Partner-guided cancer pain management at the end of life: a preliminary study.

This preliminary study tested the efficacy of a partner-guided cancer pain management protocol for patients who are at the end of life. Seventy-eight advanced cancer patients meeting criteria for hospice eligibility and their partners were randomly assigned to a partner-guided pain management training intervention, or usual care control condition. The partner-guided pain management training protocol was a three-session intervention conducted in patients' homes that integrated educational information about cancer pain with systematic training of patients and partners in cognitive and behavioral pain coping skills. Data analyses revealed that the partner-guided pain management protocol produced significant increases in partners' ratings of their self-efficacy for helping the patient control pain and self-efficacy for controlling other symptoms. Partners receiving this training also showed a trend to report improvements in their levels of caregiver strain. Overall, the results of this preliminary study suggest that a partner-guided pain management protocol may have benefits in the context of cancer pain at the end of life. Given the significance of pain at the end of life, future research in this area appears warranted.

Assisting couples to develop healthy relationships: effects of couples relationship education on cortisol.

INTRODUCTION: Couple conflict in unhappy marriages is suggested to impair individual health via chronic psychophysiological stress reactions in couples' everyday lives. As a consequence, we hypothesized that standard couples relationship education (CRE) would decrease psychophysiological stress, namely salivary cortisol levels, during couple conflict in the laboratory as compared to a standard psychological stress paradigm. We considered cortisol to be of particular interest in this context, as it mediates endocrine and immune responses to stress, and thus might influence couples' health. METHODS: Salivary cortisol was repeatedly investigated in 61 couples during (a) a standard psychological stress test with no relevance for the couples, and (b) a standard couple conflict discussion in the laboratory before and after CRE. In addition, increases in self-evaluated relationship quality were analyzed with regard to their influence on salivary cortisol. Data were analyzed using multilevel modeling. RESULTS: Cortisol responses to the couple-external psychological stress test were unaffected by CRE, but specifically cortisol responses during the couple conflict discussion were significantly reduced following CRE compared to pre-intervention levels. Moreover, cortisol decreases during conflict were partially mediated by increases in self-reported relationship quality following CRE. CONCLUSIONS: These data suggest that CRE might buffer the harmful effects of repeated conflict in close relationships. Rather than ameliorating overall stress resilience, CRE might thus specifically improve individual health through increased relationship quality and reduced HPA axis activity during couple conflict.

Caregiver-assisted coping skills training for patients with COPD: background, design, and methodological issues for the INSPIRE-II study.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a progressive illness characterized by airflow obstruction and dyspnea that afflicts over 12 million people and represents a leading cause of death in the United States. Not surprisingly, COPD is often associated with emotional distress and reduced psychosocial adjustment, which can negatively impact physical functioning and impair quality of life. However, the psychosocial consequences of COPD remain largely untreated. A previous randomized trial from our research team demonstrated that coping skills training (CST) can improve pulmonary-specific quality of life among pulmonary patients awaiting lung transplant (the INSPIRE study). To date, however, no studies have examined the effects of a caregiver-assisted CST intervention in patients with COPD with less severe disease. PURPOSE: INSPIRE II is a randomized clinical trial (RCT) funded by the NHLBI to evaluate the effects of telephone-based enhanced CST for patients with COPD and their caregivers compared to standardized medical care (SMC) including COPD education and symptom monitoring on medical outcomes, physical functioning, and quality of life. METHODS: Six hundred COPD patients and their respective caregivers recruited from Duke University and Ohio State University will be evaluated and randomized (in a 1:1 ratio) to enhanced CST (including sessions promoting physical activity, relaxation, cognitive restructuring, communication skills, and problem solving) or to SMC. The primary outcomes include all-cause mortality, COPD-related hospitalizations/ physician visits, and quality of life. These endpoints will be measured through self-report questionnaires, behavioral measures of functional capacity (i.e., accelerometer and six minute walk test) and pulmonary function tests (e.g., FEV(1)). RESULTS: This article reviews prior studies in the area and describes the design of INSPIRE-II. Several key methodological issues are discussed including the delivery of CST over the telephone, encouraging physical activity, and inclusion of caregivers as patient coaches to enhance the effectiveness of the intervention. LIMITATIONS: We recognize that SMC does not adequately control for attention, support, and non-specific factors, and that, in theory, non-specific effects of the intervention could account for some, or all, of the observed benefits. However, our fundamental question is whether the telephone intervention produces benefits over-and-above the usual care that patients typically receive. The SMC condition will provide education and additional weekly telephone contact, albeit less than the attention received by the CST group. We recognize that this attention control condition may not provide equivalent patient contact, but it will minimize group differences due to attention. We considered several alternative designs including adding a third usual care only arm as well as an education only control arm. However, these alternatives would require more patients, reduce the power to detect significant effects of our primary medical endpoints, and add a significant additional expense to the cost of the study that would make such an undertaking neither scientifically or financially viable. CONCLUSIONS: We believe that this novel approach to patient care in which caregivers are used to assist in the delivery of coping skills training to patients with COPD has the potential to change the way in which COPD patients are routinely managed in order to reduce distress, enhance quality of life, and potentially improve medical outcomes.