Current status of palliative care--clinical implementation, education, and research.

Palliative and end-of-life care is changing in the United States. This dynamic field is improving care for patients with serious and life-threatening cancer through creation of national guidelines for quality care, multidisciplinary educational offerings, research endeavors, and resources made available to clinicians. Barriers to implementing quality palliative care across cancer populations include a rapidly expanding population of older adults who will need cancer care and a decrease in the workforce available to give care. Methods of integrating current palliative care knowledge into care of patients include multidisciplinary national education and research endeavors, and clinician resources. Acceptance of palliative care as a recognized medical specialty provides a valuable resource for improvement of care. Although compilation of evidence for the importance of palliative care specialities is in its initial stages, national research grants have provided support to build the knowledge necessary for appropriate palliative care. Opportunities are available to clinicians for understanding and applying appropriate palliative and end-of-life care to patients with serious and life-threatening cancers.

Evolution and effectiveness of palliative care.

OBJECTIVE: : What is the evidence for the effectiveness of palliative medicine? METHOD: : A search of the PubMed database for clinical trials using search terms "Palliative Care" or "Palliative Medicine" or "Hospice" or "end of life" and "effectiveness" was conducted, and 63 articles were returned. Of these, 10 were related to outcomes of interest related to components of palliative medicine such as quality of life, length of life, or healthcare utilization. None were randomized, controlled trials looking at a global measure of effectiveness of palliative medicine. Consequently, additional searches using Google and Google Scholar, and searching bibliographies of published articles and presentations, were conducted. RESULTS: : There were not enough studies with which to perform a structured review. The findings from single trials of satisfactory methodological quality are summarized and presented. CONCLUSION: : Palliative care has been proven to be more effective than standard approaches to care. The thrust of research must now turn to ways to ensure that palliative care is part of standard care.

25 Years: Looking Back, Looking Forward.

Palliative medicine and the practice of palliative care has disseminated around the world for the past 25 years. In many countries, palliative medicine is a formally recognized specialty of medicine. Yet, there is a high variability, due in part to the variable resources devoted to its development. New research is needed to improve our ability to control symptoms and to know how best to implement the existing science so that the patients who need palliative care can get it easily and equitably. Achieving this level of access requires expertise in organizational structure and system change strategies. Building the evidence base for best practices requires us to forge research collaborations with collegues from all medical subspecialities, including experts from allied health disciplines, and partner closely with patients and families. It also compels us to look critically at ourselves to overcome the barriers we put in our own way to becoming a routine part of standard health care in all countries.

Symptom Control Research.

The need for symptom control research has never been greater. Yet, this is an underdeveloped area in hospice and palliative care. Expert symptom control researchers point out a number of issues that show the way forward over the next 25 years. Chief among them is the need to do the research, rather than being content with the evidence we have. A barrier is to have the self-discipline to honestly evaluate the state of the palliative care science where the gold standard of randomized controlled trials has not been used to establish current practice. Commitment to organized symptom control research groups and clinical trials networks is important. Combining symptom control research with disease-directed research is a promising way forward. Investing in training junior clinicians and researchers is critical. All palliative care fellows and clinicians must receive training in the basics of research methods so that they can effectively support and advance research and evidence-based best practices.

Incentives for Palliative Care.

The past 25 years have proved that palliative care is effective in improving care of seriously ill patients. Research attention must pivot to focus on policy changes and systems and models of care that ensure easy access to quality palliative care to all patients who need it. Education, alone, has not worked. Leaving it to individual organizations to decide has not worked. The question of whether incentives should be used has arisen. Should we design treatment algorithms, such as for cardiopulmonary resuscitation, where palliative care is part of standard care and requires an "opt out"? Should payers pay more to health care organizations who demonstrate they provide universal access to palliative care and how can we control for unintended consequences? Should provision of specialist palliative care be required for a health care organization to be accredited? How can we advance the state of the science and best support the workforce?

