Journal of pain and symptom management最新文献

Depression in serious illness is common, disabling, and often requires rapid improvement. Traditional antidepressants may take weeks to work, whereas second-generation antipsychotics (SGAs) have evidence for faster onset and robust augmentation effects in general psychiatric populations. In this Palliative Care Rounds, we review the general psychiatric and serious illness-specific evidence for the use of SGAs as monotherapy and augmentation therapy for depression. In the psychiatric literature, SGA augmentation improves response and remission rates (ORs 1.34-2.93; NNT 7-13), with onset of improvement within 1-2 weeks. Monotherapy is less well tolerated and not guideline-recommended. No RCTs have evaluated SGAs specifically for depression in serious illness, but numerous cancer trials support their safety for nausea, appetite, and other symptoms. Despite the absence of serious illness-specific psychiatric trials, SGAs have the strongest evidence base among augmentation options and may offer meaningful benefits when prognosis or symptom severity necessitates rapid improvement. Low-dose augmentation should be considered early, rather than only after multiple failed antidepressants, particularly when SGAs can also target co-occurring physical symptoms relevant to palliative care.

Context: Prognostic information is crucial for end-of-life decision-making. While survival predictions are common, the impact on family members remains unclear. There is also a need to understand the role of discussions about functional prognosis.

Objectives: This study aimed to explore 1) the frequency of discussion about life expectancy and that about functional prognosis in family members and 2) the impact of the discussion on family outcomes.

Methods: This pre-planned analysis of a nationwide post-bereavement survey examined communication regarding life expectancy and functional prognosis. The study included bereaved family members of cancer patients who died in palliative care units between May and January of 2024. Complicated grief, depression, and unfinished business were measured using validated scales. It compared outcomes between those with and without these discussions.

Results: Of the 988 questionnaires sent, 582 were analyzed. Regarding discussions with clinicians, 85.7% of family members discussed life expectancy, while 68.0% of family members discussed functional prognosis. Family members experienced better scores on measures of grief and depression. All subscales of "unfinished business" showed better outcomes in the groups that had these discussions.

Conclusion: Discussions about life expectancy were more prevalent than discussions about functional prognosis for family members. These discussions were linked to reduced grief, depression and unfinished business for family members.

The experience of having a child in the PICU can be emotionally and psychologically overwhelming for families leading to many challenges.

Objectives: To identify and explore the psychosocial needs of families of critically-ill pediatric patients with non-cancer diagnoses, allowing for the development of mitigation strategies and interventions.

Methods: We conducted one-on-one interviews with caregivers of critically-ill pediatric patients with non-cancer diagnoses admitted to a large urban PICU. We used a constant comparison analytic approach to derive themes from interviews.

Results: We conducted 20 interviews, identifying five unique themes. First, families feel a profound obligation to be present at their child's bedside, making it difficult to address their own needs. Second, the physical environment of the PICU can provide challenges that hinder caregivers' ability to care for themselves and their children. Third, families noted the importance of emotional support from bedside nursing, which provided tremendous comfort in times of uncertainty. Fourth, an ICU admission can deeply impact patients' siblings, which often goes unrecognized. Fifth, families often feel immense fear and loneliness while admitted, which can persist after discharge.

Conclusions: By identifying unique themes representing the needs of families of critically-ill pediatric patients with non-cancer diagnoses, we developed recommendations for how to address these needs and mitigate the psychosocial effects associated with a PICU admission, creating a more balanced support system for all patients and their caregivers. These interventions can be practiced by all team members caring for children in the PICU, including but not limited to palliative care specialists.

Background: Children with severe neurological impairment (SNI) experience recurrent, complex pain and distress that are difficult to assess and manage. Specialized pediatric palliative care (SPPC) teams are well positioned to support this population, yet no structured palliative care interventions targeting distress in SNI have been evaluated.

Objectives: To refine the PediQUEST (PQ)-ResPOND intervention, electronic parent-reported outcome (PRO) with SPPC integration, by assessing feasibility, acceptability, perceived usefulness, and preliminary outcome patterns prior to a pilot randomized controlled trial.

Methods: We conducted an 8-week, mixed-methods B-phase training case series with child/parent dyads (child with SNI with moderate-to-severe pain) receiving care at a U.S. tertiary pediatric hospital. Parents completed weekly PRO surveys via the PQ-system and participated in semi-structured interviews (weeks 4 and 8). Parents and primary/SPPC clinicians received weekly automated PQ-Reports summarizing child symptoms. SPPC team integration consisted of initial consultation, follow-up triggered by PQ-Reports, and use of a standardized guide for assessment and multimodal management of distress. Outcomes were analyzed using descriptive statistics (quantitative) and reflexive thematic analysis (qualitative).

Results: Enrollment of three dyads led to intervention refinement. Survey completion was high. Acceptability was excellent. The PQ-System was valued as a tool for promoting reflection, organizing symptom information, and enhancing advocacy. The SPPC component was perceived as timely, family-centered, and quality-of-life-focused, and adhered to the protocol. Iterative refinements improved report usability, communication preferences, and documentation. All children showed reductions in most troublesome pain scores.

Conclusions: Refined PediQUEST-ResPOND was feasible, acceptable, and useful, supporting advancement to a pilot randomized trial.

Objectives: The use of 2% lidocaine oral viscous is constrained by its inconvenience of portability, coupled with difficulty swallowing in some cases, and its unpleasant taste. This study aimed to compare the effects of 2% peppermint lidocaine spray with conventional 2% lidocaine oral viscous on the immediate pain reduction score at baseline and 5 minutes, feasibility, and quality of life in head and neck cancer patients with chemoradiation-induced mucositis.

