers to their provision need to be understood.ObjectiveTo provide a comprehensive description of the facilitators and barriers to GP and GPN provision of PC or EoLC.MethodSystematic literature review. Data included papers (2000 to 2017) sought from Medline, PsycInfo, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 62 reviewed papers reported the GP’s and GPN’s role in EoLC or PC practice. Six themes emerged: patient factors; personal GP factors; general practice factors; relational factors; co-ordination of care; availability of services. Four specific settings were identified: aged care facilities, out-of-hours care and resource-constrained settings (rural, and low-income and middle-income countries). Most GPs provide EoLC to some extent, with greater professional experience leading to increased comfort in performing this form of care. The organisation of primary care at practice, local and national level impose numerous structural barriers that impede more significant involvement. There are potential gaps in service provision where GPNs may provide significant input, but there is a paucity of studies describing GPN routine involvement in EoLC.ConclusionsWhile primary care practitioners have a natural role to play in EoLC, significant barriers exist to improved GP and GPN involvement in PC. More work is required on the role of GPNs.

Background Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either “generally”, “sometimes” or “exceptionally” appropriate for NH residents with severe dementia. Methods A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents’ families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran’s-Q tests. Results The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a “sometimes appropriate” medication post-intervention were 0.81 (95% CI: 0.71–0.92) and 0.83 (95% CI: 0.74–0.94), respectively. Conclusion A simple KE intervention using a medication review guidance tool categorizing medications as being either “generally”, “sometimes” or “exceptionally” appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention. Electronic supplementary material The online version of this article (10.1186/s12877-018-0895-z) contains supplementary material, which is available to authorized users.

Background High rates of sleep-wake difficulties have been found in patients with cancer receiving palliative care. Pharmacotherapy is the most frequently used treatment option to manage these difficulties despite numerous adverse effects and the absence of empirical evidence of its efficacy and innocuity in palliative care. Objective This pilot study aimed to assess the feasibility and acceptability of a cognitive-behavioral and environmental intervention (CBT-E) to improve insomnia and hypersomnolence in patients with a poor functioning level and to collect preliminary data on its effects. Methods Six patients with cancer receiving palliative care (Eastern Cooperative Oncology Group score 2-3), who had insomnia and/or hypersomnolence, received 1 CBT-E individual session at home. They applied the strategies for 3 weeks. Patients completed the Insomnia Severity Index, the Epworth Sleepiness Scale, a daily sleep diary, and a 24-hour actigraphic recording (7 days) at pretreatment and posttreatment, in addition to a semistructured interview (posttreatment). Results Participants found strategies easy to apply most of the time, and none was rated as impossible to use because of their health condition. However, their adherence and satisfaction toward CBT-E were highly variable. Results on the effects of CBT-E were heterogeneous, but improvements were observed in patients with a persistent insomnia disorder. Conclusions The CBT-E protocol tested among this highly selected sample was fairly well received and suggested positive outcomes in some patients, particularly those with an insomnia complaint alone. Implications Efforts should be pursued to adapt CBT-E and develop other nonpharmacological interventions, in order to provide an alternative to pharmacotherapy for sleep-wake difficulties in this population.

ObjectivesHigh rates of sleep difficulties have been found in patients with advanced cancer. However, not much is known about factors that are associated with sleep impairments in this population and that could constitute their potential risk factors or consequences. This study conducted in patients with cancer receiving palliative care aimed to evaluate the relationships of subjective (sleep diary; Insomnia Severity Index, ISI) and objective (actigraphy) sleep–wake variables with several physical and psychological symptoms, maladaptive sleep behaviours, erroneous beliefs about sleep, quality of life, time to death and environmental factors.MethodsThe sample was composed of 57 community-dwelling patients with cancer receiving palliative care and with an Eastern Cooperative Oncology Group Scale score of 2 or 3. Actigraphic, light and sound recording and a daily sleep and pain diary were completed for seven consecutive days. A battery of self-report scales was also administered.ResultsGreater disruptions of subjective and objective sleep–wake variables were more consistently associated with worse physical symptoms than with psychological variables. Disrupted objective sleep–wake parameters were also associated with a greater frequency of maladaptive sleep behaviours. Finally, a greater nocturnal noise in the bedroom was correlated with more impairments in subjective and objective sleep–wake variables while a lower 24-hour light exposure was associated with more disruption of subjectively assessed sleep only.ConclusionsAlthough longitudinal studies are needed to establish the etiology of sleep–wake difficulties in patients with advanced cancer, our findings suggest that physical symptoms, maladaptive sleep behaviours and environmental factors can contribute to their development or their persistence and need to be adequately addressed.

