Methadone and neuropathic cancer pain subcomponents: a prospective cohort pilot study.

Forty per cent of cancer pain associate neuropathic and nociceptive pain simultaneously, and refractory pain affects 15% of cancer pain. Methadone is an effective opioid in treating nociceptive pain and could have an effect on neuropathic pain. Uncertainty remains on its effects on the different subcomponents of neuropathic pain. OBJECTIVES: To identify which subcomponents of neuropathic cancer pain are addressed using methadone. METHODS: An observational prospective cohort study of palliative care inpatients after rotation for refractory neuropathic cancer pain. Pain intensity was assessed weekly for 28 days, using a Visual Analogue Scale (VAS) and the Neuropathic Pain Symptom Inventory (NPSI). RESULTS: Forty-eight patients were included and 17 completed the 28 days follow-up. VAS pain rating decreased by at least 20 mm in 47% of patients and the pain intensity was significantly lower at day 28 with 53% of patients with a VAS inferior to 4 (p<0.001). The pressure/squeezing component (NPSI score) decreased by more than 2 points in 50% of patients.A linear regression showed allodynia and pressure/squeezing were responsible for the largest part of the overall alleviation of pain (p=0.01). CONCLUSIONS: Methadone could significantly improve neuropathic pain through a targeted effect of allodynia and its pressure/squeezing component.

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.

Transcultural Validation of the French Version of the Modified Edmonton Symptom Assessment Scale: The ESAS12-F.

Background: Cancer-related physical symptoms can decrease patients' overall quality of life and are often underdiagnosed. The Edmonton Symptom Assessment Scale (ESAS) is widely used in palliative care for cancer patients to easily assess cancer patients' symptoms. It has been often modified, adding symptoms and explanations, and translated into many languages. The European Association of Palliative Care research team developed a database, which included the modified 12-item ESAS-r as the symptom assessment tool. Objectives: The purpose of this study was to achieve the translation and cross-cultural validation in French of the 12-item ESAS-r, the ESAS12-F. Design: A French version of the ESAS-r was developed using a standardized forward and backward translation method. Patients completed the ESAS12-F and provided feedback on the translation. Setting/Subjects: Forty-five patients with advanced cancer, followed by the palliative care team from the Lyon Sud University Hospital in France, were recruited. Results: Eighty-nine percent of patients considered the ESAS easy to understand. They highlighted some concerns more about the tool itself than the translation: the time line "now," the difficulty to quantify a symptom in a numerical evaluation. Some items (sleep and appetite) needed to be reread and for some others (digestive and psychological symptoms, and well-being) to be reordered in the questionnaire. Conclusion: The ESAS12-F is well accepted and easy to use for the cancer patients. The next step is to carry out a psychometric validation of the definitive version of the ESAS12-F.

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.

The perceptions and experiences of osteopathic treatment among cancer patients in palliative care: a qualitative study.

PURPOSE: This research aimed to explore the perceptions and experiences of cancer patients receiving osteopathic treatment as a complementary therapy when it is used in addition to conventional treatment for cancer pain. METHODS: This qualitative study employed semi structured interviews of cancer patients in a palliative care unit in Lyon, France, who received treatment from an osteopath alongside their conventional cancer treatment. We analysed data using grounded theory and qualitative methods. RESULTS: We interviewed 16 patients. The themes identified through the analysis included a low awareness of osteopathy among the population and an accompanying high level of misconceptions. The benefits of osteopathy were described as more than just the manual treatments with participants valuing osteopathy as a holistic, meditative, and non-pharmaceutical approach. Participants also described the osteopathic treatments as assisting with a range of cancer-related health complaints such as pain, fatigue, and sleep problems. Offering osteopathic treatment at an accessible location at low or no cost were identified by participants as enablers to the continued use of osteopathy. CONCLUSIONS: The findings of this study provides preliminary data which suggests, when delivered alongside existing medical care, osteopathy may have health benefits for patients with complex conditions such as cancer.

Cancer Patients Dying in the Intensive Care Units and Access to Palliative Care.

BACKGROUND: In France, cancer has become the leading cause of death. Intensive care units (ICU) focus on survival, which may not be an appropriate setting to provide palliative care (PC) as needed by cancer patients and families. OBJECTIVE: To describe the cancer patients who died in the ICU in 2010 in a French academic medical center. DESIGN: Retrospective study Measurements: We reviewed medical records of all cancer patients who died in the ICU in 2010. The information collected from electronic medical records included patient sociodemographics and clinical characteristics, PC service referral, and the date of first contact with PC. RESULTS: Among the 536 cancer patients who died in 2010, 42 (8%) died in the ICU. The cancers were hematological (21%), gastrointestinal (21%) and head and neck (21%). One patient had a PC referral versus 45% in the total population (p < 0.001) and the referral was the same day as the death. Eight (19%) patients had chemotherapy during their last month of life and 2 during the ICU hospitalization. Seventy-four per cent of patient admissions to the ICU related directly to malignancy. The mean time between diagnosis of cancer and death was 2.3 years (standard deviation, 4.4). CONCLUSIONS: Our work highlights the need for early PC in the illness trajectory of cancer patients to prevent the transfer of dying patients to the ICU. More studies are needed to understand the decision making leading to such transfers.

