Nessa Coyle

Character of terminal illness in the advanced cancer patient: Pain and other symptoms during the last four weeks of life

There is a great variability among advanced cancer patients in the experience of symptoms and their impact on lifes activities. A subgroup of difficult patients particularly tax the clinical skills and compassion of practitioners. Although the need for information about these patients is evident, their characteristics have not been explored heretofore. We describe our experience with such patients, a group referred to the Supportive Care Program of the Pain Service at Memorial Sloan-Kettering Cancer Center. Prevalence of pain and other symptoms, patterns of opioid use and routes of drug administration, and the prevalence of suicidal ideation and requests for euthanasia are discussed.

Individual variability in the response to different opioids: report of five cases

Although it is widely appreciated that patients can demonstrate highly variable responses to different opioid drugs, there have been few detailed descriptions of this phenomenon. To illustrate this variability, we present 5 patients, 4 with cancer pain and 1 with non-malignant pain, who underwent dose titration with more than 1 opioid and developed markedly different responses to each. In every case, dose escalation led to successful treatment with 1 opioid and to intolerable side effects without adequate relief with others. The existence of this individual variability in the response to different opioids has important implications for both clinical practice and current understanding of opioid pharmacology in man. It contradicts the view that any opioid is inherently more efficacious than any other, suggests that patients who fail to obtain adequate pain relief at maximally tolerated doses of 1 opioid may benefit from an alternative drug, and underscores the potential importance of genetic factors as a determinant of opioid response.

Controversies in the long-term management of analgesic therapy in patients with advanced cancer

The management of pain in the patient with advanced cancer requires comprehensive assessment and expertise in the application of many therapeutic techniques. Given the complexity of the problems posed by these patients, it is not surprising that most aspects of palliative care derive from personal anecdote and clinical consensus, rather than well-defined guidelines based on research findings. In the absence of such guidelines, unresolved issues and controversies abound. This review discusses some of the most important of these topics, which range from the overall system of care and quality of assessment to the specifics of pharmacotherapy and other modalities of treatment. In so doing, the rationale for some of the accepted clinical approaches can be clarified, others that are as yet little known can be highlighted, and the issues most in need of further investigation can be defined.

Global efforts to improve palliative care: the International End‐of‐Life Nursing Education Consortium Training Programme

AIM This paper is a report of an evaluation study to determine the feasibility and effectiveness of the End-of-Life Nursing Education Consortium-International training conference in providing education and support materials to participants so they might return to their home countries and disseminate palliative care information. BACKGROUND More than 50 million people die each year, many without access to adequate pain control or palliative care. Numerous barriers to implementation of palliative care exist, including lack of education provided to healthcare professionals regarding these principles. Because they spend the most time with patients and their families, nurses have the greatest potential to change the way palliative care is provided. METHOD A Course Evaluation Form and a Postcourse Activity Evaluation was completed by a convenience sample of 38 nurses from 14 Eastern and Central European, former Soviet, and Central Asian countries. The data were collected in 2006 using Likert scales and open-ended questions. FINDINGS Evaluations of speakers ranged from a mean of 4.4 to 4.9 on the 5-point scale, with five denoting the highest level. The mean rating of the conference overall was 4.9. Strengths included the professional level of presentations, practical, clinically based content, extensive resources and availability of the educators. CONCLUSION The first End-of-Life Nursing Education Consortium-International training programme demonstrated the feasibility of providing high-quality, essential education to nurses from a variety of countries. Because End-of-Life Nursing Education Consortium is designed as a train-the-trainer programme, assistance with translation to native languages, along with textbooks and other resources, is needed to allow participants to fully implement this curriculum.

Development and validation of a patient needs assessment tool (PNAT) for oncology clinicians.

The Patient Needs Assessment Tool (PNAT) is an interviewer-rated scale that may be completed through a simple structured interview and screens cancer patients for potential problems in physical and psychosocial functioning. The instrument provides separate scores for physical, psychological, and social status, and can potentially clarify the types of interventions needed to address specific areas of dysfunction. Reliability and validity was tested in two studies that used prescreened patient videotapes and other materials to assess the performance of the PNAT in groups of oncology nurses, physicians, and social workers. The data demonstrate that subscale scores for the physical, psychological, and social dimensions have good inter-rater reliability and internal consistency (intraclass correlation coefficients of 0.71-0.97). Criterion and construct validity was suggested through high correlations of each subscale with the evaluation of expert raters (correlation coefficients of 0.85-0.95) and with scores on validated patient-rated instruments appropriate to the functional area. These analyses suggest that the PNAT is a valid scale for the assessment of a range of functional disturbances in the cancer population.

