Toward reducing racialized pain care disparities: Approaching cannabis research and access through the lens of equity and inclusion.

There is growing interest in cannabis use for cancer pain. This commentary aims to discuss the evidence surrounding cannabis use for cancer pain in the context of the long-racialized landscape of cannabis policies and the disparity in pain control among cancer patients holding minoritized racial identities. Much evidence surrounding both the benefits and harms of cannabis use in cancer patients, and all patients in general, is lacking. Although drawing on the research in cancer that is available, it is also important to illustrate the broader context about how cannabis' deep roots in medical, political, and social history impact patient use and health care policies. There are lessons we can learn from the racialized disparities in opioid risk mitigation strategies, so they are not replicated in the settings of cannabis for cancer symptom management. Additionally, the authors intentionally use the term "cannabis" here rather than "marijuana.: In the early 1900s, the lay press and government popularized the use of the word "marijuana" instead of the more common "cannabis" to tie the drug to anti-Mexican prejudice.

Patterns of Change in Pain-related Physical, Mental, and Social Health Outcomes in a Military Population.

OBJECTIVE: Military persons frequently experience pain conditions stemming from noncombat and combat injuries. This study assessed the patterns of change over time and the associations of pain intensity and interference with physical, mental, and social health domains in a military sample. METHODS: A secondary analysis of Pain Assessment Screening Tool and Outcomes Registry (PASTOR) was conducted using data collected over 10 months. Participants selected for analysis completed ≥3 assessments with an interval of ≥14 days between assessments. The Defense and Veterans Pain Rating Scale (DVPRS) measured average and worst pain intensity, and Patient-Reported Outcomes Measurement Information System (PROMIS®) T-scores measured pain and health outcomes. RESULTS: The sample (N = 190) majority reported being active duty (96%); serving in the U.S. Army (93%); and being enlisted (86%). The percent difference from assessment one to assessment three showed improvement for DVPRS average pain (-4.85%) and worst pain (-2.16%), and PROMIS Pain Interference T-score (-1.98%). Improvements were observed for all PROMIS outcomes except depression. The Defense and Veterans Pain Rating Scale average and worst pain intensity and PROMIS pain interference were strongly correlated with physical function. Multilevel models showed that an increase in average and worst pain, and pain interference were associated with a decrease in satisfaction with social roles. CONCLUSION: Analysis identified patterns of change over time in physical, mental, and social health outcomes, as well as associations important to understanding the complexities of pain. This work has implications for pain management nursing in ambulatory settings where ongoing collection and analyses of multivariable outcomes data can inform clinical care.

Development of the perceived miscommunication measure in the pediatric intensive care unit.

PURPOSE: Miscommunication between parents and healthcare providers in the Pediatric Intensive Care Unit (PICU) can affect family-provider relationships and outcomes. This paper reports on the development and psychometric testing of a measure for parent perceived miscommunication, defined as the failure to communicate clearly as perceived by relevant stakeholders in the PICU. DESIGN AND METHODS: Miscommunication items were identified through a review of the literature with interdisciplinary experts. In a cross-sectional quantitative survey, the scale was tested with 200 parents of children discharged from a PICU at a large Northeastern Level 1 Pediatric hospital. The psychometric properties of a 6-item miscommunication measure were assessed using exploratory factor analysis and internal consistency reliability. RESULTS: Exploratory factor analysis yielded one factor explaining 66.09% of the variance. Internal consistency reliability in the PICU sample was α = 0.89. As hypothesized, there was a significant correlation between parental stress, trust, and perceived miscommunication in the PICU (p < .001). Confirmatory factor analysis supported good fit indices in testing the measurement model (χ2/df = 2.57, Goodness of Fit Index (GFI) = 0.979, Confirmatory Fit Index (CFI) =0.993 and Standardized Mean Residual (SMR) = 0.0136). CONCLUSIONS: This new six-item miscommunication measure shows promising psychometric properties including content and construct validity, which can be further tested and refined in future studies of miscommunication and outcomes in PICU. PRACTICE IMPLICATIONS: Awareness of perceived miscommunication in the PICU can benefit stakeholders within the clinical environment by recognizing the importance of clear and effective communication and how language affects the parent-child-provider relationship.

Use of complementary and integrative health in cancer pain management among patients undergoing cancer treatments: a qualitative descriptive study.