Decisional control preferences of patients with advanced cancer receiving palliative care.

ABSTRACTObjective:Understanding patients' decisional control preferences (DCPs) is important to improving the quality of care and the satisfaction of patients who have advanced cancer with their care. In addition to passive decisional control (i.e., the patient prefers his/her doctor or family caregiver to make a decision on their behalf) and active decisional control (i.e., the patient decides alone), shared decisional control, where patients and caregivers decide together, could be more appropriate. The primary aim of our study was to describe the decision-making process and the DCPs of patients with advanced cancer receiving palliative care in France. METHOD: We conducted a prospective survey with advanced cancer patients referred to a palliative care team in an outpatient setting. We collected information about patients' demographic and clinical characteristics using the Decision Control Preference Scale, the Satisfaction with the Decisions and Care questionnaire, and the Understanding of Illness questionnaire. RESULTS: A total of 200 patients were evaluable. The median age was 63.5 years and 53.5% female. The cancers most commonly represented were gastrointestinal and breast. A total of 72 patients (36.2%) preferred active decisional control, 52 (26.1%) preferred shared decisional control, and 75 (37.7%) preferred passive decisional control. Younger age (p = 0.003), higher education (p < 0.001), and employment status (p = 0.046) were found to be associated with active or shared DCPs. Some 82% of patients were satisfied with the decision-making process, 35% of whom expressed wishes that did not match the actual decision-making process. Only 23% of patients thought they could be cured of their illness, and 47% thought that their treatment would "get rid of " their disease. SIGNIFICANCE OF RESULTS: The decision-making processes are shared in the three models of DCPs in our cohort of French patients with advanced cancer. Further prospective studies are needed.

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.

[Improving the quality of cancer pain management in palliative care unit: Targeted clinical audit]. / Qualité de la prise en charge de la douleur du cancer en unité de soins palliatifs : audit clinique ciblé.

Goal This study aims to assess the quality of the cancer pain management in Palliative care unit. METHOD: The method used was the targeted clinical audit. The audit grid was built according to the recommendations of the pilot Committee, and tested until the final version with 19 items was obtained. In this retrospective study, 60 consecutive patients were studied on 2 periods of time. The first one (T1) shows the gap between the patient's chart and the expected standard, and proposes corrective measures. The second one (T2) re-assesses, using the same items list, the efficacy of these measures. RESULTS: After the corrective measures, the patients' medical record documentation was significantly improved at T2 for: neuropathic pain assessment improved, from 3% (T1) to 67% (T2) (P<0.001), so did pain assessment during the titration, from 6.7% (T1) to 90% (T2) (P<0.001). The overdoses symptoms assessment improved from 17% at T1 to 93% at T2, (P=0.002) and breakthrough pain evaluation improved from 3% at T1 to 73% at T2, (P<0.001). The pain reassessment after the rescue doses improved from 10% at T1 to 73% at T2 (P<0.001). The other points improved but not significantly. CONCLUSION: The quality of the pain cancer management was improved during the audit, but some points (patient education and in patient medical record documentation) can be improved. We need to continue to implement the improvement measures in our unit.

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.

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.

Perception of naturopathy for female patients with metastatic gynecological cancer: A qualitative study.

OBJECTIVE: Women with gynecological cancer have been reported as very high users of complementary medicine. The goal of our study was to explore the perceptions of patients with an advanced gynecological cancer who use naturopathy as complementary medicine. We were looking more specifically at patients' opinions on the effect of naturopathy on their quality of life and its relation to conventional oncological treatments. METHOD: This pilot qualitative study used semistructured interviews, and data were analyzed using grounded theory and qualitative methods. The main criterion for inclusion in the study was the use of naturopathy as a treatment complementary to conventional cancer treatment for gynecological metastatic cancer on the oncology day care unit. RESULTS: Six patients were included until data saturation. They express the physical and psychological impact of treatments and disease. Usually, chemotherapy is perceived as something that may be curative or may at least lead to remission. Unlike conventional treatments, naturopathy is not perceived as drugs, and it is seen as a way to relieve symptoms, improve well-being, and as a way of enabling them to take an active decision-making role in their care journey. Patients want to have more information about naturopathy. SIGNIFICANCE OF RESULTS: This study suggests that patients are aware of the benefits of a specific cancer treatment as chemotherapy, but they resort to naturopathy for symptom control, and also to take a more active role during treatment.

[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).