Jeannine M. Brant

Building dynamic models and theories to advance the science of symptom management research.

AIM This paper is a description, comparison, and critique of two models and two theories used to guide symptom management research, and a proposal of directions for new theory or model development. BACKGROUND Symptom management research has undergone a paradigmatic shift to include symptom clusters, longitudinal studies that examine symptom trajectories, and the effects of interventions on patient outcomes. Models and theories are used to guide descriptive and intervention research. Over the past 15 years, four conceptual models or theories (i.e. Theory of Symptom Management, the Theory of Unpleasant Symptoms, the Symptoms Experience Model and the Symptoms Experience in Time Model) were used in a variety of symptom management studies. DATA SOURCES Literature searches were performed in Medline and the Cumulative Index of Nursing and Allied Health Literature between 1990 and 2008 for models and theories that guide symptom management research. Related papers and book chapters were used as supporting documentation. DISCUSSION Comparison and critique of the models and theories revealed important gaps including lack of consideration of symptom clusters, failure to incorporate temporal aspects of the symptom experience and failure to incorporate the impact of interventions on patient outcomes. CONCLUSION New models and theories should incorporate current trends in symptom management research, capture the dynamic nature of symptoms and incorporate concepts that will facilitate transdisciplinary research in symptom management. Researchers and clinicians need to build more expansive and dynamic symptom management models and theories that parallel advances in symptom research and practice.

Symptom trajectories in posttreatment cancer survivors.

Background: Cancer survivorship following cancer treatment is uncertain as physical and psychological sequelae related to the disease or its treatment may persist. However, little is known about the experience of symptoms after treatment. Objectives: The purposes of this study were to (1) examine postchemotherapy (post-CTX) symptom trajectories in cancer survivors and (2) determine whether demographic characteristics predicted symptom trajectories. Methods: One hundred patients who recently completed CTX for lung cancer, colorectal cancer, or lymphoma rated symptoms on an electronic patient care monitor system prior to ambulatory care visits. Latent growth curve analyses were conducted to examine the trajectories of pain, fatigue, sleep disturbance, distress, and depression for 16 months after initial CTX. Results: Symptoms were present at the first follow-up visit following CTX (P < .0001) and persisted over 16 months. The depression trajectory was predicted by sex: males showed a convex curvilinear growth trajectory, whereas females showed a concave trajectory (P < .05). Higher distress was predicted by younger age (P < .05). Conclusions: Psychological and physical symptoms persisted over the 16-month period following CTX for the entire sample. Sex differences in coping could partially explain the different trajectories of growth for depression, but further studies are warranted. Younger patients may be more vulnerable for distress during this posttreatment phase. Implications for Practice: The posttreatment surveillance plan for cancer survivors should include a comprehensive assessment of psychological and physical symptoms. Persistence of symptoms can be expected in some patients, and supportive interventions should be tailored according to symptom reports.

Symptom trajectories during chemotherapy in outpatients with lung cancer colorectal cancer, or lymphoma.

PURPOSE Pain, depression, distress, fatigue, and sleep disturbance are common symptoms in oncology patients, but little data are available that examine the trajectories of these symptoms during chemotherapy (CTX). The purposes of this study were to examine the trajectories of these symptoms during the first six cycles of CTX and to determine whether individual characteristics predicted the trajectories of these symptoms. METHODS Oncology outpatients (n = 118) with newly diagnosed lung cancer, colorectal cancer, or lymphoma rated symptoms using an electronic patient care monitor system. Pain, fatigue, and sleep disturbance were rated on 0-10 numeric rating scales; depression and distress were evaluated using scales converted to normalized T scores. Latent growth curve analyses (LGCA) examined for intra- and inter-individual differences in the trajectories of these five symptoms during the six cycles of CTX. RESULTS Symptoms were present at the initiation of CTX (p < 0.0001) for all symptoms (p < 0.05). Distress (p = 0.03) and pain (p = 0.02) intensity decreased significantly over the six cycles of CTX. Advanced disease and a higher number of comorbidities predicted higher fatigue at baseline (p = 0.02 and 0.01 respectively). A diagnosis of lung cancer predicted an increasing intensity of fatigue during CTX (p = 0.04). Concurrent radiation therapy predicted more intense pain over time (p = 0.03). CONCLUSIONS While symptom trajectories were highly variable in patients undergoing initial CTX, the majority of the symptom intensity scores decreased over time. However, patients with lung cancer, those with a higher number of comorbidities, and those with advanced disease experienced more intense fatigue and sleep disturbance over time.

Palmar-plantar erythrodysesthesia.

