Hypnosis for Symptom Management in Adult Cancer Patients: What is the Evidence?

OPINION STATEMENT: As a palliative care specialist and a hypnotherapist, I use therapeutic communication and conversational hypnosis daily in my patient - doctor relationship. Formal hypnotherapy sessions are integrated in my practice whenever patients are open or wish for such an approach in relation to a specific symptom, for better overall management of their disease burden and/or enhanced well-being. Although hypnosis has been used for centuries in medical practice and for thousands of years in healing practices in ancient cultures all over the world, the evidence remains scarce. Nevertheless, in the last 10 years several randomised controlled trials have been conducted, building up an evidence base. In contrast to most oncological treatments, hypnotherapy is far from being considered evidence-based "standard care". It is however, if practiced by a trained health care professional, almost free of side effects and therefore potentially has a very favourable benefit-to-harm ratio. The question arises whether hypnotherapy will ever become a standard of care intervention? This seems unlikely since its efficacy may be influenced by the patient's belief in hypnosis and compliance to therapy. Furthermore, a fundamental necessity is a personalised approach that moves hypnotherapy more into the category of individual-centred care rather than standard care.

[End of life at home: all you need to know]. / Fin de vie au domicile : comment s'y prendre.

Many patients in Switzerland wish to die at home. Nevertheless, end-of-life home care requests specific considerations such as basic palliative care knowledge among health care professionals and a well-organized and coordinated health care network which needs to be put in place as early as possible. Beforehand, an open discussion with the patient and the caregiver about their expectations and wishes is mandatory. Furthermore, anticipation about the evolution of the disease, potential symptoms, material requests, psychological and social barriers is the key element to provide home palliative care until the end of life. Most "cantons from the Romandie" have a large offer in health care services allowing for home end-of-life care.

Une fin de vie à domicile est souhaitée par beaucoup de patients en Suisse, mais sa mise en place nécessite entre autres des connaissances en matière de soins palliatifs et l'organisation précoce d'un réseau de soins interprofessionnel bien organisé et coordonné. Un prérequis est également une discussion ouverte avec le patient et son entourage quant aux attentes et souhaits de soins. L'anticipation par rapport à différents sujets tels que l'évolution de la maladie, les symptômes potentiels, les besoins en matériel, les difficultés psychiques et les problématiques sociales est l'élément clé pour une réussite d'une fin de vie à domicile. Plusieurs cantons romands offrent une large gamme de soins permettant un maintien au domicile jusqu'au décès.

"I Am Not the Same Man ": A Case Report of Management of Post-COVID Refractory Dyspnea.

The SARS-CoV-2 pandemic brings with it a significant number of post-COVID symptoms, including persistent dyspnea and neuropsychological sequelae. The palliative approach in the treatment of these refractory symptoms is effective and widely applicable in different settings. We report the case of a patient with refractory dyspnea admitted to a specialized palliative care unit with a very poor prognosis. The application of different tools of the palliative approach proved to be effective: a detailed advanced care planning and open communication, the respect for the patient's wishes and optimal use of his resources-the salutogenesis- an adaptation of the rhythm of care to that of the patient. The patient was then discharged for rehabilitation, and finally returned home.

Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults.