Methods: This study was an open-label randomized controlled trial. The patients were randomized using a block of four and divided into two groups. A research nurse collected data on pain scores and quality of life using the modified Oral Mucositis Weekly Questionnaires-Head and Neck Cancer (OMWQ-HN) (supplement 1) In addition, the nurse monitored the use of the product by approaching patients every Friday of each week until the end of the radiation course. Randomization was performed using computer-generated blocks of four prepared by an independent statistician. Allocation concealment was maintained using sealed opaque envelopes.

Results: A total of 60 patients, patients in the 2% peppermint lidocaine spray group had significantly better scores on the OMWQ-HN-12 items and found it more practical to use and with a better flavor compared to the 2% lidocaine viscous group. The immediate reduction in pain did not differ between the groups. Therefore, we conclude that 2% peppermint lidocaine spray promotes better satisfaction and quality of life without compromising pain control in patients with head and neck cancer with chemoradiation induced mucositis.

Conclusions: The 2% peppermint lidocaine spray did not demonstrate significantly better immediate pain reduction compared to 2% viscous xylocaine, but did improve the global quality of life in patients with head and neck cancer with chemoradiation-induced mucositis.

Context: Single-fraction 8 Gy palliative radiotherapy (RT) is a standard regimen for the relief of painful bone metastases. However, the delivery of single-fraction RT may result in higher retreatment rates compared to longer courses.

Objectives: To compare 6‑month retreatment rates after 8 Gy x 1 versus 8 Gy x 2 and evaluate pain response, quality of life, and adverse events (AEs).

Methods: In this prospective, randomized, multi-center phase 2 trial, adults with painful bone metastases were randomized to 8 Gy x 1 (arm 1) or 8 Gy x 2 (arm 2). The primary endpoint was the 6-month cumulative incidence of retreatment, with death as a competing risk. Secondary endpoints included pain response, adverse events, and quality of life using multiple patient-reported outcome measures.

Results: 102 patients were randomized and treated (51 per arm). The 6-month retreatment rates were 11.5% in arm 1 v. 10.3% in arm 2 (p=1.00). The cause-specific hazard ratio of retreatment in arm 2 (v. arm 1) was 0.87 (p=0.83). Rates of death without retreatment at 6-months were 23.3% and 29.4%, respectively. Pain response rates at 3 months were similar between arms: 55% v. 72% in arms 1 v. 2, respectively (p=0.20). No substantial differences in QOL were observed between groups. Grade 2+ AEs occurred in 13.7% and 15.7% (p=0.78).

Conclusion: No differences were observed in retreatment rates, pain response, or QOL between 8 Gy x 1 and 8 Gy x 2. Single-fraction palliative RT remains a standard for patients with painful bone metastases.

The National Palliative Care Research Center (NPCRC) was founded in 2005 with the goal of strengthening the evidence base and developing research scholars in the field of palliative care. Given its accomplishments and adding extensively to the literature regarding the science of PPC, plans to sunset NPCRC occurred in 2025. At the final NPCRC Kathleen Foley Research Retreat in October 2025, a group of pediatric palliative care (PPC) researchers and advocates convened a workshop to discuss their vision for the next 25 years. After reviewing the progress that this young field has achieved since its founding, participants identified priorities for the future of PPC research during small group discussions. The discussion centered on three main questions: 1) who has been a part of PPC research and whose voices are missing, 2) what key research has been done in the field and what should be prioritized going forward, and 3) how can we apply rigorous and innovative methods to further the science of PPC? Using an established method for collaborative dialogue which included rotations through each of the facilitated small groups, the full group came together to report out key topics, expand and clarify findings, and place the discussion in the context of future research to inform policy and advocacy to improve the care of children with serious illness and their families. This paper describes the workshop proceedings and outlines important next steps for the future of PPC research.

Background/objective: Physician-patient end-of-life care discussions are vital yet underused and rarely examined longitudinally, often overlooking patient-family interdependence in death preparedness for care planning. This cohort study examined changes in physician-patient/family discussions and their associations with dyadic concordance on death preparedness during patients' final 6 months.

Methods: In 694 dyads, we examined associations between previously identified dyadic-concordance death-preparedness states (unprepared-, cognitive-, emotional-, and sufficient-concordant vs. discordant) and patient- and family-reported end-of-life-care discussions (physician-patient only, physician-family only, and physician-patient-and-family vs. no discussions) using hierarchical generalized multinomial logistic regression with discordant and no discussions as reference groups.

Results: Patients were predominantly male (75.9%; mean age 59.98±10.35 years), and caregivers were mainly female spouses (79.1%, 73.5%; mean age 54.83±12.40 years). Physician discussions increased over time and were largely family-centered: no discussions declined (82.8%→41.6%), physician-family-only discussions increased (13.8%→35.7%), and physician-patient-and-family discussions rose (1.7%→18.1%), while physician-patient-only discussions remained rare (1.7%→4.6%). Compared with discordant dyads, sufficient-concordant dyads were more likely to engage in physician-family-only (adjusted odds ratio [AOR]=1.87; 95% confidence interval [CI]: 1.17-2.98) and physician-patient-and-family (3.09 [1.51-6.29]) discussions, while cognitive-concordant dyads were more likely to engage in physician-patient-and-family discussions (3.61[1.82-7.18]), relative to no discussion.

Conclusion: Physician silence decreased near death, while physician-family-only and physician-patient-and-family discussions increased in the last month. Dyadic concordance on death preparedness was associated with these patterns, underscoring the need for physicians to foster death preparedness with prognostic awareness and emotional readiness early in the terminal-illness trajectory to promote engagement in end-of-life-care planning.