Nursing home hospital transfers in the terminally ill: night shift nurses matter!

BACKGROUND: French demographic projection expects an increasing number of older, dependent patients in the next few years. A large proportion of this population lives in nursing homes and their transfer to hospitals at the end of life is an ongoing issue. OBJECTIVE: This study explored the factors influencing the transfer of patients living in nursing homes to hospital at the end of life. DESIGN: We used a mixed-methods questionnaire developed by an expert group and assessing different characteristics of the nursing homes. PARTICIPANTS: All the nursing homes in the Rhône-Alpes area (n=680) were surveyed. RESULTS: We obtained 466 (68%) answers. We found that a palliative care programme was present in 336 (72%) nursing homes. The majority had a coordinating physician 428 (82%) and a mean number of 6 nurses for 83 beds, with 83 (18%) having a night shift nurse. There was a mean number of 19 deaths per nursing home during the recorded year. The main cause of death was dementia (41%), cancer-related death (13%). Death occurred mostly in the nursing home (14 74%). Night shift nurse attendance was significantly associated with the place of death: 27 deaths occurred in nursing homes with a night shift nurse versus 12 in those without one (p<0001). CONCLUSIONS: The location of the death of frail elderly patients is a major health issue that needs to be addressed. Our results suggests that the presence of a night shift nurse decreases the number of emergency transfers and deaths in the hospital.

Inequalities in Financial Distress, Symptoms, and Quality of Life Among Patients with Advanced Cancer in France and the U.S.

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 < .001; 100 [98%] vs. 48 [34%], p < .001,). QOL was rated higher by the U.S. patients than by the French (69 [SD, 18] vs. 63 [SD, 18], p = .003). French patients had more psychological symptoms such as anxiety (8 [SD, 4] vs. 6 [SD, 5], p = .008). Associations were found between FD and U.S. residence, FD and single status (0.907, p = .023), and FD and metastasis (1.538, p = .036). In contrast, negative associations were found between FD and older age (-0.052, p = .003) and FD and France residence (-3.376, p = .001). CONCLUSION: Regardless of health care system, FD is frequent in patients with advanced cancer. U.S. patients were more likely to have FD than French patients but reported better QOL. Further research should focus on factors contributing to FD and opportunities for remediation. IMPLICATIONS FOR PRACTICE: Suffering is experienced in any component of the lives of patients with a life-threatening illness. Financial distress (FD) is one of the least explored cancer-related symptoms, and there are limited studies describing its impact on this frail population. This study highlights the high frequency and severity of FD in patients with advanced cancer in the U.S. and France as well as its impact on their physical and emotional symptoms and their quality of life in these different health care systems. It is necessary for all health care providers to explore and evaluate the presence of FD in patients living with life-threatening illnesses.

Palliative care referral and associated outcomes among patients with cancer in the last 2†weeks of life.

BACKGROUND: Palliative care (PC) improves the quality of life of patients with advanced cancer. Our aim was to describe PC referral among patients with advanced cancer, and associated outcomes in an academic medical centre. METHODS: We reviewed the medical records of 536 inpatients with cancer who had died in 2010. Our retrospective study compared patients who accessed PC services with those who did not. Statistical analysis was conducted using non-parametric tests due to non-normal distribution. We also conducted a multivariate analysis using a logistic regression model including age, gender, type of cancer and metastatic status. RESULTS: Out of 536 patients, 239 (45%) had PC referral. The most common cancer types were respiratory (22%) and gastrointestinal (19%). Patients with breast cancer (OR 23.76; CI 6.12 to 92.18) and gynaecological cancer (OR 7.64; CI 2.61 to 22.35) had greater PC access than patients with respiratory or haematological cancer. Patients referred to PC had significantly less chemotherapy in the last 2 weeks of life than non-referred patients, with 22 patients (9%) vs 59 (19%; p<0.001). PC-referred patients had significantly fewer admissions to intensive care units in the last month of life than non-referred patients, with 14 (6%) vs 58 (20%; p<0.001). CONCLUSIONS: There was a large variation in access to PC according to the type of cancer. There is a need to improve collaboration between the PC service and the respiratory, cancer and haematology specialists. Further research will be required to determine the modality and the impact of this collaboration.

The Effect of Message Content and Clinical Outcome on Patients' Perception of Physician Compassion: A Randomized Controlled Trial.

