Journal of pain and symptom management最新文献

Context and objectives: Patients with cancer living in war zones face significant quality of life (QoL)-related challenges. This study examined an integrative oncology (IO) intervention in northern Israel for pain and autonomic response.

Methods: This prospective, randomized, controlled and pragmatic study examined an IO intervention with manual-relaxation, with acupuncture (Group A) or without (Group B). ESAS (Edmonton Symptom Assessment Scale), EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire), and MYCAW (Measure Yourself Concerns and Wellbeing) tools were used to examine QoL. Heart rate and variability (HRV) were measured at baseline and 15 minutes post-treatment, comparing frequency-domain variable changes (e.g., LN Power Total, Power HF, Power LF, Power VLF).

Results: Of 125 patients, Groups A (67) and B (58) had similar demographic and cancer-related characteristics. ESAS pain scores improved in both groups post-treatment (A, P<0.001; B, P=0.002), as did anxiety, depression, and fatigue. At three weeks, Group B reported greater improvement on ESAS pain (p=0.039) and MYCAW pain-related concerns (p=0.025), both showing within-group improvement on EORTC pain. HRV showed greater change in Group A, with decreased LN Power Total (p=0.006), LN Power LF (p=0.02), and LN Power VLF (p=0.026). While Relative Power HF increased marginally (p=0.054), heart rate decreasing more significantly in Group B (p=0.005).

Conclusions: IO treatments led to reduced pain among patients with cancer living in a war zone, with no additive effect of acupuncture. HRV changes suggest enhanced parasympathetic activity, with acupuncture-treated patients showing additional frequency-domain changes attributed to decreased sympathetic tone.

Context: Although hospice policies vary in where they permit staff to be physically located during key stages of the medical aid in dying (MAID) procedure, data needed to inform best practices concerning if and how clinicians themselves are present are lacking.

Objectives: To (1) assess the sample proportion of clinician presence during each individual stage of the MAID procedure and (2) typologize the distinct trajectories of clinician presence across stages of the MAID procedure.

Methods: We used secondary cross-sectional survey data from a convenience sample of interdisciplinary US hospice clinicians indicating permissive state and organizational MAID participation policies. Participants reported whether they had ever been present during medication self-administration, after medication self-administration, and after death by indicating if they had been in the same room, in the same residence but not the same room, or never present. We assessed presence and typologized trajectories via frequency and percentage.

Results: The sample comprised 106 hospice physicians, nurses, social workers, and chaplains. The sample majority reported never having been present during any stage. Across stages, the sample demonstrated 13 distinct trajectories of clinician presence. The most common trajectories illustrated uniformity in physical location across stages. The remaining trajectories reflected transitions in physical locations across stages. Transition subgroups depicted increasing proximity to bedside, increasing distance from bedside, and a combination of both.

Conclusions: High variability in hospice clinician presence throughout the MAID procedure may differentially affect patient care. Future best-practices research should explore stakeholder experiences of trajectories and stratify trajectories by professional discipline.

Context: Advance care planning (ACP) may prepare older adults for future health problems including cognitive and physical decline. Depressive symptoms are observed among those engaging in ACP. However, the directionality of the association between ACP engagement and depressive symptoms remains uncertain.

Objectives: To investigate bidirectional associations between engaging in ACP and depressive symptoms in older adults at a within-person level after accounting for cognitive and physical decline.

Methods: A longitudinal study design using random intercept cross-lagged panel models. Community-dwelling older adults from the Longitudinal Aging Study Amsterdam with 3 assessments at T0 (2015-2016), T1 (2018-2019), and T2 (2021-2022). Discussion of end-of-life wishes with a physician was used as a proxy measure for ACP engagement.

Results: Participants included 1669 older adults (mean [SD] age, 69.7 [7.7] years at T0; 923 [55.3%] were women). Poor cognition at T0 was associated with having discussed end-of-life wishes at T1 (β = -0.12 [95%CI, -0.23 to -0.01]), that was prospectively associated with increased depressive symptoms (0.12 [0.01 to 0.24]), decreased cognition (-0.13 [-0.22 to -0.04]), and decreased physical performance (-0.16 [-0.27 to -0.04]) at T2.