BACKGROUND: Dyspnoea is a common symptom in advanced cancer, with a prevalence of up to 70% among patients at end of life. The cause of dyspnoea is often multifactorial, and may cause considerable psychological distress and suffering. Dyspnoea is often undertreated and good symptom control is less frequently achieved in people with dyspnoea than in people with other symptoms of advanced cancer, such as pain and nausea. The exact mechanism of action of corticosteroids in managing dyspnoea is unclear, yet corticosteroids are commonly used in palliative care for a variety of non-specific indications, including pain, nausea, anorexia, fatigue and low mood, despite being associated with a wide range of adverse effects. In view of their widespread use, it is important to seek evidence of the effects of corticosteroids for the management of cancer-related dyspnoea. OBJECTIVES: To assess the effects of systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Science Citation Index Web of Science, Latin America and Caribbean Health Sciences (LILACS) and clinical trial registries, from inception to 25 January 2018. SELECTION CRITERIA: We included randomised controlled trials that included adults aged 18 years and above. We included participants with cancer-related dyspnoea when randomised to systemic corticosteroids (at any dose) administered for the relief of cancer-related dyspnoea or any other indication, compared to placebo, standard or alternative treatment. DATA COLLECTION AND ANALYSIS: Five review authors independently assessed trial quality and three extracted data. We used means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). We assessed the risk of bias and quality of evidence using GRADE. We extracted primary outcomes of sensory-perceptual experience of dyspnoea (intensity of dyspnoea), affective distress (quality of dyspnoea) and symptom impact (burden of dyspnoea or impact on function) and secondary outcomes of serious adverse events, participant satisfaction with treatment and participant withdrawal from trial. MAIN RESULTS: Two studies met the inclusion criteria, enrolling 157 participants (37 participants in one study and 120 in the other study), of whom 114 were included in the analyses. The studies compared oral dexamethasone to placebo, followed by an open-label phase in one study. One study lasted seven days, and the duration of the other study was 15 days.We were unable to conduct many of our predetermined analyses due to different agents, dosages, comparators and outcome measures, routes of drug delivery, measurement scales and time points. Subgroup analysis according to type of cancer was not possible.Primary outcomesWe included two studies (114 participants) with data at one week in the meta-analysis for change in dyspnoea intensity/dyspnoea relief from baseline. Corticosteroid therapy with dexamethasone resulted in an MD of lower dyspnoea intensity compared to placebo at one week (MD -0.85 lower dyspnoea (scale 0-10; lower score = less breathlessness), 95% CI -1.73 to 0.03; very low-quality evidence), although we were uncertain as to whether corticosteroids had an important effect on dyspnoea as results were imprecise. We downgraded the quality of evidence by three levels from high to very low due to very serious study limitations and imprecision.One study measured affective distress (quality of dyspnoea) and results were similar between groups (29 participants; very low-quality evidence). We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Both studies assessed symptom impact (burden of dyspnoea or impact on function) (113 participants; very low-quality evidence). In one study, it was unclear whether dexamethasone had an effect on dyspnoea as results were imprecise. The second study showed more improvement for physical well-being scores at days eight and 15 in the dexamethasone group compared with the control group, but there was no evidence of a difference for FACIT social/family, emotional or functional scales. We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Secondary outcomesDue to the lack of homogenous outcome measures and inconsistency in reporting, we could not perform quantitative analysis for any secondary outcomes. In both studies, the frequency of adverse events was similar between groups, and corticosteroids were generally well tolerated. The withdrawal rates for the two studies were 15% and 36%. Reasons for withdrawal included lost to follow-up, participant or carer (or both) refusal, and death due to disease progression. We downgraded the quality of evidence for these secondary outcomes by three levels from high to very low due to serious study limitations, inconsistency and imprecision.Neither study examined participant satisfaction with treatment. AUTHORS' CONCLUSIONS: There are few studies assessing the effects of systemic corticosteroids on cancer-related dyspnoea in adults with cancer. We judged the evidence to be of very low quality that neither supported nor refuted corticosteroid use in this population. Further high-quality studies are needed to determine if corticosteroids are efficacious in this setting.

The Impact of Provision of Professional Language Interpretation on Length of Stay and Readmission Rates in an Acute Care Hospital Setting.

The provision of professional interpreting services (PIS) in the hospital setting can decrease clinically significant communication errors and improve clinical outcomes. The aim of this study was to investigate the differences in length of stay (LOS) and 30 day readmission rates associated with provision of PIS in the Emergency Department (ED) and inpatient wards. A retrospective audit at a tertiary referral adult hospital in Brisbane, Australia, identified all admissions of patients requiring an interpreter. Patients provided an interpreter in the Emergency Department had a mean (age-adjusted) LOS 22.4 h less than patients not provided an interpreter in ED (95% CI 10.9-33.9). For patients provided with an interpreter on the ward the mean LOS was longer, (IRR 2.2, 1.8-2.3, p < 0.0001). There was no association between interpreter provision in either ED or the inpatient ward and readmission rate. Provision of PIS in the Emergency Department to those patients who require it can significantly reduce hospital LOS.