Mid-Career Training to Advance Palliative Care.

The demand for specialist palliative medicine physicians, advanced practice providers, and other team members outstrips supply. Traditional paths to specialty practice will not meet projected need. Therefore, innovation and research are required. One innovation is the training of midcareer professionals; those who have been in practice and want to change to palliative care. Barriers to leaving practice and returning to traditional training are high; not the least of which is the opportunity cost. In this roundtable, experts discuss what they have learned from current research, and point the way to additional needed research.

Why oncologists should refer patients earlier for hospice care.

The majority of patients with advanced malignancy die with a predictable disease trajectory. Increasing use of chemotherapy and radiotherapy near the end of life has not changed that trajectory. For adults with advanced solid tumors, the period from becoming symptomatic to death of the patient is 4 to 6 weeks. Poor performance status is still the most important prognostic factor, among others that have been described. The data are now in; hospice care is the best standard of care for cancer patients, it is not an alternative to standard care. Payers for high-quality cancer care will expect referral with an interval of care--generally on the order of 4 to 6 weeks of enrollment--as a measure of quality cancer care given by the oncologist. In this article, prognostic data are summarized and a suggested approach for discussing hospice enrollment with patients is presented.

Psychiatry resident education in palliative care: opportunities, desired training, and outcomes of a targeted educational intervention.

OBJECTIVES: To assess the educational offerings provided to psychiatry residents in palliative care as well as their concomitant interest in learning more about this subspecialty. To measure the pre- and post-levels of competence, concern, and knowledge exhibited by psychiatry residents when completing a formalized clinical rotation in hospice and palliative care, with additional comparisons to family and internal medicine residents completing the same clinical rotation. METHODS: Fifty-two Psychiatry Program Directors and 98 psychiatry residents completed an online survey assessing the current course offerings and level of interest in palliative care. Thirty psychiatry residents were additionally evaluated before and after completion of a clinical rotation in hospice and palliative care. RESULTS: Few programs offered any formalized training in palliative care, although nearly all psychiatry residents reported interest in this area. A clinical rotation in palliative care significantly increased psychiatry residents' competence and knowledge while simultaneously decreasing their concerns about practice in this area; most were at levels comparable to family and internal medicine residents completing the same rotation. Psychiatry residents' knowledge of pain assessment, pain management, and generalized non-pain management were also enhanced during the rotation. CONCLUSIONS: Results indicate that training opportunities in palliative care are lacking for psychiatry residents in the United States although residents report strong interest in this area. This study finds psychiatry residents can benefit as much as other disciplines from receiving palliative care training. The need to offer such training within psychiatry residencies is highlighted and the welcoming of psychiatrists into palliative care is suggested.

Pathophysiology of pain in cancer.

Contemporary management of pain is guided by a contemporary understanding of the pathophysiology of pain. Treatment modalities are chosen based on the demonstrated or presumed pathophysiology of cancer pain. When rational oral polypharmacy is used, cancer pain is controlled to the patient's satisfaction 70%-90% of the time.

Cancer breakthrough pain in the presence of cancer-related chronic pain: fact versus perceptions of health-care providers and patients.

Cancer breakthrough pain is a flare in pain that "breaks through" well-controlled persistent cancer pain. Although the condition is highly prevalent, the concept of cancer breakthrough pain is not well understood and is therefore underdiagnosed and undertreated. The purpose of this review is to examine the roles the health-care practitioner and patient/family caregiver play in the undertreatment of breakthrough pain. A lack of technical knowledge about pain management and pain assessment, attitudes about opioid addiction, and regulatory guidelines influence the manner in which opioids are prescribed. Patients harbor a variety of fears and misconceptions, such as opioid addiction, tolerance, side effects, and the meaning of pain, which can create a barrier to effective communication with their health-care provider regarding their cancer pain management and specifically their breakthrough pain. Identifying these issues gives health-care professionals and patients an opportunity to develop strategies that can improve the treatment of cancer breakthrough pain.