Conclusion: Older adults appear at risk for having depressive symptoms following discussing end-of-life wishes with their physicians. End-of-life communication may reflect an ongoing trajectory of cognitive decline which could result in further functional decline and increased depressive symptoms. A better understanding of how and which elements of end-of-life discussions are associated with the mood of older adults will provide implications for the implementation of ACP.

Context: . Breathlessness is the most common and distressing symptom in lung cancer, but no systematic review has examined the effectiveness of mindfulness-based interventions on breathlessness.

Objectives: . To evaluate the effectiveness of mindfulness-based interventions on breathlessness, pulmonary function, and psychological well-being in lung cancer.

Methods: . According to the PRISMA guidelines, we conducted a systematic search across ten databases from inception to February 2025. Only randomized controlled trials were included.

Results: Fourteen RCTs from 15 papers (N=1190) were included. Pooled results: compared with a control, mindfulness-based interventions did not show a significant improvement in breathlessness [SMD=-0.44, 95%CI:-0.92 - 0.05, n=5]; indicated a significant improvement in pulmonary function including vital capacity [MD=0.44 L, 95%CI:0.18 - 0.70, n=2], peak expiratory flow [MD=14.72 L/s, 95%CI:6.14 - 23.30, n=2], forced expiratory volume in one second (FEV₁) [MD=0.49 L, 95%CI:0.17 - 0.81, n=9], forced vital capacity (FVC) [MD=0.55 L, 95%CI:0.28 - 0.83, n=8], FEV₁/FVC [MD=8.02%, 95%CI:5.77 - 10.28, n=6]; indicated a significant reduction in psychological distress including depressive symptoms [SMD=-1.28, 95%CI:-2.25 - -0.31, n=6], and anxiety [SMD=-1.54, 95%CI:-2.34 - -0.74, n=7]. Subgroup analysis: patients receiving mindfulness-based respiratory function interventions indicated significant improvements in breathlessness [SMD=-0.53, 95%CI:-0.86 - -0.21], FEV₁ [MD=0.28 L, 95%CI:0.17 - 0.39], and FVC [MD=1.29, 95%CI: 0.64 - 1.95], compared with those receiving respiratory function intervention.

Conclusion: . Mindfulness-based interventions did not demonstrate a statistically significant improvement in self-reported breathlessness compared to controls. However, subgroup analysis indicated that combining mindfulness with respiratory function training may offer additional benefits for alleviating breathlessness. Further high-quality RCTs are needed to determine the optimal intervention dosages and long-term impact of mindfulness-based interventions on improving breathlessness.

Context: Evaluation of palliative care programs in nursing homes often includes symptom assessments. For residents with cognitive impairment, proxy symptom reports, such as those from family members or nursing home staff, may be used as outcome measures.

Objectives: This analysis compares differences between family and staff proxy reports of symptoms of nursing home residents with moderate to severe cognitive impairment.

Methods: Data were collected as part of a clinical trial, conducted in 16 nursing homes (NHs) in Indiana and Maryland (U.S.). We calculated the difference in total modified End-of-Life Dementia Comfort Assessment in Dying (EOLD-CAD) scores between family and staff respondents for 194 residents, and quantified characteristics associated with discordance.

Results: About half of responding staff were licensed nurses and 37% were certified nursing assistants. Adult children of residents were the most common (57%) family respondents. There was fair agreement between the respondent groups (kappa = 0.26) for the total modified EOLD-CAD scale. Overall, family members reported higher symptom burden than staff. Some symptoms, including discomfort, pain, restlessness and agitation, were reported as more burdensome by both groups of proxies vs. symptoms such as gurgling or choking. Proxy symptom reports on residents with more advanced cognitive impairment were less likely to be substantially discordant (OR = 0.50, 95% CI 0.26, 0.99, P = 0.047).

Conclusion: Proxies are often used to report symptom experiences for people living with cognitive impairment. Multiple perspectives may be needed to obtain a fuller picture of symptom burden in this population.

Registration: CLINICALTRIALS.GOV: NCT04520698.

Background: In low- and middle-income countries, the incidence of cancer is rising, with diagnoses frequently made at advanced stages, limited access to treatments, and high mortality rates. Palliative care may alleviate suffering, enhance quality of life, and reduce costs. In this review, we aimed to explore the development of palliative care in low- and middle-income settings and assess if and how this contributes to mitigating or alleviating the human suffering of people with cancer.

