Contemporary accuracy of death certificates for coding prostate cancer as a cause of death: Is reliance on death certification good enough? A comparison with blinded review by an independent cause of death evaluation committee.

BACKGROUND: Accurate cause of death assignment is crucial for prostate cancer epidemiology and trials reporting prostate cancer-specific mortality outcomes. METHODS: We compared death certificate information with independent cause of death evaluation by an expert committee within a prostate cancer trial (2002-2015). RESULTS: Of 1236 deaths assessed, expert committee evaluation attributed 523 (42%) to prostate cancer, agreeing with death certificate cause of death in 1134 cases (92%, 95% CI: 90%, 93%). The sensitivity of death certificates in identifying prostate cancer deaths as classified by the committee was 91% (95% CI: 89%, 94%); specificity was 92% (95% CI: 90%, 94%). Sensitivity and specificity were lower where death occurred within 1 year of diagnosis, and where there was another primary cancer diagnosis. CONCLUSIONS: UK death certificates accurately identify cause of death in men with prostate cancer, supporting their use in routine statistics. Possible differential misattribution by trial arm supports independent evaluation in randomised trials.

Vitamin D deficiency as a cause of chronic pain in the palliative medicine clinic: two case reports.

BACKGROUND: Vitamin D deficiency is common in the general population and has been implicated as a cause of chronic pain. The palliative care population has a number of risk factors for vitamin D deficiency. We present two cases of unexplained pain in patients attending the palliative medicine outpatient clinic that improved after vitamin D replacement. CASES: Case 1 is a 46-year-old man with thalassaemia intermedia and back and leg pain without a clear cause. Case 2 is a 28-year-old woman undergoing treatment for cervical cancer whose initial disease and treatment-related abdominal pain resolved but subsequently reported ongoing non-specific aches and pains. Case management: Both patients were found to have vitamin D levels <50 nmol/L and were treated with vitamin D replacement therapy. Case outcome: Following vitamin D replacement therapy, pain resolved in both patients allowing a reduction in analgesic therapy. CONCLUSIONS: The prevalence of vitamin D deficiency in the palliative care population merits further investigation, since these patients are at high risk of deficiency. Having an index of suspicion, particularly in those patients with known risk factors and pain that is not fully explained, may result in better pain control and functional outcomes.

What do patients with advanced incurable cancer want from the management of their pain? A qualitative study.

BACKGROUND: Pain is one of the most frequent symptoms among patients with metastatic cancer, yet little is known about what patients with advanced cancer want from the management of their pain. Measuring the effectiveness of the management of pain is challenging as it is a subjective phenomenon and a multifaceted process. Determining how we currently define whether a patient with pain due to advanced cancer has controlled pain (or not) is important, particularly from the patient's perspective. AIM: To explore how patients with advanced cancer describe the control of pain and what they want from management of this pain. DESIGN: Qualitative study using face-to-face interviews. Data were analysed using a constant comparison approach. SETTING/PARTICIPANTS: Purposive sample of patients with advanced cancer known to palliative care services. RESULTS: Twelve interviews took place until saturation of data was achieved. Four themes emerged: maintaining role, self and independence; compromising/modifying expectations; role of healthcare professionals; and meaning of pain in context of advanced cancer. CONCLUSION: Patients determined whether their pain was 'controlled' by whether or not they were able to perform activities or tasks and maintain relationships with family or friends, which determined themselves as individuals. Numerical rating scales did not appear to be useful for patients in measuring whether they are able to perform these activities or maintain a sense of control and independence. Individualised goal/task/role/activity setting for patients with advanced cancer pain may be useful to allow patients themselves to determine what they want from the 'management' of their pain.

Can the impact of an acute hospital end-of-life care tool on care and symptom burden be measured contemporaneously?