Context In Canada, governments have increased spending on home care to promote better end-of-life care. In the province of Quebec, Canada, home palliative care (PC) services (HPCS) are provided by Public Local Community-Based Health Care Service providers (Centres Locaux de Services Communautaires [CLSC]) with universal coverage. Accordingly, there should be no regional variations of these services and their effect on quality of end-of-life PC (QEoLPC) indicators. Objectives To test if all the CLSCs provided the same level of HPCS to cancer patients in the province of Quebec, Canada, and the association between level of HPCS and QEoLPC indicators. Methods Characteristics of 52,316 decedents with cancer were extracted from administrative databases between 2003 and 2006. Two gender-specific "adjusted performance of CLSCs in delivering HPCS" models were created using gender-specific hierarchical regression adjusted for patient and CLSC neighborhood characteristics. Using the same approach, the strength of the association between the adjusted performance of CLSCs in delivering HPCS and the QEoLPC indicators was estimated. Results Overall, 27,255 (52.1%) decedents had at least one HPCS. Significant variations in the adjusted performance of CLSC in delivering HPCS were found. Higher performance led to a lower proportion of men having more than one emergency room visit during the last month of life (risk ratio [RR] 0.924; 95% CI 0.867–0.985), and for women, a higher proportion dying at home (RR 2.255; 95% CI 1.703–2.984) and spending less time in hospital (RR 0.765; 95% CI 0.692–0.845). Conclusion Provision of HPCS remained limited in Quebec, but when present, they were associated with improved QEoLPC indicators.

Background: Improvement in the quality of end-of-life care for advanced dementia is increasingly recognized as a priority in palliative care. Aim: To evaluate the impact of a multidimensional intervention to improve quality of care and quality of dying in advanced dementia in long-term care facilities. Design: Quasi-experimental study with the intervention taking place in two long-term care facilities versus usual care in two others over a 1-year period. The intervention had five components: (1) training program to physicians and nursing staff, (2) clinical monitoring of pain using an observational pain scale, (3) implementation of a regular mouth care routine, (4) early and systematic communication with families about end-of-life care issues with provision of an information booklet, and (5) involvement of a nurse facilitator to implement and monitor the intervention. Quality of care was assessed with the Family Perception of Care Scale. The Symptom Management for End-of-Life Care in Dementia and the Comfort Assessment in Dying scales were used to assess the quality of dying. Participants: A total of 193 residents with advanced dementia and their close family members were included (97 in the intervention group and 96 in the usual care group). Results: The Family Perception of Care score was significantly higher in the intervention group than in the usual care group (157.3 vs 149.1; p = 0.04). The Comfort Assessment and Symptom Management scores were also significantly higher in the intervention group. Conclusions: Our multidimensional intervention in long-term care facilities for patients with terminal dementia resulted in improved quality of care and quality of dying when compared to usual care.

BackgroundEnd of life care (EoLC) is a fundamental role of general practice, which will become more important as the population ages. It is essential that general practice’s role and performance of at the end of life is understood in order to maximise the skills of the entire workforce.ObjectiveTo provide a comprehensive description of the role and performance of general practitioners (GPs) and general practice nurses (GPNs) in EoLC symptom control.MethodSystematic literature review of papers from 2000 to 2017 were sought from Medline, PsycINFO, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 46 papers reported GP performance in symptom management. There was no reference to the performance of GPNs in any paper identified. Most GPs expressed confidence in identifying EoLC symptoms. However, they reported lack of confidence in providing EoLC at the beginning of their careers, and improvements with time in practice. They perceived emotional support as being the most important aspect of EoLC that they provide, but there were barriers to its provision. GPs felt most comfortable treating pain, and least confident with dyspnoea and depression. Observed pain management was sometimes not optimal. More formal training, particularly in the use of opioids was considered important to improve management of both pain and dyspnoea.ConclusionsIt is essential that GPs receive regular education and training, and exposure to EoLC from an early stage in their careers to ensure skill and confidence. Research into the role of GPNs in symptom control needs to occur.