BACKGROUND: In a previous randomized crossover study, patients perceived a physician delivering a more optimistic message (MO) as more compassionate and professional. However, the impact of the clinical outcome of the patient on patient's perception of physician's level of compassion and professionalism has not been previously studied. Our aim was to determine if the reported clinical outcome modified the patient's perception of physician compassion, professionalism, impression, and preference for physician. MATERIALS AND METHODS: One hundred twenty-eight advanced cancer patients in an outpatient Supportive Care Center were randomized to complete validated questionnaires about patients' perception of physician's level of compassion, professionalism, impression, and preference of physician for themselves and their family after watching scripted videos depicting a physician delivering an MO versus a less optimistic (LO) message followed by a clinical vignette depicting a worse outcome. RESULTS: Median age was 61 years and 55% were female. There was no difference in compassion score after the vignette in the MO and LO groups. However, there were significantly worse overall impression and professionalism scores in both the MO and LO groups after the vignette. In the MO group, preference for the physician for themselves and their family significantly decreased after the vignette. CONCLUSION: Seeing a worse clinical outcome did not change the patients' appraisal of an inappropriately optimistic physician. However, it reduced the overall impression of both physicians that conveyed an MO or an LO message and it also resulted in less likelihood of choosing the MO physician for themselves and their family. IMPLICATIONS FOR PRACTICE: The study found that a patient's perception of a physician's compassion did not change after reading a vignette describing a negative clinical outcome, regardless of whether the physician had given a more or a less optimistic message to the patient. However, the results suggested that patients perceived worse professionalism and overall physician impression scores for both more and less optimistic physicians and lower likelihood to choose the more optimistic physician for themselves and their family.

Financial distress in patients with advanced cancer.

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<0.001), single (33 (62%) versus 40(44%), p = 0.03) and had a breast cancer (26 (36%), p = 0.024). Patients with FD had a lower FACT-G score (59 versus 70, p = 0.005). FD decreased physical (14 versus 18, p = 0.008), emotional (14 versus 16, p = 0.008), social wellbeing (17 versus 19, p = 0.04). Patients with FD had higher HADS-D (8 versus 6 p = 0.007) and HADS-A (9 versus 7, p = 0.009) scores. FD was linked to increased ESAS score (59 (18SD) versus 67 (18SD), p = 0.005) and spiritual suffering (22(29SD) versus 13(23SD), p = 0.045). CONCLUSION: The high rate of patient-reported FD was unexpected in our studied population, as the French National Health Insurance covers specific cancer treatments. The FD was associated with a poorer quality of life. Having a systematic assessment, with a simple tool, should lead to future research on interventions that will increase patients' QOL.

Barriers to venipuncture-induced pain prevention in cancer patients: a qualitative study.

BACKGROUND: Procedural pain reduces the quality of life of cancer patients. Although there are recommendations for its prevention, there are some obstacles for its management. The purpose of this study was to analyze the barriers to procedural pain prophylaxis in cancer patients reflecting the views of the nurses. METHODS: We used qualitative methodology based on semi-structured interviews conducted with nurses, focusing on practices of venipuncture-induced and needle change for implantable central venous access port (ICVAP) pain management in cancer patients. A thematic analysis approach informed the data analysis. RESULTS: Interviews were conducted with 17 nurses. The study highlighted 4 main themes; technical and relational obstacles, nurses' professional recognition, the role of the team, and organizational issues. Participants understood the painful nature of venipuncture. Despite being aware of the benefits of the anesthetic patch, they did not utilize it in a systematic way. We identified several barriers at different levels: technical, relational and previous experience of incident pain. Several organizational issues were also highlighted (e.g. lack of protocol, lack of time). CONCLUSIONS: The prevention of venipuncture-induced cancer pain requires a structured training program, which should reflect the views of nurses in clinical practice.

Predictors of Trust in the Medical Profession among Cancer Patients Receiving Palliative Care: A Preliminary Study.