A model of continuity of care for cancer patients with chronic pain.

A patient and family-centered, nurse-coordinated model is presented in which a collaborative approach among nurse, physician, and social worker is used. The team is based at a hospital or cancer center, but is oriented toward the community. In the model, the nurse is responsible for the day to day management of the patients pain, and works with the patient, family, and community physicians and nurses in symptom control and supportive care.

Evaluation of palliative care nursing education seminars

PURPOSE More than 50 million people die each year around the world. Nurses are crucial in providing care to these individuals and their families as they spend the most time at the bedside with patients and families. Yet many nurses have received little or no education about palliative care. METHODS/SAMPLE The Open Society Institute (OSI) and the Open Medical Institute (OMI) partnered with End-of-Life Nursing Education Consortium (ELNEC) to develop an international nursing palliative care curriculum. This international curriculum was implemented with two training courses held in Salzburg, Austria in October 2006 (n=38) and April 2008 (n=39) representing 22 Eastern European/Central Asian countries. Participants were asked to establish goals in disseminating the palliative care information when they returned to their country. The participants were mentored/followed for a 12-month period to evaluate their palliative care knowledge as well as challenges encountered. KEY RESULTS The participants provided excellent ratings for the training courses indicating that the courses were stimulating and met their expectations. The 12-month follow-up demonstrated many challenges (i.e., lack of funds, institutional support, fear of death), in advancing palliative care within each participants setting/country as well as many examples of successful implementation. CONCLUSIONS There is an urgent need for improved palliative care throughout the world. The ELNEC-International curriculum is designed to address the need for increased palliative care education in nursing. In order to improve the quality of life for those facing life-threatening illnesses around the world, ongoing support is needed for world-wide palliative care educational efforts.

Treatment of cancer pain in a former opioid abuser: Fears of the patient and staff and their influence on care

A 48-yr-old man with an extensive history of polysubstance abuse (opioids, cocaine, amphetamines, and marijuana) presented with neck and shoulder pain associated with lung cancer. The history included intravenous heroin abuse from 18 to 36 years of age, at which time he entered a methadone maintenance program as part of a legal agreement to avoid imprisonment for selling heroin. During the next year, he stopped all drug abuse and subsequently withdrew from the methadone maintenance program. In the years that followed, he became professionally involved in social work programs with drug abusers, completed college, and married. At the time of presentation, he had been “drug-free,” except for cigarette smoking and social alcohol use for 12 years. The cancer was metastatic to bone at the time of diagnosis. There was destruction of the C6 and C7 vertebral bodies, paravertebral soft tissue

Audio-Visual Communication and Its Use in Palliative Care

The technology of telemedicine has been used for over 20 years, involving different areas of medicine, providing medical care for the geographically isolated patients, and uniting geographically isolated clinicians. Today audio-visual technology may be useful in palliative care for the patients lacking access to medical services due to the medical condition rather than geographic isolation. We report results of a three-month trial of using audio-visual communications as a complementary tool in care for a complex palliative care patient. Benefits of this system to the patient included 1) a daily limited physical examination, 2) screening for a need for a clinical visit or admission, 3) lip reading by the deaf patient, 4) satisfaction by the patient and the caregivers with this form of communication as a complement to telephone communication. A brief overview of the historical prospective on telemedicine and a listing of applied telemedicine programs are provided.

Continuity of care for the cancer patient with chronic pain

The care of patients with cancer and chronic pain, often complicated and demanding, strains the resources of a single physician. Continuity of care programs, such as that developed by the Pain Service of Memorial Sloan‐Kettering Cancer Center (New York), with good communication and liaison work between hospital and community, add a much needed dimension to the pain management of these patients in the home. Although continuity of care programs resemble hospice programs in philosophy, there are major differences in admission criteria: the program is not restricted to dying individuals; patients may live alone; they may receive active therapy with a focus on cure or remission; and they continue to receive their care, including pain management, within a standard medical system under the supervision of their primary physician and nurse.