Background Family caregivers (FC) often experience higher distress levels than their relative with cancer. Many cancer centers have implemented distress screening programs, but most of them concentrate their efforts on patients, with little attention to their FC. To fill this gap, a pragmatic intervention has been designed to improve supportive care for FC of patients with lung cancer. This article describes the study protocol of a single-center randomized controlled trial to assess its effectiveness. Methods/design A total of 120 lung cancer patients and their FC are randomly assigned to the experimental group (exposed to intervention, N = 60) or to the control group (usual care, N = 60). The intervention includes: (1) systematic FC distress screening and problem assessment near their relative’s cancer diagnosis, and every 2 months, (2) privileged contact with an oncology nurse (ON) away from the patient to address FC problems and (3) liaison by the ON with the family physician of FC reporting high distress (thermometer score ≥5/10), or problems relying on FP expertise. In both groups, FC, patient and process-of-care outcomes are measured at baseline and every 3 months, up to 9 months. The primary endpoint is FC distress measured by the Hospital Anxiety and Depression Scale (HADS) and the Psychological Distress Index used in the Quebec Health Survey (PDQHS). Individual interviews with 10 FC and a focus group with the oncology team will be conducted at the study end to further document the effectiveness of the intervention and its impact on quality of life (for FC) and practice organization (for the oncology team). Discussion This trial will assess the effectiveness of an innovative intervention based on interprofessional collaboration between primary care and oncology care. It targets a population in great need, yet often neglected, and has the potential to clearly improve patient and caregiver experience of cancer care, and reduce the burden of disease. Trial registration ClinicalTrials.gov, ID: NCT02531464. Registered on 15 July 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2044-y) contains supplementary material, which is available to authorized users.

BackgroundGeneral practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide end-of-life care (EoLC) as the population ages. To enhance primary palliative care (PC), the care they provide needs to be understood to inform best practice models of care.ObjectiveTo provide a comprehensive description of the self-reported role and performance of GPs and GPNs in (1) specific medical/nursing roles, (2) communication, (3) care co-ordination, (4) access and out-of-hours care, and (5) multidisciplinary care.MethodSystematic literature review. Data included papers (2000 to 2017) sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 29 reviewed papers reported the GPs’ and GPNs’ role in EoLC or PC practice. GPs report a central role in symptom management, treatment withdrawal, non-malignant disease management and terminal sedation. Information provision included breaking bad news, prognosis and place of death. Psychosocial concerns were often addressed. Quality of communication depended on GP–patient relationships and GP skills. Challenges were unrealistic patient and family expectations, family conflict and lack of advance care planning. GPs often delayed end-of-life discussions until 3 months before death. Home visits were common, but less so for urban, female and part-time GPs. GPs co-ordinated care with secondary care, but in some cases parallel care occurred. Trust in, and availability of, the GP was critical for shared care. There was minimal reference to GPNs’ roles.ConclusionsGPs play a critical role in palliative care. More work is required on the role of GPNs, case finding and models to promote shared care, home visits and out-of-hours services.