BACKGROUND: Trust influences healthcare through the willingness to seek care, disclose sensitive information, adhere to treatment, and satisfaction with care. Understanding factors that influence trust may help in physician-patient relationship particularly at end of life. OBJECTIVES: We explored the association between trust and other demographic and psychosocial factors. We also explored the performance of the single-item Degree of Trust scale (0 best to 10 worst) compared with the validated five-item Trust in Medical Profession scale (5 best to 25 worst). DESIGN: A secondary analysis of prospectively collected data was performed. Trust scores completed by 100 patients were correlated with age, gender, ethnicity, educational level, anxiety, depression, and hopefulness (Herth Hope Index [12 best to 48 worst]). SETTING/SUBJECTS: The study was conducted on 100 patients in an outpatient Supportive Care Center in a cancer center in Houston, Texas. RESULTS: Median age was 57 years (49-65), depression was 6 (3-9), and hopefulness was 22 (20-25). Trust in Medical Profession score was 13, 11-14 (median, IQR) and Degree of Trust score was 2, 1-4 (median, IQR) with moderate correlation (r = 0.587, p < 0.001). On evaluating performance of Degree of Trust scale to the validated Trust in Medical Profession scale, a moderately high performance was found (Youden's J = 0.73; Topleft = 0.21). Older age (p = 0.02) lower depression scores (p < 0.01) and more hopefulness (p = 0.01) were associated with higher levels of trust. CONCLUSIONS: Trust was associated with older age, less depressed, and more hopeful patients. A single 0-10 item trust scale was found to perform adequately compared with a multiple-item questionnaire.

Burnout among physicians in palliative care: Impact of clinical settings.

OBJECTIVE: Burnout syndrome is a work-related professional distress. Palliative care physicians often have to deal with complex end-of-life situations and are at risk of presenting with burnout syndrome, which has been little studied in this population. Our study aims to identify the impact of clinical settings (in a palliative care unit (PCU) or on a palliative care mobile team (PCMT)) on palliative care physicians. METHOD: We undertook a cross-sectional study using a questionnaire that included the Maslach Burnout Inventory (MBI), and we gathered sociodemographic and professional data. The questionnaire was sent to all 590 physicians working in palliative care in France between July of 2012 and February of 2013. RESULTS: The response rate was 61, 8% after three reminders. Some 27 (9%) participants showed high emotional exhaustion, 12 (4%) suffered from a high degree of depersonalization, and 71 (18%) had feelings of low personal accomplishment. Physicians working on a PCMT tended (p = 0.051) to be more likely to suffer from emotional exhaustion than their colleagues. Physicians working on a PCMT worked on smaller teams (fewer physicians, p < 0.001; fewer nonphysicians, p < 0.001). They spent less time doing research (p = 0.019), had fewer resources (p = 0.004), and their expertise seemed to be underrecognized by their colleagues (p = 0.023). SIGNIFICANCE OF RESULTS: The prevalence of burnout in palliative care physicians was low and in fact lower than that reported in other populations (e.g., oncologists). Working on a palliative care mobile team can be a more risky situation, associated with a lack of medical and paramedical staff.

Patient Perception of Physician Compassion After a More Optimistic vs a Less Optimistic Message: A Randomized Clinical Trial.

IMPORTANCE: Information regarding treatment options and prognosis is essential for patient decision making. Patient perception of physicians as being less compassionate when they deliver bad news might be a contributor to physicians' reluctance in delivering these types of communication. OBJECTIVE: To compare patients' perception of physician compassion after watching video vignettes of 2 physicians conveying a more optimistic vs a less optimistic message, determine patients' physician preference after watching both videos, and establish demographic and clinical predictors of compassion. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial at an outpatient supportive care center in a cancer center in Houston, Texas, including English-speaking adult patients with advanced cancer who were able to understand the nature of the study and complete the consent process. Actors and patients were blinded to the purpose of the study. Investigators were blinded to the videos observed by the patient. INTERVENTION: One hundred patients were randomized to observe 2 standardized, roughly 4-minute videos depicting a physician discussing treatment information (more optimistic message vs less optimistic message) with a patient with advanced cancer. Both physicians made an identical number of empathetic statements (5) and displayed identical posture. After viewing each video, patients completed assessments including the Physician Compassion Questionnaire (0 = best, 50 = worst). MAIN OUTCOMES AND MEASURES: Patients' perception of physician compassion after being exposed to a more optimistic vs an equally empathetic but less optimistic message. RESULTS: Patients reported significantly better compassion scores after watching the more optimistic video as compared with the less optimistic video (median [interquartile range], 15 [5-23] vs 23 [10-31]; P < .001). There was a sequence effect favoring the second video on both compassion scores (P < .001) and physician preference (P < .001). Higher perception of compassion was found to be associated with greater trust in the medical profession independent of message type: 63 patients observing the more optimistic message ranked the physician as trustworthy vs 39 after the less optimistic message (P = .03). CONCLUSIONS AND RELEVANCE: Patients perceived a higher level of compassion and preferred physicians who provided a more optimistic message. More research is needed in structuring less optimistic message content to support health care professionals in delivering less optimistic news. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02357108.

