Anita Jablonski

Symptom clusters in elderly patients with lung cancer.

PURPOSE/OBJECTIVES To identify the number, type, and combination (cluster) of symptoms experienced by patients with lung cancer. DESIGN A secondary analysis of data collected as part of a larger study. SETTING 24 sites that included community hospitals, medical clinics, oncology clinics, and radiation-oncology clinics. SAMPLE 220 patients newly diagnosed with lung cancer, ranging in age from 65-89 years (mean = 72 years, SD = 5.02), 38% with early-stage and 62% with late-stage lung cancer. METHODS Subject self-report. FINDINGS Factor analysis found that the symptoms of fatigue, nausea, weakness, appetite loss, weight loss, altered taste, and vomiting form a cluster. Initial staging of cancer, the number of comorbid conditions, and being treated with chemotherapy emerged as significant predictors of the symptoms reported. Few differences were noted between men and women. Correlation was found among the numbers of symptoms reported, symptom severity, and limitations attributed to symptoms. CONCLUSIONS Patients with lung cancer report multiple distressing symptoms related to symptom severity and limitations. IMPLICATIONS FOR NURSING Assessment of multiple symptoms is recommended in patients with lung cancer.

A cluster of symptoms over time in patients with lung cancer

BackgroundPatients with lung cancer present late in the disease and have multiple symptoms. Previous research has shown the symptom cluster of fatigue, weakness, weight loss, appetite loss, nausea, vomiting, and altered taste to be present at time of lung cancer diagnosis. ObjectivesThe study determined whether the symptom cluster identified at the time of diagnosis remained 3 and 6 months later, and whether there was a difference in the mean number of symptoms and the mean level of symptom severity over time. The relation of the severity rating for individual symptoms at the time of diagnosis and at 3 and 6 months after diagnosis was examined. Predictors for the number of symptoms and whether the symptom cluster was predictive of death were determined. MethodsSecondary analysis of an existing data set for 112 patients with newly diagnosed lung cancer assessed at diagnosis and at 3 and 6 months was performed and determined whether they were alive or dead 19 months after diagnosis. ResultsThe cluster of seven symptoms had internal consistency that remained at 3 and 6 months. The mean symptom severity and the number of symptoms at diagnosis were correlated with later ratings, but decreased in severity over time. A similar decrease in severity rating was seen for the individual symptoms in the cluster. The stage of cancer at diagnosis was the most predictive of the number of cluster symptoms reported. Death 6 to 19 months after diagnosis was predicted by age, stage of cancer at diagnosis, and symptom severity at 6 months. ConclusionsThe symptom cluster remains over the course of lung cancer and is an independent predictor of the patient’s death. Symptom severity, the number of symptoms reported, and the severity of the individual symptoms decreased over time. The stage of cancer at diagnosis is the best predictor of symptoms later in the disease.

Nursing Home Staff Adherence to Evidence-Based Pain Management Practices

The purpose of this study was to determine the extent to which nursing home staff adhere to current evidence-based guidelines to assess and manage persistent pain experienced by elderly residents. A retrospective audit was conducted of the medical records of 291 residents of 14 long-term care facilities in western Washington State. Data revealed a gap between actual practice and current best practice. Assessment of persistent pain was limited primarily to intensity and location. Although prescribing practices were more in line with evidence-based guidelines, a significant number of residents did not obtain adequate pain relief. Nonpharmacological pain management methods were rarely implemented. Nursing home staff and administrators must critically examine both system and individual staff reasons for failure to comply with best pain management practices. Research is needed to determine factors that contribute to less-than-optimal adherence to evidence-based guidelines for pain management, as well as the best methods for implementing practice change.

A model for identifying barriers to effective symptom management at the end of life

A number of initiatives have been launched in recent years aimed at improving the quality of end-of-life care, particularly in the area of symptom management. Despite these efforts, however, many patients will not experience a peaceful death free of pain and suffering. A number of barriers continue to block efforts to ease symptom burden at the end of life. A conceptual model that helps to identify these obstacles is the Symptom Management Model developed by the faculty at the School of Nursing, University of California, San Francisco. Two components of the model are explored in this article. Discussion of the Symptom Management Strategies dimension of the model focuses on factors related to professional nursing that block effective symptom control. In addition, barriers related to the Environment Domain (ie, physical, social, and cultural context in which a symptom occurs) are also examined for their impact on symptom relief. Healthcare providers are encouraged to use the Symptom Management Model to identify and correct impediments to effective symptom management and reduce patient suffering at the end of life.

Evidence-based pain management practices

The purpose of this study was to determine the extent to which nursing home staff adhere to current evidence-based guidelines to assess and manage persistent pain experienced by elderly residents. A retrospective audit was conducted of the medical records of 291 residents of 14 long-term care facilities in western Washington State. Data revealed a gap between actual practice and current best practice. Assessment of persistent pain was limited primarily to intensity and location. Although prescribing practices were more in line with evidence-based guidelines, a significant number of residents did not obtain adequate pain relief. Nonpharmacological pain management methods were rarely implemented. Nursing home staff and administrators must critically examine both system and individual staff reasons for failure to comply with best pain management practices. Research is needed to determine factors that contribute to less-than-optimal adherence to evidence-based guidelines for pain management, as well as the best methods for implementing practice change.