Symptom control in stem cell transplantation: a multidisciplinary palliative care team approach. Part 2: psychosocial concerns.

Stem cell transplantation (SCT) offers a potential cure for patients with otherwise incurable benign and malignant disorders. However, the treatment will cause considerable physical, social, psychological, and spiritual suffering. In part 1 of this review, the management of the physical symptoms was reviewed. In part 2, we discuss the approaches to managing the other aspects of distress that are primarily psychological, social, and spiritual in nature. In practice, these dimensions are not so easily distinguished; the division between physical and psychological symptoms is blurred, and physical symptoms are often interrelated with the patient's emotional status and social support.

Symptom control in stem cell transplantation: a multidisciplinary palliative care team approach. Part 1: Physical symptoms.

Stem cell transplantation (SCT) offers a potential cure for patients with otherwise incurable benign and malignant disorders, but the arduous SCT process may cause considerable physical, social, psychological, and spiritual suffering. Relief of suffering associated with SCT begins by understanding the patient experience and the SCT culture. Symptom burden is the combined impact of all disease- or therapy-related symptoms on the patient's ability to function. In approaching symptom management, the division between physical and psychological symptoms is blurred; physical symptoms are often interrelated with the patient's emotional status and social support. Physical symptoms that frequently occur in SCT include pain, nausea, mucositis, diarrhea, and delirium. At the same time, SCT is recognized as one of the most stressful treatments in modern cancer care, resulting in psychological distress, social isolation, and role changes. Psychological symptoms include depression/ anxiety, grief/loss, demoralization, and anger. Based on our experience on an academic SCT ward for adults, we review physical, psychological, social, and spiritual symptoms during the course of SCT in a two-part series and offer an approach to their management. This month, in part I, we focus on physical symptoms linked to SCT. In a future issue, part II will highlight psychosocial concerns in SCT.

Current concepts in malignant bowel obstruction management.

Malignant bowel obstruction (MBO) is a challenging complication of advanced cancer. Several pathophysiologic mechanisms are responsible for the syndrome, including mechanical compression, motility disorders, gastrointestinal secretion accumulation, decreased gastrointestinal absorption, and inflammation. The treatment of related symptoms requires a collaborative approach of surgical, interventional, and medical specialists. The surgical approach proves beneficial in selected patients with operable lesions, life expectancy greater than 2 months, and good performance status. Interventionalists place self-expanding metallic stents as a minimally invasive palliative method either as a definitive treatment or as a bridge to surgery. However, most patients with MBO are not candidates for surgery or stent placement. Medical management with opioids, antispasmodics, antiemetics, antisecretory agents, and corticosteroids is effective in controlling the symptoms associated with MBO. This article discusses the current understanding of MBO pathophysiology and emphasizes current MBO management concepts; it then reviews surgical, interventional, and medical approaches.

Subcutaneous methylnaltrexone for the treatment of opioid-induced constipation in patients with advanced illness: a double-blind, randomized, parallel group, dose-ranging study.

Methylnaltrexone, a peripherally-acting quaternary opioid antagonist, is an investigational treatment for opioid-induced constipation in patients with advanced illness. This randomized, parallel-group, repeated dose, dose-ranging trial included a double-blind phase for one week followed by an open-label phase for a maximum of three weeks. Opioid-treated patients with advanced illness who met criteria for opioid-induced constipation despite laxative therapy were potentially eligible. Double-blind treatment occurred on Days 1, 3, and 5; open-label therapy could be administered as often as every other day. The initial dose range of 1mg, 5mg, or 12.5mg was extended by adding a 20mg group during the study while still maintaining the double blind; the initial open-label dose of 5mg could be titrated. The primary outcome was a laxation response within four hours after the first dose. Thirty-three patients received at least one dose of methylnaltrexone. Only one of 10 patients (10%) who received the 1mg dose experienced laxation within four hours of dosing. The median time to laxation was >48 hours for the 1mg dose group, compared to 1.26 hours for all patients receiving >or=5mg (P=0.0003). There was no apparent dose-response above 5mg. Most adverse events were related to the gastrointestinal system, were mild, and did not lead to discontinuation. In conclusion, methylnaltrexone relieved opioid-induced constipation at doses >or=5mg in patients with advanced illness, and did not reduce analgesia or cause opioid withdrawal symptoms.