BACKGROUND: Pain is a common symptom in patients undergoing cancer treatment. Despite recommendations for the stronger integration of complementary and integrative health (CIH) in cancer pain management, little is known about the individual experience of using this approach for cancer pain, particularly in certain populations such as African Americans. OBJECTIVE: This study aimed to describe the experiences of using CIH for pain in African American and White patients with cancer undergoing cancer treatments. METHODS: A secondary analysis of qualitative descriptive data from a subsample of patients with cancer in a parent study of their illness concerns was employed. Atlas.ti 8.0 was used for data management and qualitative analysis. Counts of participant-endorsed themes were tabulated to discern differences in themes by group. RESULTS: Of 32 participants (16 African American, 16 White), 22 reported CIH usage for cancer pain management, with equal distribution between groups (11 each). Three themes emerged: Approach to, Reasons for, and Barriers to CIH Use. Psychological approaches were most common (n = 15). Nutritional, physical, and combination approaches were less common and more often employed by White participants. Reasons for CIH use were to reduce opioid consumption or for an opioid adjuvant. Personal limitations and access issues contributed to Barriers to CIH use. CONCLUSIONS: Both African American and White patients used CIH for pain management while undergoing cancer treatments. However, some preferential differences in CIH approaches by race surfaced. Further research into these differences may uncover new ways of addressing disparities in cancer pain management with CIH.

International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

Fear of analgesic side effects predicts preference for acupuncture: a cross-sectional study of cancer patients with pain in the USA.

PURPOSE: Approximately one in two cancer patients globally are under-treated for pain. Opioids and other analgesics represent the mainstay of cancer pain management; however, barriers to their use are well-documented. We evaluated whether acupuncture would be a preferable treatment option among cancer patients with attitudinal barriers to pharmacological pain management. METHODS: We conducted a cross-sectional survey of cancer patients at a tertiary urban cancer center and eleven suburban/rural hospitals in the Northeastern United States. We assessed attitudinal barriers to pharmacological pain management with the Barriers Questionnaire (BQ-13). The BQ-13 consists of two subscales: pain management beliefs and analgesic side effects. We also asked patients whether they prefer acupuncture, analgesics, or have no preference between these two modalities for pain management. Covariates included sociodemographics, clinical characteristics, and attitudes/beliefs about acupuncture. We used logistic regression to examine the association between attitudinal barriers and acupuncture preference. RESULTS: Among 628 patients, 197 (31.4%) preferred acupuncture for pain management, 146 (23.3%) preferred analgesics, and 285 (45.4%) had no preference. The highest reported attitudinal barriers were fear of addiction and fear of analgesic-associated constipation and nausea. Adjusting for covariates, we found that attitudinal barriers related to fear of analgesic side effects were significantly associated with acupuncture preference (adjusted odds ratio [AOR] 1.45, 95% confidence interval [CI] 1.17-1.81), but barriers related to pain management beliefs were not (AOR 1.17, 95% CI 0.91-1.51). Attitudes/beliefs about acupuncture (i.e., greater expected benefits, fewer perceived barriers, and more positive social norms) and female gender also predicted acupuncture preference, whereas race and educational status did not. CONCLUSION: Acupuncture may be a preferable treatment option among cancer patients at risk of inadequately controlled pain due to fear of analgesic side effects. Evidence-based integration of acupuncture and analgesics, guided by patient treatment preferences, represents an essential aspect of patient-centered care and has potential to address unmet cancer pain management needs.

Gaps in the Use of Long-Acting Opioids Within Intervals of Consecutive Days Among Cancer Outpatients Using Electronic Pill Caps.

OBJECTIVE: This study describes individual cancer patients' nonuse of extended-release or long-acting (ER/LA) opioids, including periods of gap between opioid doses taken. DESIGN: Secondary analysis of a three-month observational study of prescribed ER/LA opioids monitored using electronic pill caps. SETTING: Two outpatient oncology clinics of a large health system in the Mid-Atlantic region. PARTICIPANTS: Inclusion was based on self-identified African Americans and whites, at least 18 years old, diagnosed with solid tumors or multiple myeloma. For the current analysis, the additional inclusion criterion was prescription of an oral ER/LA opioid for cancer pain to be taken around the clock. METHODS: The electronic monitoring period for each study participant was partitioned into intervals of days between days with one or more openings (using medication event monitoring systems) representing rates of ER/LA opioid nonuse over consecutive days and over time. RESULTS: Of the sample (N = 109), two-thirds of the cancer patients had some nonuse of prescribed ER/LA opioids, with one in four having nonuse during 31.5-87.5% of their electronic-monitoring periods. Nonuse over periods of five or more, six or more, and seven or more consecutive days occurred for 37.6%, 34.9%, and 30.3% of the participants, respectively. CONCLUSIONS: About one in three ambulatory cancer patients in this study had substantial gaps between days of ER/LA opioid use, potentially resulting in risk of overdose depending upon the prescribed ER/LA opioid type, dose, and length of the time the opioid was stopped and resumed at the previous dose. This phenomenon has received little to no attention in the opioid safety discourse.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

Parental Decision-Making in the Pediatric Intensive Care Unit: An Integrative Review.