Fillion et al. (2012) recently designed a conceptual framework for professional cancer navigators describing key functions of professional cancer navigation. Purpose: Building on this framework, this study defines the core areas of practice and associated competencies for professional cancer navigators. Methods: The methods used in this study included: literature review, mapping of navigation functions against practice standards and competencies, and validation of this mapping process with professional navigators, their managers and nursing experts and comparison of roles in similar navigation programs. Findings: Associated competencies were linked to the three identified core areas of practice, which are: 1) providing information and education, 2) providing emotional and supportive care, and 3) facilitating coordination and continuity of care. Conclusion: Cancer navigators are in a key position to improve patient and family empowerment and continuity of care. Implications: This is an important step for advancing the role of oncology nurses in navigator positions and identifying areas for further research. Key words: patient navigation, professional navigators, cancer patient navigator, pivot nurse in oncology, competency standards, empowerment, continuity of care, coordination of care, supportive care, collaborative care, specialized nurses, domains of practice, core areas of practice

Fillion et ses collaborateurs (2012) ont recemment concu un cadre conceptuel pour les navigateurs professionnels en oncologie decrivant les principales fonctions de la navigation professionnelle en oncologie. Objectif : Cette etude se fonde sur ce cadre pour definir les principaux domaines d’exercice et les competences associees des navigateurs professionnels en oncologie. Methodes : L’etude a fait appel aux methodes suivantes : revue de la litterature, schematisation des fonctions liees a la navigation au vu des normes et competences de pratique, et validation de ce processus de schematisation aupres de navigateurs professionnels, de leurs gestionnaires et de specialistes des soins infirmiers et comparaison des roles dans des programmes de navigation similaires. Constats : Les competences associees ont ete reliees aux trois principaux domaines d’exercice degages a savoir : 1) fournir de l’information et de l’education; 2) dispenser des soins de soutien et un appui emotionnel; 3) faciliter la coordination et la continuite des soins. Conclusion : Les navigateurs en oncologie occupent une position privilegiee pour ameliorer l’empowerment du patient et de sa famille ainsi que la continuite des soins. Implications : Il s’agit d’un pas important dans l’avancement du role des infirmieres en oncologie occupant des postes de navigateurs et dans le degagement de domaines exigeant de nouvelles recherches. Mots cles: navigation des patients; navigateurs professionnels; intervenant-pivot en oncologie; infirmiere pivot en oncologie; normes de competence; empowerment; continuite des soins; coordination des soins; soins de soutien, soins en collaboration, infirmiere specialisee, domaines de la pratique, principaux domaines d’exercice

Dans de nombreux programmes de lutte contre le cancer, la navigation en oncologie est devenue une strategie ciblee visant a ameliorer l’acces aux soins de soutien ainsi que l’experience des patients qui recoivent des soins en cancerologie. Cette etude vise a ameliorer la comprehension de la navigation professionnelle par la comparaison de deux modeles canadiens du role associe a la navigation professionnelle en oncologie : l’infirmiere pivot en oncologie (IPO) du Quebec et l’infirmiere responsable de la navigation professionnelle en oncologie (Cancer patient navigator—CPN) de la Nouvelle-Ecosse. Nous avons mene des entrevues qualitatives aupres de d’IPO et de CPN, de patients et de membres de leur famille, de membres du personnel de premiere ligne, de medecins et d’administrateurs des soins de sante (entrevues : n = 49; groupes de discussion : n = 10). Les deux modeles ont ete analyses au moyen du cadre conceptuel sur la navigation professionnelle (Fillion et al., 2012). Bien que les modeles soient differents, les resultats indiquent que les Intervenants pivots (IP) en oncologie des deux programmes ont des fonctions semblables et font face a des defis similaires. Cette etude met en relief la complexite et la valeur de la navigation en oncologie et recommande des mesures pertinentes qui visent a optimiser sa gestion au sein du systeme de soins.

Purpose/objectives To elaborate, refine, and validate the professional navigation framework in a Canadian context. Research approach A two-step approach consisting of a qualitative evaluative design and formal consultations. Setting Two applications of professional navigators in Quebec and Nova Scotia, Canada. Participants Patient navigators, medical oncology specialists, nurses and oncology staff, administrators, family physicians, patients with cancer, and patients' families and significant others. Methods Individual interviews (n = 49) and focus groups (n = 10) were conducted with professional navigators, patients and family members, front-line staff, family physicians, and health administrators. Formal consultations (n = 13) occurred with clinical experts, managers, and researchers from across Canada. Main research variables The interview guide was based on an evaluative conceptual framework integrating questions related to the implementation process of the role of professional navigators and their organizational and clinical functions. Findings Results support a bi-dimensional framework and define key role functions. The first dimension, health system-oriented, refers to continuity of care. The second dimension, patient-centered, corresponds to empowerment. For each dimension, related concepts were illustrated from data. Examples of outcomes also were suggested. Conclusions The framework brings clarity to the role and functions of professional navigators and suggests relevant outcomes for program evaluations. Interpretation With a clear definition of their role, professional navigators may be more efficient and less challenged in terms of setting priorities and making decisions while having to face demands from the health system and patients. The integrative framework could improve the effectiveness of cancer navigation programs.