Pain Management: Time to Minimize Variations in Practice.

There continue to be great variations in the management of pain in palliative care. Efforts need to be made within the field develop strategies to address this to avoid undue distress in patients.

Assessing the role of human recombinant hyaluronidase in gravity-driven subcutaneous hydration: the INFUSE-LR study.

BACKGROUND: Subcutaneous hydration has potential advantages over intravenous. Despite studies supporting the efficacy and safety of subcutaneous hydration it has not been studied extensively to date either with or without hyaluronidase. OBJECTIVES: To compare flow rate, tolerability, and safety of gravity-driven subcutaneous fluid administration with and without recombinant human hyaluronidase (rHuPH20) in healthy volunteers. DESIGN: Randomized, double-blind, placebo-controlled, within-subject trial. SETTING: Contract research organization. PARTICIPANTS: Fifty-four volunteers. INTERVENTION: 24-gauge angiocatheters were placed subcutaneously in both upper arms. Each arm received rHuPH20 (150 U, 750 U, or 1500 U) or equal volume saline placebo. Immediately, 400 mL Lactated Ringer's (LR) solution was gravity-infused from a 100 cm height. In the pilot stage, 5 subjects also received a similar intravenous infusion. MEASUREMENTS: Primary outcome was time to infuse 400 mL LR. Secondary outcomes included discomfort assessments, edema, arm circumference, time to recover to baseline arm circumference, subject and investigator global preference, and adverse events. RESULTS: rHuPH20 150 U, 750 U, and 1500 U yielded mean flow rates of 383 +/- 119 mL/hr, 518 +/- 154 mL/hr, and 494 +/- 136 mL/hr, respectively, compared to their respective placebo rates of 82 +/- 30 mL/hr, 148 +/- 57 mL/hr, and 124 +/- 50 mL/hr. rHuPH20 was well tolerated. CONCLUSIONS: In volunteers, clinically relevant fluid volumes can be rapidly delivered subcutaneously with rHuPH20 in a well-tolerated manner without a pump. These findings suggest that this method of hydration could potentially replace intravenous infusions in many clinical settings; further studies with rHuPH20, in patients, are warranted.

Outcomes from a national multispecialty palliative care curriculum development project.

BACKGROUND: In 1998 we completed a successful regional pilot project in palliative care curriculum development among 32 internal medicine residency programs recruited from the mid-western United States. Between 1999 and 2004 this project was expanded to include 358 U.S. programs, from four specialties, based on new training requirements in internal medicine, family medicine, neurology, and general surgery. OBJECTIVE: To assess the 1-year outcomes from residency programs participating in a national multispecialty palliative care curriculum development project. MEASUREMENT: Outcome data obtained from residency programs' responses to a structured progress report 12 months after enrolling in the project and from published residency project reports. RESULTS: Three hundred fifty-eight residency programs, representing 27% of all eligible training programs in the four specialties, participated in the project. Outcome data was available from 224 residencies (63%). Most programs started new teaching in pain, non-pain symptom management, and communication skills. More than 50% of programs integrated palliative care topics within established institutional grand rounds, morbidity/mortality conferences or morning report. More than 70% of internal medicine and family practice programs began new direct patient care training opportunities utilizing hospital-based palliative care or hospice programs. New faculty development initiatives and use of quality improvement projects to drive curriculum change were reported in less than 50% of programs. CONCLUSIONS: Focused short-term instruction in palliative care curriculum development, in a diverse group of residency programs, is feasible and associated with significant curriculum change.