Parents are commonly responsible for making health care decisions for their seriously ill children in the pediatric intensive care unit (PICU); however, the factors influencing their decisions may vary. This integrative review examined the empirical literature between 2013 and 2018 to understand factors pertaining to parents' decision-making about serious illness care of their children in the PICU. Seventeen studies met the inclusion criteria with three key findings. First, parent-clinician communication in the PICU is critical; second, most parents want to be the final decision-maker for their critically ill child; and third, parents' emotions, support systems, and the child's clinical status impact decision-making. Parental perspectives are important to consider when discussing serious illness care decisions for critically ill children. Further inquiry is needed into how the parent-clinician encounter impacts the decision-making process and subsequent outcomes in this population.

Bridging the Gap Among Clinical Practice Guidelines for Pain Management in Cancer and Sickle Cell Disease.

Opioids are a critical component of pain relief strategies for the management of patients with cancer and sickle cell disease. The escalation of opioid addiction and overdose in the United States has led to increased scrutiny of opioid prescribing practices. Multiple reports have revealed that regulatory and coverage policies, intended to curb inappropriate opioid use, have created significant barriers for many patients. The Centers for Disease Control and Prevention, National Comprehensive Cancer Network, and American Society of Clinical Oncology each publish clinical practice guidelines for the management of chronic pain. A recent JAMA Oncology article highlighted perceived variability in recommendations among these guidelines. In response, leadership from guideline organizations, government representatives, and authors of the original article met to discuss challenges and solutions. The meeting featured remarks by the Commissioner of Food and Drugs, presentations on each clinical practice guideline, an overview of the pain management needs of patients with sickle cell disease, an overview of perceived differences among guidelines, and a discussion of differences and commonalities among the guidelines. The meeting revealed that although each guideline varies in the intended patient population, target audience, and methodology, there is no disagreement among recommendations when applied to the appropriate patient and clinical situation. It was determined that clarification and education are needed regarding the intent, patient population, and scope of each clinical practice guideline, rather than harmonization of guideline recommendations. Clinical practice guidelines can serve as a resource for policymakers and payers to inform policy and coverage determinations.

Predictors of psychological distress and sleep quality in former family caregivers of people with dementia.

Objectives: The stress-related psychological symptoms experienced by informal family caregivers do not always improve or resolve after the death of the care recipient. The purpose of this study was to explore the independent associations of sociodemographic variables, personality and coping, environmental variables, and caregiver guilt with the sleep quality and psychological distress of former family caregivers of individuals with dementia following care recipient's death.Method: A cross-sectional, correlational study was conducted with a sample of 171 former family caregivers of people with dementia. Participants completed an online survey comprised of six instruments and demographic items. Caregiver personal variables (e.g. personality and coping), environmental variables, guilt, psychological distress (depressive and anxiety symptoms), and sleep quality were evaluated using psychometrically validated measures.Results: In bivariate analysis, post-caregiving guilt was significantly associated with depressive and anxiety symptoms (p < 0.01). After controlling for covariates, dysfunctional coping and neuroticism explained 32% of the variance in depressive symptoms (R2 = .52, ΔR2 = .32, F(5, 165) = 36.24, p < .001) and 24% of the variance in anxiety symptoms (R2 = .41, ΔR2 = .24, F(5, 165) = 22.65, p < .001), while dysfunctional coping, pre-loss depression, and extraversion accounted for 16% of the variance in sleep quality (R2 = .30, ΔR2 = .16, F(6, 164) = 11.44, p < .001).Conclusion: This study demonstrates the critical role of personal variables, including personality traits, coping strategies, and pre-loss depression, in explaining psychological distress and sleep quality in this sample of former dementia caregivers.

Factors Associated with Depression in African American Patients Being Treated for Cancer Pain.