Financial Distress and Its Associations With Physical and Emotional Symptoms and Quality of Life Among Advanced Cancer Patients.

OBJECTIVE: There are limited data on the effects of financial distress (FD) on overall suffering and quality of life (QOL) of patients with advanced cancer (AdCa). In this cross-sectional study, we examined the frequency of FD and its correlates in AdCa. PATIENTS AND METHODS: We interviewed 149 patients, 77 at a comprehensive cancer center (CCC) and 72 at a general public hospital (GPH). AdCa completed a self-rated FD (subjective experience of distress attributed to financial problems) numeric rating scale (0 = best, 10 = worst) and validated questionnaires assessing symptoms (Edmonton Symptom Assessment System [ESAS]), psychosocial distress (Hospital Anxiety and Depression Scale [HADS]), and QOL (Functional Assessment of Cancer Therapy-General [FACT-G]). RESULTS: The patients' median age was 60 years (95% confidence interval [CI]: 58.6-61.5 years); 74 (50%) were female; 48 of 77 at CCC (62%) versus 13 of 72 at GPH (18%) were white; 21 of 77 (27%) versus 32 of 72 (38%) at CCC and GPH, respectively, were black; and 7 of 77 (9%) versus 27 of 72 (38%) at CCC and GPH, respectively, were Hispanic (p < .0001). FD was present in 65 of 75 at CCC (86%; 95% CI: 76%-93%) versus 65 of 72 at GPH (90%; 95% CI: 81%-96%; p = .45). The median intensity of FD at CCC and GPH was 4 (interquartile range [IQR]: 1-7) versus 8 (IQR: 3-10), respectively (p = .0003). FD was reported as more severe than physical distress, distress about physical functioning, social/family distress, and emotional distress by 45 (30%), 46 (31%), 64 (43%), and 55 (37%) AdCa, respectively (all significantly worse for patients at GPH) (p < .05). AdCa reported that FD was affecting their general well-being (0 = not at all, 10 = very much) with a median score of 5 (IQR: 1-8). FD correlated (Spearman correlation) with FACT-G (r = -0.23, p = .0057); HADS-anxiety (r = .27, p = .0014), ESAS-anxiety (r = .2, p = .0151), and ESAS-depression (r = .18, p = .0336). CONCLUSION: FD was very frequent in both groups, but median intensity was double among GPH patients. More than 30% of AdCa rated FD to be more severe than physical, family, and emotional distress. More research is needed to better characterize FD and its correlates in AdCa and possible interventions. IMPLICATIONS FOR PRACTICE: Financial distress is an important and common factor contributing to the suffering of advanced cancer patients and their caregivers. It should be suspected in patients with persistent, refractory symptom expression. Early identification, measurement, and documentation will allow clinical teams to develop interventions to improve financial distress and its impact on quality of life of advanced cancer patients.

Agreement for depression diagnosis between DSM-IV-TR criteria, three validated scales, oncologist assessment, and psychiatric clinical interview in elderly patients with advanced ovarian cancer.

BACKGROUND: Depression, a major outcome in cancer patients, is often evaluated by physicians relying on their clinical impressions rather than patient self-report. Our aim was to assess agreement between patient self-reported depression, oncologist assessment (OA), and psychiatric clinical interview (PCI) in elderly patients with advanced ovarian cancer (AOC). METHODS: This analysis was a secondary endpoint of the Elderly Women AOC Trial 3 (EWOT3), designed to assess the impact of geriatric covariates, notably depression, on survival in patients older than 70 years of age. Depression was assessed using the Geriatric Depression Scale-30 (GDS), the Hospital Anxiety Depression Scale, the distress thermometer, the mood thermometer, and OA. The interview guide for PCI was constructed from three validated scales: the GDS, the Hamilton Depression Rating Scale, and the Montgomery Asberg Depression Rating Scale (MADRS). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, revised (DSM) criteria for depression were used as a gold standard. RESULTS: Out of 109 patients enrolled at 21 centers, 99 (91%) completed all the assessments. Patient characteristics were: mean age 78, performance status ≥2: 47 (47%). Thirty six patients (36%) were identified as depressed by the PCI versus 15 (15%) identified by DSM. We found moderate agreement for depression identification between DSM and GDS (κ=0.508) and PCI (κ=0.431) and high agreement with MADRS (κ=0.663). We found low or no agreement between DSM with the other assessment strategies, including OA (κ=-0.043). Identification according to OA (yes/no) resulted in a false-negative rate of 87%. As a screening tool, GDS had the best sensitivity and specificity (94% and 80%, respectively). CONCLUSION: The use of validated tools, such as GDS, and collaboration between psychologists and oncologists are warranted to better identify emotional disorders in elderly women with AOC.

