Pain and Palliative Care Pharmacotherapy Literature Summaries and Analyses

ABSTRACT

Timely and important studies are reviewed and commentaries provided by leading palliative care clinicians. Symptoms, interventions, and treatment-related adverse events addressed in this issue are optimizing buprenorphine antinociception with the addition of naltrexone; reliably assessing the internal state of persons with cognitive impairment, for the purpose of measuring perception of their sense of purpose; improving understanding of prognosis over time by means of early palliative care intervention in patients with non-small cell lung cancer (NSCLC); and examining reasons for cancer patients’ emergency department (ED) visits and outcomes of the visits.

KEYWORDS. :

• buprenorphene
• naltrexone
• dementia
• well-being
• purpose
• palliative care
• prognosis
• NSCLC
• emergency department
• ED utilization
• cancer center

Source

• Hay JL, La Vincente SF, Somogyi AA, Chapleo CB, White JM. Potentiation of buprenorphine antinociception with ultra-low dose naltrexone in healthy subjects. Eur J Pain. 2011;15:293–298.

GOAL PURSUIT AND PURPOSE IN PEOPLE WITH DEMENTIA

Background

To improve quality of care, it is important to recognize the first-hand experience of a person with dementia. Is there a relationship between self-reported levels of purpose in life, which is one aspect of well-being, and goal pursuit in people with dementia?

Design and Participants

Community-dwelling adults with dementia who demonstrated adequate comprehension of study procedures were recruited from adult daycare centers. Consenting individuals underwent baseline measures of dementia severity (modified Telephone Interview for Cognitive Status [TICS-m]), goal pursuit (Tenacious Goal Pursuit scale [TGP]), and purpose in life (Ryff's Purpose of Life scale). Subjects were then randomized to a goal-directed activity—completing a greeting card for a sick child or a soldier (n = 46)—or to a goal-undirected activity, completing their own design (n = 45). After the activity, subjects completed the Perceived Purpose scale, modifed from the Ryff's Purpose of Life scale to assess the participants’ perception of purpose in their experimental activity. Participants (N = 91) were mean age 75 years (± SD, 9), 77% female, 51% African American, and 47% European American. Mean TICS-m score was 19 (± SD, 6), indicative of mild to moderate dementia.

Results

Participants who scored higher on the TGP were more likely to score higher on the Purpose of Life scale (r = .5; P < .001) regardless of dementia severity. Correlations were also observed between goal pursuit and dementia severity (r = .4; P < .001) and between dementia severity and perceived purpose (r = .3; P < .01). Goal condition accounted for 59% of the variance in perceived purpose among goal-directed and goal-undirected (r = .77; P < .001; means = 40.46 and 25.38, respectively) conditions. Hierarchical regression suggested that dementia severity did not moderate the relationship between goal condition and perceived purpose.

Commentary

One of the central goals of palliative care is to improve quality of life. Ameliorating existential symptoms that decrease quality of life is as important as managing physical symptoms but requires first-hand experience with the person. The cognitive impairment present in individuals with dementia would seem to present a barrier to identifying internal states of well-being and purpose in life. This study suggests that a select population of individuals with mild to moderate dementia is able to participate in care that results in improvement of well-being. Obviously none would qualify for hospice utilizing dementia as a terminal diagnosis. Results show that people with cognitive impairment are able to provide reliable information about their internal state, and those who completed a goal-directed activity perceived a sense of purpose.

Bottom Line

Individuals with mild to moderate dementia may experience a greater sense of purpose and improved well being if engaged in goal-directed activities. Professionals who care for this population can design effective care interventions to manage existential symptoms.

Reviewer

Gregory J. Miller, MD, Utah Cancer Specialists, Salt Lake City, Utah, USA.

Source

• Mak W. Self-reported goal pursuit and purpose in life among people with dementia. J Gerontol B Psychol Soc Sci. 2011;66:177–184.

PERCEPTIONS OF PROGNOSIS AND GOALS IN PATIENTS WITH METASTATIC NSCLC

Background

It is important that terminally ill patients fully comprehend their prognosis in order to make sound medical decisions. Does early palliative care improve patient understanding of prognosis?

Design and Participants

This randomized, controlled trial compared early palliative care (PC) integrated with standard oncology care to standard oncology care alone in ambulatory patients newly diagnosed with metastatic non-small cell lung cancer (NSCLC). Intervention arm patients met with a PC provider at least monthly. Patients assigned to the standard care arm were permitted to seek PC consultation. Perceptions of prognosis and goals of therapy were assessed by modifications of two previously used self-report items: “My cancer is curable” (yes/no) and “The goals of my therapy are to “help me live longer” (yes/no), “try to make me feel better” (yes/no), or “get rid of all my cancer” (yes/no).” Assessments were administered at baseline and at 12, 18, and 24 weeks. Participants (N = 151) were mean age 65 years (±10 years), 52% female, and 97% white.