M.J. is a 47-year-old woman who was diagnosed with epithelial ovarian cancer two years ago; she underwent total abdominal hysterectomy with bilateral salpingo oophorectomy and received adjuvant carboplatin and paclitaxel, but her cancer recurred within six months of completing adjuvant therapy. M.J. recently completed two cycles of liposomal doxorubicin 50 mg/m every four weeks. The likelihood of obtaining a response with this regimen is 14%–20%, with stable disease reported in 30% of patients (Campos et al., 2001). M.J. arrives at the clinic and tells the nurse that she developed intermittent tingling, erythema, and slight swelling on the palms of her hands and fi ngers, as well as red blotches between her knees, three days after her last cycle of chemotherapy. M.J. is able to perform all self-care and work-related functions and reported that the red blotches are tender to touch but not painful. The affected skin is intact, and she denies fever, rash, urticaria, or pruritis; use of new detergents, lotions, or soaps; or exposure to any allergen. The clinical assessment confi rms M.J.’s report, and the differential diagnoses include allergic reaction, palmar-plantar erythrodysesthesia (PPE), cellulitis, and contact dermatitis. The most likely diagnosis is PPE resulting from the recent liposomal doxorubicin chemotherapy.

Exposed bone in oral cavities.

Ms. N is a 54-year-old woman initially diagnosed in 2002 with stage IIIB non-small cell lung cancer, for which she received radical pneumonectomy followed by chemotherapy with carboplatin and gemcitabine. After a period of stability (i.e., approximately nine months) in which no further lesions were discovered, in a follow-up visit, she complained of lower abdominal pain, leading to the discovery of several large sclerotic lesions in her pelvis. Ms. N was diagnosed with metastatic lung cancer to the bone and began monthly therapy with zoledronic acid, a bisphosphonate approved for the treatment of metastatic lesions from lung cancer. In 2003, the patient presented with a complex ovarian mass and elevated cancer antigen 125 and began therapy for presumed ovarian cancer. Ms. N received liposomal doxorubicin and continued the monthly infusions of zoledronic acid. Her quality of life was good, and she was able to participate in her usual activities. In 2004, Ms. N began to complain of diffuse jaw pain. The pain was unresponsive to analgesics administered over several months. On examination, the gum looked edematous with mild erythema, and the initial differential diagnosis included oral abscess. After consultation with a dentist, a full panoramic radiologic study was taken of the affected area of her jaw. The patient then presented to the clinic with a complaint of exposed bone in her jaw and gum line (see Figure 1). Ms. N was started on oral clindamycin and oral chlorhexidine 0.12% mouth rinses three times a day. She was referred to an oral surgeon for further evaluation, where avascular necrosis or osteonecrosis of the jaw (ONJ) was diagnosed.

A Qualitative Analysis of Patient and Family Perspectives of Palliative Care

BACKGROUND To provide truly patient-centered palliative care services, there is a need to better understand the perspectives and experiences of patients and families. Increased understanding will provide insight into the development of health care team competencies and organizational changes necessary to improve patient care. OBJECTIVE Our aim was to explore patient and family perceptions of palliative care services at the end of life or during serious illness and to identify facilitators and barriers to receipt of palliative care services. METHODS In-depth, semi-structured patient and family interviews were conducted, transcribed, and independently reviewed using grounded theory methodology and preliminary interpretations. A combined deductive and inductive iterative qualitative approach was used to identify recurring themes. The study was conducted in a physician-led, not-for-profit, multispecialty integrated health system serving three large, western, rural states. A purposive sample of 14 individuals who received palliative care services were interviewed alone or with their families for a total of 12 interviews. RESULTS Presence, Reassurance, and Honoring Choices emerged as central themes linked to satisfaction with palliative care services. Themes were defined as including health care professional attributes of respect, approachability, genuineness, empathy, connectedness, compassion, sensitivity, an ability to listen, good communication, provision of information, empowerment, and timeliness. Honoring Choices included those pertaining to treatment, spirituality, and family needs. CONCLUSIONS At end of life or during times of serious illness, patients and families identified behaviors of Presence, Reassurance, and Honoring Choices as important. According to patients/families, health care providers must be compassionate and empathetic and possess skills in listening, connecting, and interacting with patients and families.