[Consultations in oncological supportive care mono-, multi-, ou interdisciplinary: What should we favour?]. / Consultations en soins de support oncologiques mono-, multi-, ou interdisciplinaires : que privilégier ?

According to the point 7.6 and 7.7 of the Cancer Plan 2014, all cancer patients should have access to supportive care. Indeed, the supportive care consultation in oncology is an important tool for the symptom management of cancer patients at all times of treatment. This consultation can be mono-disciplinary or multi-disciplinary (with different professions: physician, nurse, psychologist, social service assistant…) with or without integration (multidisciplinary or interdisciplinary). There are few studies focusing on the types of consultations (mono- or multidisciplinary) to promote based on their expected outcomes. After describing the different types of consultations (initial, follow-up, unscheduled, discharge) and having highlighted the main issues of these consultations, we will present the possible configurations. Our discussion will concern then the advantages and disadvantages of monodisciplinarity and different types of multidisciplinary highlighting the possible improvements. At the end of this work, after a brief synthesis of the different outcomes associated with each type of consultation, we would like to discuss the type of consultation to choose according to the outcomes.

Family caregivers' perceptions of depression in patients with advanced cancer: a qualitative study.

OBJECTIVE: Depression is a serious issue for cancer patients, resulting in impaired quality of life and probably shorter survival. However, many cancer patients with depression are not treated because of the difficulties in identifying depression within this population. Our study aimed to examine caregivers' perceptions of depression among advanced cancer patients. METHOD: This qualitative study employed semistructured interviews, and we analyzed data using grounded theory and qualitative methods. We recruited caregivers from our palliative care unit (PCU) at an academic medical center. RESULTS: We interviewed a total of 15 caregivers. Cancer patients' caregivers had a good theoretical knowledge of depression but also acknowledged that, in the context of cancer and because of their relationship with the patient, identification of depressive symptoms could be challenging. They considered themselves as partners in the patient's care with a supportive role. However, by assuming the role of partner in patient care, caregivers exposed themselves to emotional difficulties and an increased need for support and information. SIGNIFICANCE OF RESULTS: Our results suggest a significant impact of depression in advanced cancer caregivers, and it is therefore crucial that healthcare professionals develop educational programs targeting cancer patients' families as well as specific interventions to minimize the impact of the burden of patient care on caregivers.

Nurses' perceptions of depression in patients with cancer.

OBJECTIVE: Our study aimed at examining nurses' perceptions of depression in cancer patients and their role in its management. METHOD: We employed questionnaire-based semi-directed interviews. Participants were asked to classify 22 symptoms (related and specific to depression in cancer patients, related but not specific, and unrelated) as "very important," "important," "less important," or "not important" for the diagnosis of depression in cancer patients at two different timepoints (baseline and after a video education program). They were also asked to complete a questionnaire exploring their perceptions about depression and of their role in its systematic screening. We recruited nurses caring for cancer patients from four different departments (palliative care unit, hematology, medical oncology, and thoracic oncology) at an academic medical center. RESULTS: We interviewed 18 nurses and found that they had a good general knowledge of depression in cancer patients, with the majority of them being able to distinguish specific and important symptoms from nonspecific symptoms. Some nurses considered depression as a second-line symptom, and most did not employ a screening tool in their daily practice. All considered that they had a role to play in the management of depression, even as they acknowledged lacking specific training for that task. SIGNIFICANCE OF RESULTS: Our results suggest that limited resources­especially lack of training­affects nurses' ability to correctly manage depression in their cancer patients.

Screening for body image dissatisfaction in patients with advanced cancer: a pilot study.