Results

At baseline, 32% of all participants believed their cancer was curable and 97% believed that the goal of treatment was to help them live longer; there was no difference between groups. At week 12, 40% (n = 17/43) of patients receiving standard care reported their cancer was curable versus 22% (n = 12/54) of the intervention group (P = .08). This difference remained at week 18 (36% [n = 13/36] vs. 18% (n = 12/45], respectively; P = .08) but leveled out by week 24. During the 6-month study period, more patients in the intervention group maintained or developed an accurate understanding that their cancer was not curable (83% of 57 patients vs. 60% of 47 patients; P = .02).

Commentary

The authors of this study aimed to determine whether early PC consultation affects perception of prognosis for patients with newly diagnosed metastatic NSCLC. Although there were many more PC visits among the intervention group patients, the proportion of patients reporting that their disease was curable did not differ significantly among groups at all time points. This may have been secondary to low respondent numbers for this question. Over time, however, more patients in the intervention group became accurate in understanding that their disease was incurable, and fewer patients in the intervention group opted for chemotherapy near the end of life. Because no standard tool was used during the PC visits, the authors could not draw any conclusions with regard to what specific process or component of PC consultation contributed to improved understanding among the intervention group.

Bottom Line

Early palliative care intervention can improve understanding of prognosis over time and may impact decision making. More studies are needed to determine which specific components of PC consultation are responsible for this improvement in patient understanding.

Reviewer

Aaron Olden, MD, MS, Unity Health System, Rochester, New York, USA.

Source

• Temel JS, Greer JA, Admane S, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol. 2011;29:2319–2326.

EMERGENCY DEPARTMENT USE BY PATIENTS WITH CANCER

Background

Patients with cancer utilize emergency department (ED) care for disease- and treatment-related problems as well as for unrelated health concerns. Why do patients with cancer seek ED care, and which patients are admitted to hospital?

Design and Participants

This population study used data collected from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), which includes a mandated statewide population-based database of ED visits. In 2008 this tool captured 4,190,911 recorded ED visits, representing over 99% of all ED visits made. Of those, 1% (37,760) of cancer-related visits were made by 27,644 patients, of whom 23% had more than one visit. The most prevalent cancer diagnoses were lung (27%), colorectal (8%), breast (6%), and prostate (6%). Fifty-one percent of patients were male, and the mean age was 64.5 years. Expected payment source was Medicare or Medicaid for 65% and private insurers for 24%.

Results

During the study year, 63% of cancer-related ED visits resulted in hospitalization. Fifty-five percent of visits occurred on holidays and weekends and 45% during weekday clinic hours. The most common chief complaints at cancer-related ED visits related to pain (n = 9000), followed by respiratory problems (n = 5856), gastrointestinal (GI) issues (n = 3280), malaise (n = 2577), neurologic issues (n = 2218), bleeding (n = 2164), fever (n = 2000), and injury (n = 1930). Patients with lung cancer were more likely to be admitted (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.38–1.54) than patients with other cancers listed as a primary or secondary diagnosis (OR, 1.6; 95% CI, 1.6–1.53).

Commentary

Although wide variations in cancer care exist across the United States,¹ trends identified in this single-state study have widespread implications for improved cancer care, particularly outpatient care, which is becoming more accessible at cancer centers.² Three salient points are apparent from study results. First, pain, dyspnea, and nausea and vomiting, accounting for over 40% of the chief complaints, are conceivably preventable or treatable in the outpatient arena. Second, 45% of the encounters occurred during the regular office hours. Would ED utilization for symptoms be different if patients had access to palliative care clinics? Finally, it is staggering that most of these visits resulted in hospitalization. We know that the financial, emotional, and physical costs surrounding hospitalization for patients and caregivers is sizeable. Could reduction in hospitalization be realized if preparative strategies were implemented before symptoms started or if symptom treatment began earlier in their evolution?

Bottom Line

Outpatient palliative care clinics should pay attention to the opportunities presented in these results as they could be used in applications to improve cancer care.

Reviewer

Stephen J. Bekanich, MD, University of Miami, Miami, Florida, USA.

Source

• Mayer DK, Travers D, Wyss A, Leak A, Waller A. Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. J Clin Oncol. 2011;29:2683–2688.

Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.