Rasburicase: An Innovative New Treatment for Hyperuricemia Associated With Tumor Lysis Syndrome

Rasburicase is a new treatment for hyperuricemia, a metabolic manifestation of tumor lysis syndrome (TLS). Rasburicase has a unique mechanism of action that allows uric acid byproducts to be easily excreted in the urine. Clinical trials have shown that rasburicase has a rapid onset of action that allows chemotherapy to be delivered on time and prevents hyperuricemia-related complications, including renal compromise. The drug has been used successfully in adults and children. The main side effect of rasburicase is the potential for a hypersensitivity reaction. The drug is contraindicated in patients with glucose 6-phosphate dehydrogenase (G6PD) deficiency because this can precipitate hemolytic anemia. The drug has not been studied in patients with a history of allergies or asthma. Oncology nurses play a major role in the assessment and management of TLS-related complications. They must assess patients for G6PD deficiency and signs and symptoms of hypersensitivity reaction before and during chemotherapy or other therapeutic interventions. Nurses play a direct role in preventing complications related to TLS and contributing to the quality of life in this patient population.

Measuring the quality of care related to pain management: a multiple-method approach to instrument development.

Background:Research to document the effects of nursing on patient outcomes such as pain has been limited by the inability to measure the quality of nursing care effectively. Objective:The purpose of this study was to establish content validity and to evaluate patient understanding of Pain Care Quality (PainCQ) survey items using cognitive interviewing. Method:In the development phase, 101 items representing four constructs were generated from the transcriptions of 33 qualitative interviews conducted with cancer patients in pain. In the judgment phase, items were reviewed systematically by two panels of pain experts. In the final phase, cognitive interviews were conducted with hospitalized cancer patients reporting pain. Results:Content validity was established if eight of nine (p < .05) experts agreed the item was relevant or very relevant. On the basis of the expert panel review, items were deleted, reworded, and added, and 73 items remained. These items were evaluated by cognitive interviews with 39 hospitalized patients with multiple types of cancer in three states. The mean age was 58.87 years, and 60.5% were women. Most were non-Hispanic White (94.7%), and education varied. On a 0 to 10 scale, worst pain during the past shift averaged 5.24 (SD = 2.43). Participant responses to the PainCQ survey items were summarized for each item using a matrix tool and evaluated in team meetings. Through an iterative process, items were revised and reduced to produce the PainCQ survey (v3) with 44 items. Discussion:Through this deliberative and iterative process, an instrument was produced that will contribute to the measurement of the quality of nursing and interdisciplinary care related to pain management. The items retained in the PainCQ were understood and judged by hospitalized patients with pain easily. Further psychometric testing of the PainCQ is indicated.

Palliative care for adults across the cancer trajectory: from diagnosis to end of life.

OBJECTIVES To provide an overview of palliative care across the cancer trajectory from diagnosis through treatment, the chronic phase, and end of life. DATA SOURCES Journal articles, research reports, state of the science papers, and clinical practice experience and guidelines. CONCLUSION Symptoms occur throughout the cancer trajectory but are more common during active treatment and at the end of life. Symptom assessment facilitates optimal management of symptoms, promotion of comfort, and improvement in quality of life. IMPLICATIONS FOR NURSING PRACTICE Clinicians have a responsibility to anticipate and assess symptoms throughout the illness trajectory. Identification of symptoms should prompt a plan of care that is based on evidence-based guidelines and best practices.

Evaluating Palliative Care Needs in Middle Eastern Countries

BACKGROUND Cancer incidence in Middle Eastern countries, most categorized as low- and middle-income, is predicted to double in the next 10 years, greater than in any other part of the world. While progress has been made in cancer diagnosis/treatment, much remains to be done to improve palliative care for the majority of patients with cancer who present with advanced disease. OBJECTIVE To determine knowledge, beliefs, barriers, and resources regarding palliative care services in Middle Eastern countries and use findings to inform future educational and training activities. DESIGN Descriptive survey. SETTING/SUBJECTS Fifteen Middle Eastern countries; convenience sample of 776 nurses (44.3%), physicians (38.3%) and psychosocial, academic, and other health care professionals (17.4%) employed in varied settings. MEASUREMENTS Palliative care needs assessment. RESULTS Improved pain management services are key facilitators. Top barriers include lack of designated palliative care beds/services, community awareness, staff training, access to hospice services, and personnel/time. The nonexistence of functioning home-based and hospice services leaves families/providers unable to honor patient wishes. Respondents were least satisfied with discussions around advance directives and wish to learn more about palliative care focusing on communication techniques. Populations requiring special consideration comprise: patients with ethnic diversity, language barriers, and low literacy; pediatric and young adults; and the elderly. CONCLUSIONS The majority of Middle Eastern patients with cancer are treated in outlying regions; the community is pivotal and must be incorporated into future plans for developing palliative care services. Promoting palliative care education and certification for physicians and nurses is crucial; home-based and hospice services must be sustained.