BACKGROUND: Cancer and its treatment can significantly affect appearance and body integrity. A number of studies have explored the impact of cancer and its treatment on body image, primarily in head and neck and breast cancer. The aim of this pilot study was to examine the construct of body image dissatisfaction and its measurement using a single question in patients with advanced cancer. METHODS: Outpatients with advanced cancer were recruited (n=81). Assessments included Body Image Scale (BIS), Appearance Schema Inventory (ASI-R), Edmonton Symptom Assessment System (ESAS) with a total symptom distress score (TSDS) and two subscales scores (physical distress [PHS] and psychological distress [PSS]), Hospital Anxiety Depression Scale (HADS), and one question assessing the overall appearance satisfaction from the Multidimensional Body-Self Relations Questionnaire (MBSRQ). We also asked patients to rate the body image changes importance compared with five symptoms (pain, fatigue, depression, insomnia, lack of appetite). RESULTS: Forty-seven (58%) patients had a BIS score >10 (body image dissatisfaction) with a median of 11 (first-third quartiles, Q1-Q3; 5-16) and a median ASI-R of 3.1 (Q1-Q3; 2.8-3.5). Sensitivity and specificity of ≤3 for body image dissatisfaction in the single overall appearance question using the BIS as a standard was 0.70 and 0.71, respectively. BIS score was significantly correlated with ASI-R (r=0.248; p=0.025), age (r=-0.225; p=0.043), HADS-A (r=0.522, p<0.001), HADS-D (r=0.422, p<0.001), PSS score (r=0.371, p=0.001), PHS score (r=0.356, p=0.001), TSDS score (r=0.416, p<0.001), and the overall appearance question (MBSRQ; r=-0.449, p<0.001). CONCLUSION: Body image dissatisfaction was frequent and associated with symptom burden. A single item ≤3 has a sensitivity of 70% for body image satisfaction screening.

Family conferences in palliative care: a survey of health care providers in France.

CONTEXT: Family conferences are conducted to assist with end-of-life discussions and discharge planning. OBJECTIVES: This study describes the current practices of family conferences in palliative care units (PCUs) in France. METHODS: A cross-sectional descriptive survey was sent to each PCU in France (n = 113). Members of the interdisciplinary health care team (palliative care physician, nurse, psychologist, and social worker) who were active in each PCU at the time of the survey were asked to respond. RESULTS: Two hundred seventy-six of 452 responses (61%) were obtained from members of the health care team in 91 units (81%). Two hundred seventy-two of 276 health care providers (HCPs) (99%) reported conducting family conferences in their clinical practice. Only 13 participants (5%) reported that they followed a structured protocol. Most respondents completed the questionnaire: palliative care physicians (n = 225; 82%), nurses (n = 219; 79%), and psychologists (n = 181; 66%). The three primary goals of family conferences were to allow family members to express their feelings (n = 240; 87%), identify family caregivers (n = 233; 84%), and discuss the patient's plan of care (n = 219; 79%). The primary reasons for conducting a family conference were: the patient's illness was terminal (n = 216; 78%), family caregivers requested a conference (n = 208; 75%), or terminal sedation was required (n = 189; 69%). One hundred six of 452 HCPs (38%) reported that patients were not invited to participate. The primary indications and goals for a family conference were significantly different among the four health care disciplines. CONCLUSION: Most HCPs in our study conducted family conferences. However, most of the family conferences had no structured protocol, half of the participants preferred no patient participation, and a significant variation was noted in the primary indications and goals among disciplines.

[Audit: medical record documentation among advanced cancer patients]. / Audit : traçabilité de l'information dans la prise en charge de patients atteints de cancer en phase avancée.

Medical record documentation of cancer inpatients is a core component of continuity of care. The main goal of the study was an assessment of medical record documentation in a palliative care unit (PCU) using a targeted clinical audit based on deceased inpatients' charts. Stage 1 (2010): a clinical audit of medical record documentation assessed by a list of items (diagnosis, prognosis, treatment, power of attorney directive, advance directives). Stage 2 (2011): corrective measures. Stage 3 (2012): re-assessment with the same items' list after six month. Forty cases were investigated during stage 1 and 3. After the corrective measures, inpatient's medical record documentation was significantly improved, including for diagnosis (P = 0.01), diseases extension and treatment (P < 0.001). Our results highlighted the persistence of a weak rate of medical record documentation for advanced directives (P = 0.145).

[Depression and advanced cancer: agreement between different screening strategies]. / Dépression et cancer en phase avancée : concordance entre différentes stratégies de dépistage.