BACKGROUND: Among cancer patients in the United States, African American cancer patients have the highest mortality rate and shortest survival rate. Although depression is known as a predictor of mortality in cancer and a potential barrier to health care utilization, research on depression in African American patients is limited. Cancer pain can interfere with an individual's ability to cope with depression. AIMS: To identify factors that are associated with a positive screening of depressive symptoms assessed by the PHQ-8 in African American patients treated for cancer pain. DESIGN: Secondary data analysis of a cross-sectional study of opioid adherence. SETTING: Medical oncology, palliative care, and radiation oncology clinics in Atlanta, Georgia. PARTICIPANTS/SUBJECTS: African American patients with cancer pain in the parent study. METHODS: Independent samples t-test was used to assess variable correlations with and without depressive symptoms. Adjusted logistic regression was conducted to identify factors that were associated with presence of depressive symptoms. RESULTS: Mean patient age was 55.6 years, and nearly 38% had a PHQ-8 score of >10 indicating presence of moderate to severe depressive symptoms. Participants with depressive symptoms had significantly higher means for anxiety and pain interference with mood than those without depressive symptoms. Factors that were significantly associated with depressive symptoms were anxiety, pain interfering with mood, and lack of involvement with a religious congregation. CONCLUSIONS: The findings of this study help to identify African American cancer patients at risk for depression and demonstrates the need for increased screening for depression in this underserved population.

Both Race and Insurance Type Independently Predict the Selection of Oral Opioids Prescribed to Cancer Outpatients.

BACKGROUND: Previous research suggests that racial disparities in patients' reported analgesic adverse effects are partially mediated by the type of opioid prescribed to African Americans despite the presence of certain comorbidities, such as renal disease. AIMS: We aimed to identify independent predictors of the type of opioid prescribed to cancer outpatients and determine if race and chronic kidney disease independently predict prescription type, adjusting for relevant sociodemographic and clinical confounders. DESIGN: We conducted a secondary analysis of a 3-month observational study. SETTING: Outpatient oncology clinics of an academic medical center. PARTICIPANTS/SUBJECTS: Patients were older than 18 years of age, self-identified as African American or White, and had an analgesic prescription for cancer pain. METHODS: Cancer patients (N = 241) were recruited from outpatient oncology clinics within a large mid-Atlantic healthcare system. RESULTS: Consistent with published literature, most patients (75.5%) were prescribed either morphine or oxycodone preparations as oral opioid therapy for cancer pain. When compared with Whites, African Americans were significantly more likely to be prescribed morphine (33% vs 14%) and less likely to be prescribed oxycodone (38% vs 64%) (p < .001). The estimated odds for African Americans to receive morphine were 2.573 times that for Whites (95% confidence interval 1.077-6.134) after controlling for insurance type, income, and pain levels. In addition, the presence of private health insurance was negatively associated with the prescription of morphine and positively associated with prescription of oxycodone in separate multivariable models. The presence of chronic kidney disease did not predict type of analgesic prescribed. CONCLUSIONS: Both race and insurance type independently predict type of opioid selection for cancer outpatients. Larger clinical studies are needed to fully understand the sources and clinical consequences of racial differences in opioid selection for cancer pain.

Patient Trade-Offs Related to Analgesic Use for Cancer Pain: A MaxDiff Analysis Study.

PURPOSE: Many patients with cancer pain deviate from prescribed analgesic regimens. Our aim was to elicit the trade-offs patients make based on their beliefs about analgesic use and rank utilities (importance scores) using maximum difference (MaxDiff) scaling. We also investigated if there were unique clusters of patients based on their analgesic beliefs. METHODS: This was a secondary analysis of a three-month, prospective observational study. Patients (N = 207) were self-identified African Americans and Whites, >18 years, diagnosed with multiple myeloma or solid tumor, and were prescribed at least one around-the-clock analgesic for cancer pain. MaxDiff analysis allowed us to identify patients utilities. Second, a cluster analysis assisted in ranking how analgesic beliefs differed by groups. Third, clusters were described by comparing key sociodemographic and clinical variables. RESULTS: Participants' beliefs were a significant factor in choices related to analgesic use (chi-square = 498.145, p < .0001). The belief, 'Pain meds keep you from knowing what is going on in your body', had the highest patient endorsement. Two distinct clusters of patients based on analgesic beliefs were identified; 'knowing body' was ranked as top priority for both clusters. The belief that cancer patients become addicted to analgesics was moderately important for both clusters. Severity of side effects was the only key variable significantly different between clusters (p = .043). CONCLUSIONS: Our findings support tailored pain management interventions that attend to individual beliefs about cancer pain and analgesic use. Future research should explore the relationship between analgesic utilities, actual analgesic taking behaviors, and how they impact patients' cancer pain outcomes.