Symptom Assessment of Patients With Chronic Obstructive Pulmonary Disease

The primary purpose of this secondary data analysis was to evaluate the efficacy and suitability of the Memorial Symptom Assessment Scale (MSAS) for use with patients with severe chronic obstructive pulmonary disease (COPD). Symptoms experienced by patients with severe COPD were assessed in the original investigation using the 32-item MSAS. The sample consisted of 72 individuals with COPD ranging in age from 36 to 79 years. To increase its efficiency for use with severely ill COPD patients, the original MSAS was shortened to include the 19 most frequently reported symptoms. Reliability of the revised tool remained high (Cronbachs alpha = .86). Content and convergent validity of the revised tool were also established. The revised MSAS appears to be an appropriate measure of the multidimensional, multisymptom experience of patients with severe COPD.

Addressing methodological challenges in implementing the nursing home pain management algorithm randomized controlled trial

Background Unrelieved pain among nursing home (NH) residents is a well-documented problem. Attempts have been made to enhance pain management for older adults, including those in NHs. Several evidence-based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults. Despite the proliferation and dissemination of these practice guidelines, research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting. One promising approach is the embedding of guidelines into explicit protocols and algorithms to enhance decision making. Purpose The goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence-based pain assessment and management practices, decreasing pain and depressive symptoms, and enhancing mobility among NH residents. Methods The study used a cluster-randomized controlled trial (RCT) design in which the individual NH was the unit of randomization. The Roger’s Diffusion of Innovations theory provided the framework for the intervention. Outcome measures were surrogate-reported usual pain, self-reported usual and worst pain, and self-reported pain-related interference with activities, depression, and mobility. Results The final sample consisted of 485 NH residents from 27 NHs. The investigators were able to use a staggered enrollment strategy to recruit and retain facilities. The adaptive randomization procedures were successful in balancing intervention and control sites on key NH characteristics. Several strategies were successfully implemented to enhance the adoption of the algorithm. Limitations/Lessons The investigators encountered several methodological challenges that were inherent to both the design and implementation of the study. The most problematic issue concerned the measurement of outcomes in persons with moderate to severe cognitive impairment. It was difficult to identify valid, reliable, and sensitive outcome measures that could be applied to all NH residents regardless of the ability to self-report. Another challenge was the inability to incorporate advances in implementation science into the ongoing study Conclusions Methodological challenges are inevitable in the conduct of an RCT. The need to optimize internal validity by adhering to the study protocol is compromised by the emergent logistical issues that arise during the course of the study.

Palliative care: misconceptions that limit access for patients with chronic renal disease.

There is an urgent need to incorporate palliative care into the treatment of patients with end‐stage renal disease (ESRD). These patients have a shortened lifespan and face end‐of‐life decisions as renal function declines and renal replacement therapy becomes necessary. They also experience a high symptom burden as a result of the illness as well as its treatment. Why, then, do patients with ESRD rarely receive expert palliative care services that have been shown to enhance the quality of life of patients with other life‐limiting illnesses? The lack of access to palliative care can be attributed, in part, to misconceptions about its philosophy and goals. It is hoped that clarification of these misconceptions will facilitate integration of palliative care into routine nephrology practice.

Ethical Issues in Dialysis Aaron Spital, Series Editor: Palliative Care: Misconceptions That Limit Access for Patients with Chronic Renal Disease

There is an urgent need to incorporate palliative care into the treatment of patients with end‐stage renal disease (ESRD). These patients have a shortened lifespan and face end‐of‐life decisions as renal function declines and renal replacement therapy becomes necessary. They also experience a high symptom burden as a result of the illness as well as its treatment. Why, then, do patients with ESRD rarely receive expert palliative care services that have been shown to enhance the quality of life of patients with other life‐limiting illnesses? The lack of access to palliative care can be attributed, in part, to misconceptions about its philosophy and goals. It is hoped that clarification of these misconceptions will facilitate integration of palliative care into routine nephrology practice.

Ethical Issues in Dialysis Aaron Spital, Series Editor: Palliative Care: Misconceptions That Limit Access for Patients with Chronic Renal Disease: PALLIATIVE CARE

There is an urgent need to incorporate palliative care into the treatment of patients with end‐stage renal disease (ESRD). These patients have a shortened lifespan and face end‐of‐life decisions as renal function declines and renal replacement therapy becomes necessary. They also experience a high symptom burden as a result of the illness as well as its treatment. Why, then, do patients with ESRD rarely receive expert palliative care services that have been shown to enhance the quality of life of patients with other life‐limiting illnesses? The lack of access to palliative care can be attributed, in part, to misconceptions about its philosophy and goals. It is hoped that clarification of these misconceptions will facilitate integration of palliative care into routine nephrology practice.