OBJECTIVE: To determine the utility of a screening question to identify patients who might die during hospital admission and feasibility of scoring symptoms in dying patients within a study assessing the impact of a brief end-of-life (EOL) tool. METHODS: Between March 2008 and July 2010 patients admitted to five wards of an acute hospital were screened using the question 'Is this patient so unwell you feel they could die during this admission?' Once 40 patients were recruited, the brief EOL tool was introduced to the wards and a further 30 patients were recruited. Symptom scoring using the Edmonton Symptom Assessment System (ESAS) began when the patient was recognised as dying. Relatives were asked to complete the Views of Informal Carers-Evaluation of Services questionnaire to validate the results of the contemporaneous symptom assessments and assess the impact of the tool. RESULTS: The sensitivity of the screening question was 57%, specificity 98% and positive predictive value 67%, so the question was useful in enrolling study patients. There were limitations with the ESAS but core EOL symptoms were scored more frequently after the tool was introduced. Questionnaire responses suggested relatives perceived aspects of care improved with the EOL tool in place. CONCLUSIONS: It is possible to identify dying patients and study care given to them in hospital in real time. Outcome measures need to be refined, but contemporaneous symptom monitoring was possible. We argue interventions to improve EOL care should be unequivocally evidence-based, and research to provide evidence of impact on the patient experience is possible.

Overcoming barriers to recruitment in care of the dying research in hospitals.

CONTEXT: Approximately 40% of the U.S. and 60% of the U.K. population die in hospital. Many reports have highlighted variability in the care received by these patients and national initiatives have proposed strategies to improve this care. No studies have demonstrated whether any improvements in end-of-life care have been achieved, as research in this area is challenging. OBJECTIVES: We designed a study to assess the feasibility of a novel method of identifying patients likely to die during an acute hospital admission and a model of prior consent from patients and/or assent from their relatives. METHODS: A study for collecting data on patients' symptoms before and after the introduction of an end-of-life tool (comprising medical and nursing checklists, prescribing guidance, and a symptom observation chart) within five wards in a major U.K. teaching hospital was conducted. We asked the screening question to a senior member of staff, "Is this patient so unwell that you feel they could die on this admission?" to identify appropriate patients, and recruited using the consent procedure. Patients were enrolled in the study if they became more unwell and data were then collected until they died. RESULTS: In total, 6642 patients were screened. The ward staff answered "yes" to the screening question for 327 of 6642 (4.9%) patients. Patient's prior consent or relative's assent to enroll in the study was obtained for 117 of 327 (35.8%) patients, of whom 70 of 117 (59.8%) enrolled for the study and died within the study period. The staff found that the methods used were appropriate. CONCLUSION: We have shown that identifying and involving dying patients in research is possible and acceptable to patients and carers.

Professional experience guides opioid prescribing for chronic joint pain in primary care.

BACKGROUND: Chronic joint pain is common and is a leading cause of disability. Most chronic joint pain is managed in primary care. Opioid pain medication is one option for pain management, but research suggests that its use by general practitioners (GPs) may be suboptimal. There is a widespread perception that doctors' concerns about misuse and addiction limit use of opioids. OBJECTIVES: To explore GPs' opinions about opioids and decision-making processes when prescribing 'strong' opioids for chronic joint pain. METHODS: Qualitative semi-structured interviews were conducted with 27 GPs. Using thematic analysis methods, the data were coded and grouped into themes. RESULTS: GPs described a variety of prescribing habits for chronic joint pain. Opioids engendered strong opinions. GPs said that decisions about prescribing were based on careful assessment of patients' needs and their personal views about the management of adverse effects. Although addiction and misuse were discussed, there was limited concern about these issues. The overarching influence on prescribing decisions was GPs' previous experience, including previous outcomes and exposure to palliative care settings. CONCLUSIONS: GPs' prescribing decisions are primarily influenced by previous professional experience of opioids. Much existing literature stresses that opioids are not prescribed due to concerns about addiction or misuse, but our study indicates otherwise. Augmenting GPs' exposure to and experience of opioids may be key to providing better pain management for patients.

Oxycodone for cancer-related pain: meta-analysis of randomized controlled trials.

To evaluate the efficacy and tolerability of oxycodone in cancer-related pain, we conducted a systematic review of randomized controlled trials. Four studies, comparing oral oxycodone with either oral morphine (n = 3) or oral hydromorphone (n = 1), were suitable for meta-analysis. Standardized mean differences in pain scores comparing oxycodone with control groups were pooled using random-effects models. Overall, there was no evidence that mean pain scores differed between oxycodone and control drugs (pooled standardized mean difference, 0.04; 95% confidence interval [CI], -0.29 to 0.36; P = .8; I(2) = 62%). In meta-regression analyses, pain scores were higher for oxycodone compared with morphine (0.20; 95% CI, -0.04 to 0.44) and lower compared with hydromorphone (-0.36; 95% CI, -0.71 to 0.00), although these effect sizes were small. The efficacy and tolerability of oxycodone are similar to morphine, supporting its use as an opioid for cancer-related pain.