Our goal was to develop evidence-based recommendations for the organization and structure of cancer survivorship services, and best-care practices to optimize the health and well-being of post&ndash, primary treatment survivors. This review sought to determine the optimal organization and care delivery structure for cancer survivorship services, and the specific clinical practices and interventions that would improve or maximize the psychosocial health and overall well-being of adult cancer survivors. We conducted a systematic search of the Inventory of Cancer Guidelines at the Canadian Partnership Against Cancer, the U.S. National Guideline Clearinghouse, the Canadian Medical Association InfoBase, medline (ovid: 1999 through November 2009), embase (ovid: 1999 through November 2009), Psychinfo (ovid: 1999 through November 2009), the Cochrane Library (ovid, Issue 1, 2009), and cinahl (ebsco: 1999 through December 2009). Reference lists of related papers and recent review articles were scanned for additional citations. Articles were selected for inclusion as evidence in the systematic review if they reported on organizational system components for survivors of cancer, or on psychosocial or supportive care interventions HOWELL et al. designed for survivors of cancer. Articles were excluded from the systematic review if they focused only on pediatric cancer survivor populations or on populations that transitioned from pediatric cancer to adult services, if they addressed only pharmacologic interventions or diagnostic testing and follow-up of cancer survivors, if they were systematic reviews with inadequately described methods, if they were qualitative or descriptive studies, and if they were opinion papers, letters, or editorials. Evidence was selected and reviewed by three members of the Cancer Journey Survivorship Expert Panel (SM, TC, TKO). The resulting summary of the evidence was guided further and reviewed by the members of Cancer Journey Survivorship Expert Panel. Fourteen practice guidelines, eight systematic reviews, and sixty-thee randomized controlled trials form the evidence base for this guidance document. These publications demonstrate that survivors benefit from coordinated post-treatment care, including interventions to address specific psychosocial, supportive care, and rehabilitative concerns. Ongoing high-quality research is essential to optimize services for cancer survivors. Interventions that promote healthy lifestyle behaviours or that address psychosocial concerns and distress appear to improve physical functioning, psychosocial well-being, and quality of life for survivors.

Screening for Distress is suggested as a first step to optimize response to cancer patients’ needs. This change of practice may positively impact coordination of care, a key function of professional cancer navigators. To describe the perceptions of implementing Screening for Distress with professional cancer navigators from the perspective of key actors in Quebec and Nova Scotia. A descriptive pre- and post-implementation study was performed. Interviews were conducted with professional navigators (pivot nurses in oncology from Quebec and cancer patient navigators from Nova Scotia), psychosocial and spiritual oncology staff from Quebec, and health administrators from both provinces, prior to and following the implementation process. Different actors described similar advantages and challenges within both sites. Screening for Distress was perceived as an important change of practice, improving oncology team functioning and patient-centered care. Recommendations to facilitate the implementation process were suggested. This study supports the relevance of involving professional navigators in the implementation process of Screening for Distress.

