Improving cancer care at the end of life.

Excellent care for cancer patients and their families should extend throughout the illness, and should include care provided at the end of life. Recent evidence, including a report from the Institute of Medicine, has emphasised that major reform is needed to improve relief of pain, other symptoms, and psychosocial care. This paper reviews the critical necessity for reform in end-of-life care for the field of oncology and the major educational efforts required to ensure that oncology professionals can respond to this need.

Ethical dilemmas in pain management.

The purpose of this study was to survey the membership of the American Pain Society and the American Academy of Pain Medicine to determine their beliefs about ethical dilemmas in pain management practice. Respondents rated ethical dilemmas for their importance as well as their own competence in dealing with these ethical issues. The survey also included an open-ended question that asked respondents to describe clinical situations in which they had encountered ethical dilemmas. A total of 1,105 surveys were analyzed, with physicians (N = 612), nurses (N = 189), and psychologists (N = 166) representing the professions with the greatest response. Management of pain at the end of life, general undertreatment of pain, and undertreatment of pain in the elderly were the most frequently encountered dilemmas. Qualitative data were analyzed to identify ethical issues in the case examples provided by the respondents. Major themes included inappropriate pain management, barriers to care, interactions and conflicts with others, regulatory/legal issues, euthanasia, assisted suicide, and research issues. We conclude that ethical dilemmas are common in pain management practice and that resolution of these dilemmas requires commitment by individual professionals as well as health systems.

Nurses' personal opinions about patients' pain and their effect on recorded assessments and titration of opioid doses.

In many clinical settings, nurses have a vital role in pain assessment and titration of opioid doses. Surveys of nurses have revealed knowledge deficits in these areas that are thought to contribute to under-treatment of pain. The present study surveys nurses' decisions about assessment and treatment of pain in 2 patient situations and confirms that nurses continue to undertreat severe pain. As shown in previous studies, nurses may be more influenced by the patient's behavior than the patient's self-report of pain, especially in relation to decisions about opioid titration. Nurses are less likely to increase a previously safe but ineffective dose of opioid for a smiling patient than a grimacing patient. Survey results reveal a tendency for nurses' personal opinions about the patients' pain, rather than their recorded assessments, to influence choice of opioid dose and to contribute to undertreatment of pain.

Use of routine and breakthrough analgesia in home care.

PURPOSE/OBJECTIVES: To describe current use of routine analgesics in home care and the treatment of breakthrough pain. DESIGN: Descriptive, companion study. SETTING: Homecare agencies in southern California. SAMPLE: Convenience sample of 369 patients with cancer participating in a pain-education study. METHODS: Data regarding breakthrough pain were derived from the homecare medical records and patient interviews. MAIN RESEARCH VARIABLES: Analgesic medications prescribed and used for treatment of routine and breakthrough cancer pain. FINDINGS: Results demonstrate discrepancy between recommended pain management in clinical practice guidelines and the actual practice of pain management at home. Deficiencies were found in medications prescribed as well as in actual use by patients. CONCLUSIONS: Optimum relief of cancer pain is contingent on adequate treatment of routine and breakthrough pain, including greater use of recommended analgesics in adequate doses and clinical care consistent with clinical practice guidelines. IMPLICATIONS FOR NURSING PRACTICE: Breakthrough pain is a common problem affecting the quality of life of patients with cancer. Improved management of breakthrough pain is contingent on accurate pain assessment, optimum use of analgesics, and patient education. Nurses should address the important topic of breakthrough pain as new analgesic drugs and methods of delivery become available.

Patient and family caregiver perspectives.

The introduction of any new analgesic agent or delivery system is often focused on efficacy of the agent or on considerations of use by health care professionals. Introduction of novel pain technologies should also consider the ultimate recipients of the treatments, i.e., patients and family caregivers at home. This article reviews four frequently ignored issues in the integration of new pain treatments. These are 1) recognizing that pain is managed by patients and family caregivers at home; 2) acknowledging patient and family caregivers' knowledge and beliefs about pain; 3) recognizing cost considerations; and 4) identifying common ethical dilemmas in managing pain at home. Attention to these considerations will ensure optimum pain relief and support of patients and their family caregivers.

The meaning of quality of life in cancer survivorship.