Castrate-resistant prostate cancer: lessons learnt from a pilot study in the palliative care research population.

BACKGROUND: Palliative care patients are inherently difficult to recruit to and retain on studies. Even when patients are recruited, it is hard to complete studies with sufficient data. There is a dearth of literature specific to men with castrate resistant prostate cancer (CRPC) and the clinical trials coordinator/research nurse's perspective in improving trial outcomes in palliative care. Objectives To describe the lessons learnt (by the nursing research team) from a prospective cohort study of men with CRPC and the practical implications for future research in this area. METHODS: A pilot feasibility cohort study that followed patients with CRPC from referral until death. The participants completed questionnaires while the researcher documented treatments, disease status and symptom burden. The recruitment methods, data quality and results were analysed. RESULTS AND DISCUSSION: Several lessons have been learnt with regard to facilitating trial recruitment and design. These lessons are: the importance of building relationships with local urology teams, including all men with the diagnosis of CRPC as documented by a medical oncologist or urologist, reducing questionnaire burden, capturing symptom scores in clinic, actively following up patients by phone, and recording all reasons for drop-out or lost to follow-up. These lessons can now be implemented to improve future studies involving this demographic.

Advance directives and end-of-life decisions in Switzerland: role of patients, relatives and health professionals.

BACKGROUND: Little is known in Europe about end-of-life (EOL) decisions and advance directives (AD), particularly in patients with severe advanced disease. Switzerland is a multicultural and multilingual federal country and has the particularity of being divided into four linguistic and cultural regions OBJECTIVE: To understand better in different regions of Switzerland which specific patient's characteristics could have an impact on their decision to complete AD or not. DESIGN/SETTING/PARTICIPANTS: Prospective study conducted in four palliative care units. Patients with an advanced oncological disease, fluent in French, German or Italian and with a Mini-Mental State Examination >20 were included. Demographic data, symptom burden (Edmonton Symptom Assessment System, ESAS; Hospital Anxiety and Depression Scale, HADS) and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual well-being, FACIT-sp) have been assessed. A structured questionnaire has been completed by patients, their relatives and health professionals. RESULTS: 143 patients were included (mean age 68.3 years; 62 male). 41 completed ADs. No particular features were associated with the completion of ADs. Most patients were satisfied with the medical information received. A third of them were not worrying about their future, especially those living in the German-speaking part. Should they become unable to communicate, 87 expected their relative to transmit their own wishes, but only 38 had spoken recently with them about what they wanted. 23 of the 69 included relatives would like to play a more active role in decision-making. CONCLUSIONS: These results illustrate the fact that terminally ill patients wish to be active in decision-making, but only seldom transmit their wishes to their relative or complete a written document. The discussion about ACP should be defined according to the particularity of each region and the role of healthcare professionals' attitudes towards ADs, but we should also be creative and find other ways to promote shared decision-making.

Rates and Predictors of Professional Interpreting Provision for Patients With Limited English Proficiency in the Emergency Department and Inpatient Ward.

The provision of professional interpreting services in the hospital setting decreases communication errors of clinical significance and improves clinical outcomes. A retrospective audit was conducted at a tertiary referral adult hospital in Brisbane, Australia. Of 20 563 admissions of patients presenting to the hospital emergency department (ED) and admitted to a ward during 2013-2014, 582 (2.8%) were identified as requiring interpreting services. In all, 19.8% of admissions were provided professional interpreting services in the ED, and 26.1% were provided on the ward. Patients were more likely to receive interpreting services in the ED if they were younger, spoke an Asian language, or used sign language. On the wards, using sign language was associated with 3 times odds of being provided an interpreter compared with other languages spoken. Characteristics of patients including their age and type of language spoken influence the clinician's decision to engage a professional interpreter in both the ED and inpatient ward.

Validation of the French Version of the Edmonton Symptom Assessment System.

