Palliative care and oncology partnerships in real practice.

This article addresses the practical application of palliative care (PC) in the outpatient oncology setting. While information on this topic is scarce, data published by a few outpatient practices provide the basis for potential models of integrated care. In general, the perceived impact of integrating PC into standard oncology practice is positive for patients, providers, oncology practices, and the healthcare system as a whole. As the benefits of integrating PC into oncology practice continue to be realized, more data will become available.

Development of the CASH assessment tool to address existential concerns in patients with serious illness.

INTRODUCTION: Existential suffering in patients with serious illness significantly impacts quality of life, yet it remains a challenge to define, assess, and manage adequately. Improving upon understanding and practice in the existential domain is a topic of interest for palliative care providers. METHODS: As a quality improvement project, our palliative care team created an existential assessment tool utilizing a dialogue-oriented approach with four questions designed to identify sources of existential distress as well as strengths and challenges in coping with this distress. The tool utilized the mnemonic CASH, with each letter representing the core objective of the question. Providers who requested the palliative care consult were asked to evaluate the CASH assessment. On completion of the project, palliative care consultants evaluated the appropriateness of the CASH assessment tool. RESULTS: Patient responses to the CASH questions were insightful and reflected their beliefs, priorities, and concerns. Eight of nine providers found that the assessment enabled understanding of their patient. Seven noted a positive impact on their practice, and five reported an improvement in patient care after the assessment. The palliative care consultants who used the tool enjoyed using it, and half of them suggested changes to patient care based on their assessment. The most common reasons for not using the CASH assessment were inappropriateness to the consult, lack of perceived patient/caregiver receptiveness, or consultation service too busy. CONCLUSION: Our quality improvement project demonstrated that the CASH assessment tool is useful in ascertaining existential concerns of patients with serious illness. It enhances patient care by the primary team as well as the palliative care team. As a brief set of questions with an easy-to-remember mnemonic, the CASH assessment tool is feasible for a busy palliative consult service. Furthermore, the positive results of this project merit more rigorous evaluation of the CASH assessment tool in the future.

A randomized trial of the effectiveness of topical "ABH Gel" (Ativan(®), Benadryl(®), Haldol(®)) vs. placebo in cancer patients with nausea.

CONTEXT: The topical gel known as "ABH gel," comprising lorazepam (Ativan(®)), diphenhydramine (Benadryl(®)), and haloperidol (Haldol(®)), is frequently used to treat nausea because of its perceived efficacy, relatively low cost, and ease of use in the home setting. There are limited scientific data on this medication, however. Recent pilot studies showed no absorption of the active ingredients of the gel, prompting further prospective studies into the cause of the perceived efficacy in the clinical setting. OBJECTIVES: To determine any difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea. METHODS: A randomized, double-blind, placebo-controlled, crossover, noninferiority clinical trial was developed to test the hypothesis that there is no difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea. The primary outcome was the difference in nausea score (on a 0-10 scale) at baseline and at 60 minutes in each treatment group. The difference in the ABH gel-treated group compared with placebo was evaluated for noninferiority. Secondary outcomes included the number of vomiting episodes and side effects over time. RESULTS: The mean change in nausea score from baseline to 60 minutes after treatment in the ABH gel group was 1.7 ± 2.05 and 0.9 ± 2.45 for the placebo group (P = 0.42). The placebo group was found to be noninferior to the ABH gel group in reducing the nausea score. ABH gel also did not decrease vomiting events better than placebo (P = 0.34). Only one patient reported any side effects from the treatments in either arm of the study. CONCLUSION: ABH gel in its current formulation should not be used in cancer patients experiencing nausea.

Response to pain management among patients with active cancer, no evidence of disease, or chronic nonmalignant pain in an outpatient palliative care clinic.

UNLABELLED: Abstract Background: Outpatient palliative care clinics may be required to manage patients not typically seen by palliative care. These include patients treated for cancer who no longer have evidence of disease (NED) and patients with chronic pain but no life-limiting illness (NLLI). Treatment response may differ among these groups. OBJECTIVES: Our aim was to determine treatment response by change in pain scores and morphine equivalent daily dose (MEDD) between initial visit and first follow-up in patients with active cancer (AC), NED, and those with NLLI. METHODS: A retrospective review of 143 consecutive outpatients referred to a clinic staffed by the palliative care program was conducted. Pain treatment response was defined by a ≥ 2 point difference on the Numerical Rating Scale (NRS) or ≥ 30% reduction from baseline score. RESULTS: Ninety-four patients had pain scores at both initial and follow-up visits after a median of 29.0 days. Fifty percent had AC, 27% NED, and 23% NLLI. Mean (standard deviation [SD]) pain scores at baseline were not significantly different among AC 6.0 (2.5), NED 5.6 (2.5), and NLLI 6.8 (2.2) patients (p=0.22), but were significant at follow-up between AC 4.2 (2.7) and NLLI 6.0 (2.6) (p=0.03) groups. The percent of responders differed significantly between AC 57.4% and NED 20% groups (p=0.002). MEDD increased by 17.2 mg in AC, 40.9 mg in NED, and 18.1mg in NLLI patients (p=0.88).Benzodiazepine use was significantly more frequent in the NLLI group than the AC (p=0.025) and NED (p=0.002) groups. CONCLUSIONS: Although median pain scores improved at follow-up, less than half of patients were responders. Patients with AC had a significantly better response rate than NED patients and a lower pain score than NLLI patients at follow-up.

ABH gel is not absorbed from the skin of normal volunteers.

BACKGROUND: Lorazepam (Ativan(®)), diphenhydramine (Benadryl(®)), haloperidol (Haldol(®)) (ABH) topical gel is currently widely used for nausea in hospice because of perceived efficacy and low cost and has been suggested for cancer chemotherapy. However, there are no studies of absorption, a prerequisite for effectiveness. We completed this study to establish whether ABH gel drugs are absorbed, as a prerequisite to effectiveness. INTERVENTION: Ten healthy volunteers, aged 25 to 58 years (mean 37 years), two African Americans and eight Caucasian Americans, applied the standard 1.0 mL dose (2mg of lorazepam, 25mg of diphenhydramine, and 2mg of haloperidol in a pluronic lecithin organogel), rubbed on the volar surface of the wrists by the subject. MEASURES: Blood samples were obtained at 0, 30, 60, 90, 120, 180, and 240 minutes. Plasma concentrations were analyzed by liquid chromatography-tandem mass spectrometry using deuterated internal standards for each drug. OUTCOMES: No lorazepam or haloperidol was detected in any sample from any of the 10 volunteers down to a level of 0.05 ng/mL. Diphenhydramine was found in multiple plasma samples at concentrations >0.05 ng/mL in three patients, with the highest concentration of 0.30 ng/mL in one person at 240 minutes. Overall, five of 10 patients exhibited detectable diphenhydramine in one or more samples, supporting limited absorption. No subject noted any side effects. CONCLUSIONS/LESSONS LEARNED: As commonly used, none of the lorazepam, haloperidol, or diphenhydramine in ABH gel is absorbed in sufficient quantities to be effective in the treatment of nausea and vomiting. Diphenhydramine is erratically absorbed at subtherapeutic levels. The efficacy of ABH gel should be confirmed in randomized trials before its use is recommended.