A concept analysis of analgesic nonadherence for cancer pain in a time of opioid crisis.

BACKGROUND: Pain is one of the most common symptoms identified along the cancer trajectory. Among patients with moderate to severe cancer pain, nonadherence to prescribed analgesics may complicate treatment plans and exacerbate pain severity. Nonadherent behaviors are likely due to a number of individual/family, provider, and system level factors and may lead to negative pain-related outcomes. PURPOSE: The purpose of this concept analysis is to clarify the concept of analgesic nonadherence for cancer pain and qualify its utility in the context of the opioid crisis. METHOD: Walker and Avant's (2019) method for concept analysis was used. We integrated empirical evidence, relevant literature, and sociopolitical considerations related to the opioid crisis to provide critical and timely analysis. Data were collected from a search of PubMed, CINAHL, PsycINFO, and Scopus. The search yielded 418 individual records. Empirical articles using quantitative and qualitative methodologies pertaining to analgesic nonadherence for cancer pain in adult outpatient settings, written in English, with an abstract, and published between 2010 and 2018 were considered. Other relevant literature sources were used if additional criteria were met. A total of 33 records were selected for detailed review. FINDINGS: Few studies link analgesic nonadherence to patient outcomes highlighting a significant literature gap. Given the available evidence, a definition for analgesic nonadherence is proposed for future use in research, education, practice, and policy settings. DISCUSSION: The paucity of empirical data combined with the implications of the opioid crisis and conflicting pain management guidelines create uncertainty about the utility of analgesic nonadherence. The concept of analgesic nonadherence warrants further normative and empirical research to clarify the role of opioids and the meaning of nonadherence in shaping pain-related outcomes within the current sociopolitical environment.

What if Acupuncture Were Covered by Insurance for Pain Management? A Cross-Sectional Study of Cancer Patients at One Academic Center and 11 Community Hospitals.

OBJECTIVE: In response to the national opioid crisis, governmental and medical organizations have called for broader insurance coverage of acupuncture to improve access to nonpharmacologic pain therapies, especially in cancer populations, where undertreatment of pain is prevalent. We evaluated whether cancer patients would be willing to use insurance-covered acupuncture for pain. DESIGN AND SETTING: We conducted a cross-sectional survey of cancer patients with pain at one academic center and 11 community hospitals. METHODS: We used logistic regression models to examine factors associated with willingness to use insurance-covered acupuncture for pain. RESULTS: Among 634 cancer patients, 304 (47.9%) reported willingness to use insurance-covered acupuncture for pain. In univariate analyses, patients were more likely to report willingness if they had severe pain (odds ratio [OR] = 1.59, 95% confidence interval [CI] = 1.03-2.45) but were less likely if they were nonwhite (OR = 0.59, 95% CI = 0.39-0.90) or had only received high school education or less (OR = 0.46, 95% CI = 0.32-0.65). After adjusting for attitudes and beliefs in multivariable analyses, willingness was no longer significantly associated with education (adjusted OR [aOR] = 0.78, 95% CI = 0.50-1.21) and was more negatively associated with nonwhite race (aOR = 0.49, 95% CI = 0.29-0.84). CONCLUSIONS: Approximately one in two cancer patients was willing to use insurance-covered acupuncture for pain. Willingness was influenced by patients' attitudes and beliefs, which are potentially modifiable through counseling and education. Further research on racial disparities is needed to close the gap in utilization as acupuncture is integrated into insurance plans in response to the opioid crisis.

An Integrated Review of Cannabis and Cannabinoids in Adult Oncologic Pain Management.

OBJECTIVE: The objective of this paper is to review the available literature regarding the use of cannabis and cannabinoids in adult oncologic pain management. DESIGN AND DATA SOURCES: A integrative review was conducted on March 1, 2018 using PubMed, MEDLINE, CINAHL, Embase, and Scopus. A snowball method was used to extract studies included in systematic reviews that were not included in the primary literature search. REVIEW METHOD: Articles reviewed address the use of cannabinoids or cannabis for pain management in oncology patients, either as stand- alone or adjuvant therapy. RESULTS: The final number of articles included is nine articles. Of the nine studies reviewed, eight reviewed the effect of the cannabinoid THC on cancer pain, and one study reviewed the use of medicinally available whole plant cannabis. The following study types were included: multiple multi-center, randomized, placebo- controlled trials and two prospective observational survey studies. RESULTS AND CONCLUSIONS: Of the eight studies that reviewed the effect of the cannabinoid THC, five found THC to be more effective than placebo, one found THC to be more effective than placebo in American patients but ineffective in patients from other countries, and two found THC to be no more effective than placebo. The study that reviewed the effect of the whole plant cannabis found that there was a significant decrease in pain among those patients smoking cannabis. NURSING PRACTICE IMPLICATIONS: The lack of evidence in this field of research suggests a need to change policy surrounding cannabis research.