PURPOSE/OBJECTIVES: To describe the meaning of quality of life (QOL) in long-term cancer survivors, to validate inductively derived QOL themes, and to identify and cluster over-arching themes across long-term cancer survivors. DESIGN: Qualitative study that was part of a larger, cross-sectional survey. SETTING/SAMPLE: 687 (57% response) cancer survivors at an average of 6.7 years after diagnosis. In the sample, 81% were female (with a mean age of 49.6 years), 72% were college educated, 63% were married, and 49% worked full time. METHODS: Mailed survey of three open-ended questions and standard QOL tools. A QOL conceptual model was used to frame the research study, describe the QOL responses of the participants, and explore the meaning of cancer survivorship. Content analysis was used to answer the research questions. Data collection and analysis occurred sequentially. MAIN RESEARCH CONCEPTS: Meaning, QOL cancer survivorship. FINDINGS: 25 of 30 inductively derived QOL themes were validated in this study of long-term cancer survivors; 107 additional QOL themes were identified and clustered into 11 over-arching themes across the entire data set. Over-arching themes included struggle between independence-dependence, balance, wholeness, life purpose, reclaiming life, multiple losses, having control, altered meaning of health, and surviving cancer from a family perspective. IMPLICATIONS FOR NURSING PRACTICE: The meaning of QOL in long-term cancer survivors is multifaceted and complex. CONCLUSIONS: Nurses can use this broader conception of QOL in breast cancer survivors to help patients prepare for and cope with adjustments.

Strengthening nursing education to improve end-of-life care.

The survey results provide future direction for nursing education. Results indicate an awareness in the nursing profession of the need for improved EOL care and identification of resources to achieve that goal. Many activities have been initiated within the nursing community, and the results of this project hopefully will stimulate additional activities. The imperative for improved EOL care will escalate in the future as our elderly population grows and a burdened health care system confronts the costs of chronic and terminal illness. Palliative care, which has traditionally been limited to hospice programs, must extend to other settings and be incorporated into the trajectory of care. The IOM report and other palliative care literature asserts that improved care for the dying will necessitate change at many levels. Patients and the general public must be educated to expect a higher standard of care at the EOL. Health care system changes are needed to improve access to care and to eliminate barriers such as regulatory constraints on prescribing opioids. However, central to all health care reform is the need for educated professionals to direct this change. As professionals dedicated to patient comfort and quality of life--even at the EOL, nurses should begin the revolution in EOL care by attending to the education of nurses.

The marriage: geriatrics and oncology.

Cancer always has been a disease of greater incidence and morbidity in the elderly, and sociodemographic trends predict this fact to escalate in the decades ahead. Optimum care of older adults with cancer can be enhanced through the marriage of two disciplines that have matured in recent years: geriatrics and oncology. This article reviews issues of cancer care for the elderly, including the strengths and challenges of this special population, quality of life considerations, and future directions.

Analysis of symptom assessment and management content in nursing textbooks.

This article reports on one goal of a project designed to improve end-of-life (EOL) care in nursing education. The goal was to improve the content regarding pain and EOL care included in major textbooks used in nursing education. A descriptive study design was selected using content analysis of 50 texts selected from a potential of over 700 texts. The 50 texts included 45,683 pages. The text review was conducted using an analysis framework encompassing 9 essential areas of EOL care. The study methods included content analysis as well as quantification of the content present in the texts. The 9 areas of the analysis framework were: palliative care defined; quality of life; pain; other symptom assessment/management; communication with dying patients and families; role/needs of family caregivers in EOL care; death; issues of policy, ethics, and law; and bereavement. This article reports on the findings of the analysis related to symptom assessment/management. Nursing texts have limited content on symptom assessment and management. Increased attention to this area, a critical role of nursing, is essential to improved care for patients at EOL.

Family caregiving in cancer pain management.

The experience of cancer pain is known to greatly affect family caregivers as well as patients. There are many demands placed on caregivers of cancer patients with pain at home as a result of the shifting of care from the acute setting to the home. These complex demands significantly affect caregiver quality of life. The purpose of this study was to describe the experience of pain management from the perspective of family caregivers of patients with cancer amidst the current healthcare environment. This quasi-experimental study involved 231 family caregivers of patients with cancer pain receiving home care. Family caregivers were assessed in conjunction with a pain education program that provided patient and. family education regarding pain assessment, drug and nondrug interventions. Assessment measures used were the Quality of Life (QOL)-Family Caregiver Tool, Knowledge and Attitudes about Pain (K&A) Tool, and Caregiver Finances Tool. Study findings reveal disruption to family caregiver quality of life in the areas of physical, psychological, social, and spiritual well-being. There is also a continued need for education regarding cancer pain management. Comparison between patients and family caregivers demonstrates that pain impacts both the patient experiencing it and their caregivers.

How can we improve care at the end of life?

A review and survey of nurses' responsibility for delivering care at the end of life.