Methods: A best-fit framework synthesis approach was employed, and seven databases were systematically searched in 2025. Data from eligible studies were extracted and qualitatively synthesized into themes and subthemes, initially using a framework constructed from indicators from the WHO Conceptual Model for Palliative Care Development and the Integrated Palliative Care Oncology Practice Model. The review is registered with PROSPERO (CRD42024511158) FINDINGS: Studies (n = 81) were reviewed. Interventions by multidisciplinary teams, combined with a bio-psycho-socio-spiritual approach, led to improved patient outcomes. Palliative care reduced hospital stays, decreased unnecessary end-of-life treatments, and facilitated home deaths. Community-based palliative care empowered patients and families to manage care at home, cope with uncertainties, and lower healthcare costs. Successful implementation relied on a participatory public health system and support from nongovernmental organizations, which provided access to palliative care, telehealth, and training for primary care providers. However, when compared to the indicators from the two models, only a few aligned with core elements.

Interpretation: Although progress has been made in integrating palliative care in low- and middle-income countries, evidence linking this development to international indicators of palliative care progress is insufficient. It is likely that strengthening patient-family partnerships, promoting shared decision-making, and advocating for patient rights contribute to alleviating the human suffering from cancer.

Funding: The conduct of this review is supported by an unrestricted grant from the End-of-Life Care in India Task Force (ELICIT). ELICIT supports end-of-life education, research, and policy.

Context: Pediatric palliative care (PPC) for children with cancer can improve the quality of life for patients and their families, but barriers impede the early integration of PPC for many patients.

Objectives: This study aims to investigate the current status of PPC integration for children with cancer in China, identify discrepancies between the ideal and actual timing of PPC implementation, and highlight physician-perceived barriers to PPC integration.

Methods: The assessing doctors' attitudes on palliative treatment (ADAPT) survey was recently translated into Chinese and thoroughly validated. The survey was distributed to physicians caring for children with cancer across 25 Chinese provinces. The response rate was 98.4%. Descriptive statistics were used to summarize the findings. A qualitative analysis was used for open-ended responses.

Results: Data from 368 physician responses were included in the final analysis. Most participants (83.2%) stated that the actual timing of PPC consultation for children with cancer in their center occurs at the end of life. Most participants (70.4%) also stated that PPC consultation should ideally occur at diagnosis, but only 121 (32.9%) reported this happening in their current practice (P < 0.001). The most frequently identified barriers included limited access to palliative care specialists or services (79.9%), lack of palliative care positions in tertiary hospitals (75.5%), and lack of home-based services (73.4%).

Conclusion: This study reveals a significant gap between the ideal and actual timing of PPC consultations, with most consultations occurring at the end of life or when curative options are exhausted rather than early after diagnosis. The findings also highlight the perceived barriers of limited access to specialists and home-based services, providing a focus for further intervention and capacity enhancement within China.

Context: Patients with unresectable pancreatic cancer have a poor prognosis and often high health care requirements.

Objectives: To evaluate the impact of early specialized palliative care for patients with unresectable pancreatic cancer on hospital use.

Methods: Using a quasi-experimental design, newly diagnosed patients with unresectable pancreatic cancer diagnosed from October 2019 to February 2021 were offered specialized palliative care delivered as home-visits (n = 65). The retrospective control cohort were similar patients diagnosed between December 2017 and April 2019 (n = 60). The primary endpoint was use of hospital care. Secondary outcomes included survival, quality of life and place of death.

Results: Median overall survival was significantly longer in the intervention cohort compared with the control cohort, 8.0 months (95% CI, 5.9-10.0) vs 4.9 months (95% CI, 3.5-6.3) (P = 0.029). There was no difference in use of hospital care between the cohorts, but given the longer survival in the intervention cohort there were significant reductions in monthly hospital admissions, 0.8 vs 1.2 (P = 0.002), emergency department admissions, 0.4 vs 0.6 (P = 0.009) and days in hospital, 4.2 vs 7.2 (P = 0.001) in the intervention cohort compared with the control cohort. The proportion of patients who died in hospital outside the palliative care unit was significantly lower in the intervention cohort compared with the control cohort, 14.5% vs 30.5% (P = 0.035).

Conclusion: Early specialized palliative care for patients with unresectable pancreatic cancer resulted in an increase in survival without an increase in use of hospital care.