CONTEXT: The Edmonton Symptom Assessment System (ESAS) is a brief, widely adopted, multidimensional questionnaire to evaluate patient-reported symptoms. OBJECTIVES: The objective of this study was to define a standard French version of the ESAS (F-ESAS) to determine the psychometric properties in French-speaking patients. METHODS: In a first pilot study, health professionals (n = 20) and patients (n = 33) defined the most adapted terms in French (F-ESAS). In a prospective multicentric study, palliative care patients completed the three forms of F-ESAS (F-ESAS-VI, F-ESAS-VE, and F-ESAS-NU, where VI is visual, VE, verbal, and NU, numerical), the Hospital Anxiety and Depression Scale. All patients had a test-retest evaluation during the same half-day. Standardized distraction material was used between each scale. RESULTS: One hundred twenty-four patients were included (mean age [±SD]: 68.3 ± 12; 70 women; 54 men). Test-retest reliability was high for all three F-ESAS, and the correlation between these scales was nearly perfect (Spearman rs = 0.66-0.91; P < 0.05). F-ESAS-VI, F-ESAS-VE, and F-ESAS-NU performed similarly and were equally reliable, although there was a trend toward lower reliability for F-ESAS-VI. Correlation between F-ESAS depression and anxiety and HADS depression and anxiety, respectively, were positive (Spearman rs = 0.38-0.41 for depression; Spearman rs = 0.48-0.57 for anxiety, P < 0.05). Among patients, 59 (48%), 45 (36%), and 20 (16%) preferred to assess their symptoms with F-ESAS-VE, F-ESAS-NU, and F-ESAS-VI, respectively. CONCLUSION: The F-ESAS is a valid and reliable tool for measuring multidimensional symptoms in French-speaking patients with an advanced cancer. All forms of F-ESAS performed well with a trend for better psychometric performance for F-ESAS-NU, but patients preferred the F-ESAS-VE.

[Advance directives and advance care planning]. / Planification du projet thérapeutique et directives anticipées dans la prise en soins palliative.

Advance directives (AD) and Advance Care Planning (ACP) are two measures a person may undertake to assure that their treatment preferences will be respected until the end of his / her life. Anticipation is based on an open and honest communication between the patient, the durable medical power of attorney and the health care professionals. ADs and ACPs are based on a person's values and beliefs that are important to his quality of life. ACP is a continuing process, initiated by health care professionals and integrated into the health care plan of a person. It should be adjusted all along the disease trajectory and favors communication and anticipation in the health care network. ADs are often a personal initiative to ensure one's wishes in relation to health issues. In Switzerland, they are based on a legal framework and their application is therefore mandatory for health care professionals.

Les directives anticipées (DA) et la planification anticipée du projet thérapeutique (PAPT) permettent d'établir les préférences et souhaits d'une personne en lien avec des soins thérapeutiques. L'élaboration du projet de soins repose sur la communication entre le patient, son proche de confiance et les professionnels de la santé. La qualité de vie et les valeurs de la personne sont les éléments clés de la construction de la PAPT et des DA. La PAPT est un processus qui s'adapte au fur et à mesure de la prise en soins. Elle est relayée et transmise dans un souci de coordination, d'anticipation au fil des épisodes de santé à domicile et / ou en milieu hospitalier. Les DA émanent d'une démarche personnelle le plus souvent et ont une base légale et contractuelle pour les professionnels de la santé.

Corticosteroids for adult patients with advanced cancer who have nausea and vomiting (not related to chemotherapy, radiotherapy, or surgery).