Resume L’augmentation constante et previsible de l’esperance de vie permet a un nombre croissant d’entre nous de pretendre a la vieillesse. Celle-ci s’accompagne inexorablement d’un accroissement du risque de developper et de cumuler des problemes de sante plus ou moins graves. Certains de ces problemes provoquent des douleurs aigues ou chroniques pour lesquelles une personne âgee en mesure de s’exprimer pourra obtenir un soulagement convenable de la part de professionnels competents. Outre les problematiques de sante physique, le grand âge s’accompagne ineluctablement d’une augmentation du risque de presenter les deficits cognitifs qui accompagnent la maladie d’Alzheimer et les maladies apparentees. Lorsqu’elle atteint les stades moderes et severes de ces maladies, la personne âgee deja physiquement souffrante devient egalement progressivement incapable de s’exprimer et d’obtenir le soulagement auquel elle peut toujours pretendre. Cette personne âgee vulnerable et fragile doit alors pouvoir compter sur des professionnels de la sante motives et competents, soutenus et encadres par des organisations pretes a traquer la douleur chez ceux qui ne communiquent plus mais n’en souffrent pas moins. Pour ce faire, des outils de detection et d’hetero-evaluation de la douleur de bonne qualite ont ete valides et sont disponibles. Il ne reste plus qu’a les utiliser, non pas isolement mais plutot dans le cadre de programmes de gestion rigoureux qui misent sur la sensibilisation, l’amelioration des connaissances et des competences ainsi que sur le monitoring systematique de la douleur par des equipes multidisciplinaires, permettant ainsi d’ameliorer notre efficacite collective a soulager la douleur.

Purpose This study aims to describe emotional distress and quality of life (QoL) of patients at different phases of their lung cancer and the association with their family physician (FP) involvement. Methods A prospective study on patients with lung cancer was conducted in three regions of Quebec, Canada. Patients completed, at baseline, several validated questionnaires regarding their psychosocial characteristics and their perceived level of FP involvement. Emotional distress [profile of mood states (POMS)] and QoL [European Organization for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30)] were reassessed every 3–6 months, whether patients had metastasis or not, up to 18 months. Results were regrouped according to cancer phase. Mixed models with repeated measurements were performed to identify variation in distress and QoL. Results In this cohort of 395 patients, distress was low at diagnosis (0.79±0.7 on a 0–4 scale), raising to 1.36±0.8 at the advance phase (p

BackgroundWith an increasing ageing population in most countries, the role of general practitioners (GPs) and general practice nurses (GPNs) in providing optimal end of life (EoL) care is increasingly important.ObjectiveTo explore: (1) patient and carer expectations of the role of GPs and GPNs at EoL; (2) GPs’ and GPNs’ contribution to advance care planning (ACP) and (3) if primary care involvement allows people to die in the place of preference.MethodSystematic literature review. Data sources: Papers from 2000 to 2017 were sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 51 papers were relevant. Patients and carers expect their GPs to be competent in all aspects of palliative care. They valued easy access to their GP, a multidisciplinary approach to care and well-coordinated and informed care. They also wanted their care team to communicate openly, honestly and empathically, particularly as the patient deteriorated. ACP and the involvement of GPs were important factors which contributed to patients being cared for and dying in their preferred place. There was no reference to GPNs in any paper identified.ConclusionsPatients and carers prefer a holistic approach to care. This review shows that GPs have an important role in ACP and that their involvement facilitates dying in the place of preference. Proactive identification of people approaching EoL is likely to improve all aspects of care, including planning and communicating about EoL. More work outlining the role of GPNs in end of life care is required.

Pain in older adults with severe limitations in ability to communicate is often assessed with observational methods. However, many of the behaviors that are used to assess pain often overlap with behavioral manifestations of delirium and depression. Such overlap can make the assessment of pain in patients with comorbid delirium and/or depression especially challenging. In this study, we assessed pain using the Doloplus-II (one of the most established pain assessment methods for seniors with dementia) and examined the extent to which each of its items were also predictive of delirium, depression, and dementia severity. As expected, several Doloplus-II items were found to be related to dementia severity, depression, and/or delirium. Clinicians assessing pain in dementia patients with comorbid depression or delirium should place less emphasis on items that have reduced specificity in identifying pain problems. Instead, assessment should be informed by items with higher specificity as well as other sources of information (e.g., results of physical examinations and information from caregivers). Although in this investigation we used the Doloplus-II to assess pain, it is likely that our findings generalize to other observational pain assessment measures developed for patients with dementia.