A concept analysis of the existential experience of adults with advanced cancer.

BACKGROUND: Attention to the existential dimension of an individual's experience during serious illness is important. However, existential concerns continue to be poorly defined in literature, leading to neglect in the clinical realm. PURPOSE: This concept analysis seeks to clarify the concept of the existential experience within the context of adults with advanced cancer. METHODS: Rodgers' evolutionary method of concept analysis was used. DISCUSSION: Existential experience in adults with advanced cancer is a dynamic state, preceded by confronting mortality, defined by diverse reactions to shared existential challenges related to the parameters of existence (body, time, others, and death), resulting in a dialectical movement between existential suffering and existential health, with capacity for personal growth. Personal factors and the ability to cope appear to influence this experience. CONCLUSION: These findings can drive future research and enhance clinician ability to attend to the existential domain, thereby improving patient experience at end-of-life.

Living with chronic pain: perceptions of breast cancer survivors.

PURPOSE: Breast cancer treatments may lead to chronic pain. For some breast cancer survivors (BCS), this experience can develop into the perception of living with chronic pain. The majority of BCS are postmenopausal and have hormone receptor-positive (HR+) breast cancer requiring aromatase inhibitors (AIs). Neither the prevalence nor risk factors associated with the perception of living with chronic pain among this population are well defined. METHODS: We conducted a cross-sectional survey among postmenopausal, HR+ BCS who previously took or were currently taking AIs. The primary outcome was patients' perception of living with chronic pain over the past 6 months. We measured pain and demographic and clinical variables. Multivariable logistic regression analysis was performed to evaluate risk factors associated with the perception of chronic pain. RESULTS: Among 1280 participants, 167 (13%) reported having the perception of living with chronic pain before their breast cancer diagnosis; 426 (34%) reported this perception after completion of non-hormonal cancer treatment. Seventy-eight percent of BCSs reported experiencing at least one type of treatment-related pain within the past 7 days, with 23% experiencing at least three types. The most common types of pain were AI-induced musculoskeletal pain (49%) and pain at the surgery or radiation site (31%). Younger age (< 56), BMI > 25, and the perception of living with chronic pain before diagnosis were risk factors associated with the perception of living with chronic pain. CONCLUSIONS: One in three postmenopausal, HR+ BCS considered themselves to be living with chronic pain. Effective interventions to reduce chronic pain are needed.

Utilizing Internet-based recruitment and data collection to access different age groups of former family caregivers.

As Internet accessibility grows among adults in the United States, researchers' utilization of Internet-based surveys and recruitment strategies has increased, but there is a paucity of knowledge about their use in different age groups of former dementia caregivers. The purpose of this secondary analysis is to describe 1) the use of Internet-based recruitment in obtaining a sample inclusive of young and middle aged (age 18-64), young-old (age 65-74), and older-old (age 75 and older) former dementia caregivers and 2) the feasibility of collecting data using an online survey in young and middle aged, young-old, and older-old former dementia caregivers. Utilizing convenience sampling, a four-step recruitment strategy encompassing a combination of Internet-based and non-Internet-based recruitment strategies was employed. Participants (N = 171) completed an online survey. Older-old, young-old, and young and middle-aged participants comprised 9%, 30%, and 61% of the sample respectively. All age cohorts provided minimal missing data using an online survey, but older-old participants required 15 additional minutes to complete the survey than young-old participants. Both cohorts of older adults were directed to the survey less frequently through online referral sources than young and middle-aged participants, and no older-old participants were referred via Facebook. All three age cohorts consisted of mostly white women. Internet-based surveys and recruitment were feasible among the age groups but may present challenges for the older-old and minorities. Further research on Internet-based data collection and recruitment is indicated in minority and older-old caregivers, focusing on trust, educational and financial disparities, and technological proficiency as potential barriers.