BACKGROUND: Nausea is a common symptom in advanced cancer, with a prevalence of up to 70%. While nausea and vomiting can be related to cancer treatments, such as chemotherapy, radiotherapy, or surgery, a significant number of people with advanced cancer also suffer from nausea unrelated to such therapies. Nausea and vomiting may also cause psychological distress, and have a negative impact on the quality of life of cancer patients; similarly to pain, nausea is often under-treated. The exact mechanism of action of corticosteroids on nausea is unclear, however, they are used to manage a number of cancer-specific complications, including spinal cord compression, raised intracranial pressure, and lymphangitis carcinomatosis. They are also commonly used in palliative care for a wide variety of non-specific indications, such as pain, nausea, anorexia, fatigue, and low mood. However, there is little objective evidence of their efficacy in symptom control, and corticosteroids have a wide range of adverse effects that are dose and time dependent. In view of their widespread use, it is important to seek evidence of their effects on nausea and vomiting not related to cancer treatment. OBJECTIVES: To assess the effects of corticosteroids on nausea and vomiting not related to chemotherapy, radiotherapy, or surgery in adult cancer patients. SEARCH METHODS: We searched CENTRAL, MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, Science Citation Index Web of Science, Latin America and Caribbean Health Sciences (LILACS), Conference Proceedings Citation Index - Science Web of Science, and clinical trial registries, from inception to 23rd August 2016. SELECTION CRITERIA: Any double-blind randomised or prospective controlled trial that included adults aged 18 years and over with advanced cancer with nausea and vomiting not related to chemotherapy, radiotherapy, or surgery were eligible for the review, when using corticosteroids as antiemetic treatment. DATA COLLECTION AND ANALYSIS: All review authors independently assessed trial quality and extracted data. We used arithmetic means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). We assessed the quality of the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS: Three studies met the inclusion criteria, enrolling 451 participants. The trial size varied from 51 to 280 participants. Two studies compared dexamethasone to placebo, and the third study compared a number of additional interventions in various combinations, including metoclopramide, chlorpromazine, tropisetron, and dexamethasone. The duration of the studies ranged from seven to 14 days. We included two studies (127 participants) with data at eight days in the meta-analysis for nausea intensity; no data were available that incorporated the same outcome measures for the third study. Corticosteroid therapy with dexamethasone resulted in less nausea (measured on a scale of 0 to 10, with a lower score indicating less nausea) compared to placebo at eight days (MD 0.48 lower nausea, 95% CI 1.53 lower to 0.57 higher; very low-quality evidence), although this result was not statistically significant (P = 0.37). Frequency of adverse events was not significantly different between groups, and the interventions were well tolerated. Factors limiting statistical analysis included the lack of standardised measurements of nausea, and the use of different agents, dosages, and comparisons. Subgroup analysis according to type of cancer was not possible due to insufficient data. The quality of this evidence was downgraded by three levels, from high to very low due to imprecision, likely selection bias, attrition bias, and the small number of participants in the included studies. AUTHORS' CONCLUSIONS: There are few studies assessing the effects of corticosteroids on nausea and vomiting not related to chemotherapy, radiotherapy, or surgery in adult cancer patients. This review found very low-quality evidence which neither supported nor refuted corticosteroid use in this setting. Further high quality studies are needed to determine if corticosteroids are efficacious in this setting.

Interventional options for the management of refractory cancer pain--what is the evidence?

PURPOSE: Pain is the most common symptom in cancer patients. Standard pain treatment according to the WHO three-step analgesic ladder provides effective pain management in approximately 70-90% of cancer patients. Refractory pain is defined as not responding to "standard" treatments. Interventional analgesic techniques can be used in an attempt to control refractory pain in patients in whom conventional analgesic strategies fail to provide effective pain relief or are intolerable due to severe adverse effects. This systematic review aims to provide the latest evidence on interventional refractory pain management in cancer patients. METHODS: Systematic literature search in Cochrane, EMBASE and PubMed including reviews and randomised controlled trials (RCTs) and non-randomised controlled trials in the absence of reviews. RESULTS: Neuraxial analgesia may play a role in refractory cancer pain management. Paravertebral blocks decrease the incidence of persistent post-surgical pain after breast cancer. Coeliac plexus blocks improve pain scores in refractory pancreatic cancer pain for up to 4 weeks after the intervention with fewer burdensome side effects as compared to opioids. Cordotomy has mainly been studied in mesothelioma, and the case series suggest possible benefit for pain at the expense of a relatively high risk of side effects. CONCLUSIONS: Overall, very few RCTs have been conducted on interventional pain techniques. In reality, it is very difficult to undertake large controlled trials for a number of reasons. Therefore, today's best evidence for practice may be from large case series of comparable patients with careful response and toxicity evaluation and follow-up.