This study presents the validation of the French Canadian version (PACLSAC-F) of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). Unlike the published validation of the English version of the PACSLAC, which was validated retrospectively, the French version was validated prospectively. The PACSLAC-F was completed by nurses working in long-term care facilities after observing 86 seniors, with severe cognitive impairment, in calm, painful or distressing but non-painful situations. The test-retest and inter-observer reliability, the internal consistency, and the discriminent validity were found to be satisfactory. To evaluate the convergent validity with the DOLOPLUS-2 and the clinical relevance of the PACSLAC, it was also completed by nurses during their work shift, with 26 additional patients, for three days per week during a period of four weeks. These results encourage us to test the PACSLAC in a comprehensive program of pain management targeting this population.

Objective To identify the determinants of the intention of physicians to screen for decisional conflict in clinical practice. Background Screening for decisional conflict is one of the key competencies when educating health professionals about shared decision making. Theory-based knowledge about variables predicting their intention to screen for decisional conflict in clinical practice would help design effective implementation interventions in this area. Design Data of two cross-sectional surveys embedded within a large implementation study of the Ottawa Decision Support Framework (ODSF) in primary care. Setting and participants In total, 122 health professionals from five family practice teaching units. Methods Intention to screen for decisional conflict in clinical practice was defined as the intention to use the clinical version of the Decisional Conflict Scale (DCS) with patients at the end of the clinical encounter. It was assessed at the entry and the exit from this study. Both intentions were entered as a dependent variable in multivariate analyses. Main results At entry, the intention was influenced by: attitude (P

Resume Objectifs La dyspnee est un symptome dominant dans la maladie pulmonaire obstructive chronique severe. Malgre un traitement optimal, la dyspnee demeure difficile a soulager. Les opiaces ont un role dans la prise en charge de la dyspnee refractaire. Methodes Il s’agit d’une etude retrospective de 200 patients decedes entre 1998 et 2004. Les variables suivantes ont ete etudiees : le choix de l’opiace, la duree d’utilisation, les effets secondaires et la severite de la maladie sous-jacente. Resultats Les opiaces ont ete utilises chez 98 % des patients. Dans 70 % des cas, la duree d’utilisation a ete inferieure a 7 jours. Celle-ci a varie entre 1 et 1 030 jours. La morphine a ete l’opiace le plus frequemment utilise (188/192). Les effets secondaires ont ete : nausees (16/192), constipation (61/192). Il y a eu deux cessations d’opiaces pour de la constipation. La Paco 2 moyenne etait de 56 mmHg. Conclusion L’utilisation des opiaces chez les patients avec une maladie pulmonaire obstructive chronique severe est relativement bien toleree. Toutefois, la majorite des patients en recoivent seulement quelques jours avant le deces.

Interprofessional education (IPE) is increasingly recognized as a means to improve practice in health and social care. However, to secure interprofessional learning, it is important to create occasions in prelicensure health and social services curriculum so that students can learn with, from and about each other. This paper presents the process behind the development and implementation of an IPE curriculum in 10 health and social sciences programs by a team of professors from the faculties of medicine, nursing sciences and social sciences at Universite Laval in the province of Quebec, Canada. The pedagogical approach, description of primary objectives and issues related to its implementation in the curriculum programs are also described and discussed.

Purpose: To determine the effectiveness of a multicomponent clinical intervention to reduce pain in outpatients with cancer. Methods and Materials: Sixty-four patients were randomly assigned to receive either a clinical intervention including an information session, the use of a pain diary, and the possibility to contact a physician to adjust the pain medication, or the usual treatment of pain by the staff radiation oncologist. All patients reported their average and worst pain levels at baseline and 2 and 3 weeks after the start of the intervention. Results: The study groups were similar with respect to their baseline characteristics and pain levels at randomization. After 3 weeks, the average and worst pain experienced by patients randomized to the clinical intervention group was significantly inferior to the average pain experienced by patients in the control group (2.9/10 vs. 4.4/10 and 4.2/10 vs. 5.5/10, respectively). Results showed that the experimental group patients decreased their pain levels more than the control group patients did over time. Conclusion: An intervention including patient education, a pain diary, and defining a procedure for therapeutic adjustments can be effective to improve pain relief in outpatients with cancer.

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.