Depression is a frequent problem in advanced cancer patients. However, there is no systematic screening for depression in the majority of cancer center resulting in underdiagnosed depression among cancer patients. The main objective of this study was to assess the level of agreement between self-reported depression by the patient and the physician and nurse assessment using the same tools. One of the secondary objectives was to estimate the possibility of a systematic and repeated (at one month) assessment. We used two scales for depression screening: the Brief Edinburg Depression Scale (BEDS) and the depression item of the Edmonton Symptom Assessment System (ESAS). Twenty-nine patients were included and eight of them (28%) had a BEDS score >6 and benefited from the initiation or modification of their antidepressant treatment. At visit 2, 15 patients were seen again and BEDS score was found ≤6 for all of them. A moderate concordance was found between assessment using the BEDS by patient and physician's (κ=0.519) and low agreement was found between physician and nurse regardless of the tool used (κ from 0.071 to 0.313). Researches with larger cohorts are now needed to confirm the benefits of depression's screening in this frail population and also to assess available strategies.

Association between supportive care interventions and patient self-reported depression among advanced cancer outpatients.

PURPOSE: Advanced cancer patients often experience moderate to severe physical and emotional distress. One of the main components of emotional distress is depression. The objective of this study was to examine the association between supportive care interventions and patient self-reported depression (PSRD) among advanced cancer outpatients. METHODS: We included consecutive patients seen in the outpatient Supportive Care Center between February 2008 and February 2010 with at least one follow-up visit. We used the Edmonton Symptom Assessment Scale (ESAS) to assess their symptom intensity. Clinical improvement of PSRD was defined as an improvement of at least 30% between the initial visit and the first follow-up. We used logistic regression models to assess possible predictors of improvement in PSRD. RESULTS: We included 444 patients with a median age of 59 years (Q1-Q3; 51-65). The most common type of cancer was gastrointestinal (98, 22%). Out of the 444 patients, 160 (36%) reported moderate/severe depression at baseline (ESAS item score ≥ 4/10). Higher baseline depression intensity was significantly associated to anxiety (r = 0.568, p = 0.046), total symptom distress score (TSDS; r = 0.550, p < 0.001) and personal history of depression (r = 0.242, p = 0.001). Of the 160 patients, 90 (56%) with moderate/severe PSRD at baseline showed a significant improvement at the follow-up visit (p = 0.038). Improvement in anxiety, sedation, and feeling of well-being were associated with higher depression improvement (OR 7.93, CI 3.74-16.80 and OR 2.44, CI 1.09-5.46, respectively). CONCLUSIONS: More than 50% patients with moderate/severe PSRD significantly improved after one single supportive/palliative care consultation. Improvements of anxiety and sedation were independently associated with PSRD improvement.

Methadone rotation for cancer patients with refractory pain in a palliative care unit: an observational study.

BACKGROUND: Methadone has been reported to be as effective as morphine for cancer pain management. It is commonly used as an alternative opioid in case of insufficient relief. OBJECTIVE: Our aim was to assess efficacy and tolerance of opioid rotation to methadone for refractory cancer pain management in palliative care unit (PCU) inpatients. METHODS: All the patients undergoing opioid rotation to methadone from 2008 to 2011 in two PCUs (Lyon and Nice, France) were included. Pain assessments were undertaken on day 0 (D0), day 3 (D3), day 7 (D7), and day 14 (D14) using a visual analogue scale (VAS; 0-10) and the Douleur Neuropathique 4 (DN4) scale for neuropathic pain. Patients reported pain relief using a 4-point Likert scale (1=no relief; 4=important relief ). RESULTS: Nineteen patients (7 females) with a median age of 55 (Q1-Q3; 44-58) underwent methadone rotation. The most common type of cancer was gastrointestinal. Seventeen patients had a diagnosis of mixed pain syndromes. Morphine equivalent daily dose (MEDD) prior to switching was 480 mg (Q1-Q3; 100-1021), and at least two nonmethadone opioid rotations had already been done for 13 patients. Between D0 and D7, the VAS score decreased by 4 points (p<0.001). The DN4 score became negative on D7 for 11 of 17 patients (65%). On D7, 16 of 18 patients (89%) expressed moderate to greater than moderate pain relief. Methadone was discontinued in one patient on D7 because it was deemed ineffective and for 8 patients, who were unable to take oral drugs, it was discontinued after D14. CONCLUSION: Our results suggest that methadone is effective and well tolerated for refractory cancer pain.