Anatomopathological causes of death in patients with advanced cancer: association with the use of anticoagulation and antibiotics at the end of life.

BACKGROUND: Anatomopathological studies that described the immediate causes of death of patients with advanced cancer were first published approximately 20 years ago. OBJECTIVE: Our objective was to analyze if causes of death changed with a wider use of broad spectrum antibiotics and prophylactic anticoagulation. METHODS: We conducted a retrospective study of all patients with an advanced cancer hospitalized in the Division of Palliative Medicine at the University Hospital Geneva from 2004 to 2010 who had an autopsy. RESULTS: Two hundred forty patients were included (130 men, mean age: 74±13). Main causes of death discovered at the autopsy were pulmonary infection (n=131; 55%), advanced cancer (n=39; 16%), pulmonary infection together with pulmonary embolism (PE) (n=27; 12%), PE alone (n=22; 9%), cardiac complications (n=19; 5%) and others (n=2; 1%). In a logistic regression model, with adjusting for age, gender, main diagnosis, comorbidities, blood count, corticosteroids, and antibiotics, there were no independent factors associated with pulmonary infection at autopsy. In a similar model, with adjusting for age, gender, main diagnosis, comorbidities, and anticoagulation, the only independent factor associated with PE at autopsy was the history of thrombo-embolic disease and therapeutic anticoagulation. CONCLUSION: The results of this retrospective study demonstrate that causes of death did not change with the modification of our practice. The high rate of pulmonary infection and embolism in this population, including in patients who received broad spectrum and prophylactic anticoagulation should encourage us to pursue other prospective studies to actually demonstrate the benefit of these treatments in this population.

Palliative sedation: from the family perspective.

UNLABELLED: Palliative sedation (PS) is a treatment option in case of refractory symptoms at the end of life. The emotional impact on nurses and doctors has been widely studied. We explore the experience of family members during a PS procedure. METHOD: An anonymous questionnaire was sent to the closest family members (n = 17) of patients who died while receiving palliative sedation. RESULTS: The response rate was 59% (10 of 17). Nine relatives were sufficiently informed about PS. In all, 70% evaluated the chosen moment for initiation of PS as adequate. All the relatives noticed a significant improvement in the refractory symptom with a mean reduction in the estimated suffering of 6.25 points on a visual analog scale. CONCLUSIONS: Palliative sedation should be performed in the best possible way for the patient and his family in order to efficiently reduce a refractory symptom.

Effect of topical morphine (mouthwash) on oral pain due to chemotherapy- and/or radiotherapy-induced mucositis: a randomized double-blinded study.

PURPOSE: The objective of the study was to determine if mouthwashes with a morphine-containing solution decrease oral pain associated with radiotherapy- and/or chemotherapy-induced oral mucositis (OM). METHODS: Randomized double-blinded crossover study to evaluate the effect of topical oral application of 2 per thousand morphine solution in patients suffering from radiotherapy- and/or chemotherapy-induced OM. Participants assigned to either the morphine solution or a placebo mouthwash received one of the solutions days 1-3 and were then switched over to the other treatment for days 4-6. RESULTS: Nine patients were randomized in both groups. All patients (mean age, 55.1 +/- 3.0) except one had head and neck cancers. Mean intensity of pain associated with mucosal injury (World Health Organization [WHO] mucositis > or =2) was on a 10-point visual analogue scale: 6.0 +/- 2.7). The analysis of variance (ANOVA) model that included morphine or placebo, day and time of mouthwash, and mouthwash effect shows that pain alleviation 1 hour after mouthwash was significantly influenced by the gesture of the mouthwash (p < 0.001 with either morphine or placebo) and almost by the efficiency of morphine (p = 0.020). Duration of pain relief was 123.7 (standard deviation [SD] +/- 98.2) minutes for morphine. Most other reported symptoms were present at the baseline and were probably associated with the main disease and not secondary to the morphine mouthwash. CONCLUSIONS: Our results suggest a possible analgesic effect of topical morphine in line with previous studies. However, more efforts must be made for the adjustment of systemic analgesics and the development of new alternatives to treat locally OM-associated pain.