Journal of pain and symptom management最新文献

Background: Patients with advanced illness often experience acute distressing symptoms leading to unplanned hospitalizations, despite a preference to remain at home. Existing home-based care models frequently lack the responsiveness and clinical intensity to manage such emergencies.

Aim: To assess the operational robustness and clinical impact of the Home Emergency Response Team for Palliative Care Patients (HERT-P) prototype during its regional scale-up in France.

Design: This three-year observational study (2021-2024), conducted without a control group, evaluated an innovative model integrating critical and palliative care for patients at home. The HERT-P program combined centralized coordination with decentralized mobile teams, expanding from 2 to 4 French departments (3.5 to 7 million residents). All 2326 intervention requests underwent a shared decision-making process. The primary outcome was patient trajectory; secondary outcomes included scalability, cost-effectiveness, and environmental impact.

Setting/participants: Patients with advanced illness and acute symptom exacerbations were triaged via a 24/7 hotline. Admitted patients received rapid-response care, including curative and palliative interventions, with follow-up through home visits and telemedicine.

Results: Of 2326 requests, 1806 patients (78%) were admitted. Among them, 75% died at home, 18% improved, and 1% required emergency department transfer. The program's active caseload increased from 5 to 15 over three years, while reducing per-stay costs by 12%. Compared to equivalent hospital-based care, each intervention generated a 78% lower carbon footprint. These results led the French Ministry of Health to fund 15 new HERT-P teams for national deployment in 2025.

Conclusions: The HERT-P model supported home-based trajectories through responsive care and showed potential for scalability.

Context: Globally, about 85% of palliative care need is unmet. Africa accounts for 20% and 52% of adult and pediatric palliative care burden worldwide, respectively. Nigeria has progressing palliative care provision but meets only an estimated 0.2% of national need.

Objectives: To describe extant literature detailing palliative care knowledge, implementation, medicine availability, education, policy, vitality, and research in Nigeria, propose areas for future scientific inquiry, and inform interventional targets.

Methods: Arkey and O'Malley design for scoping reviews reported per the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews guidelines. PubMed, Embase, Cochrane CENTRAL, Web of Science, Scopus, and African Index Medicus were searched in January 2024 and updated in December 2024. Full-text, peer-reviewed articles in English describing palliative care in Nigeria were included.

Results: Of the 6116 search results, 290 underwent full-text review and 59 satisfied inclusion criteria. Most studies examined palliative care knowledge, attitudes, and practices while few evaluated implementation practices or interventions. Palliative care awareness in Nigeria is low; however patients, family caregivers, and healthcare professionals have expressed interest in expanded education, infrastructure, and culturally-appropriate delivery models. Persistent challenges include opioid availability, delayed referral, inconsistent education, insufficient institutional and federal policy, and absent professional validation.

Conclusions: This review identified gaps in palliative care in Nigeria that can inform interventional targets for national acceptance and equitable delivery. It is critical to prioritize multilevel policy changes to expand access to high-quality palliative care services and mitigate the growing burden of health-related suffering among the seriously ill.

Context: Terminal restlessness is frequently observed in hospice, yet it lacks a consistent definition, diagnostic framework, and treatment approach. This ambiguity complicates care by increasing caregiver distress, delaying diagnosis, and creating uncertainty around appropriate treatment.

Objectives: This qualitative study explored how hospice clinicians define, diagnose, and pharmacologically manage terminal restlessness in practice.

Methods: We conducted semi-structured interviews with hospice clinicians from diverse settings across Michigan. Participants were asked how they define terminal restlessness, distinguish it from other end-of-life conditions, and approach its treatment. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

Results: Eighteen hospice clinicians with backgrounds in family medicine, internal medicine, pediatrics, psychiatry, and neurology participated, with a mean of 10 years' hospice experience. Most practiced in home- or facility-based settings. Five themes emerged: (1) Diagnostic challenge-clinicians reported difficulty distinguishing terminal restlessness from delirium, pain, or medication side effects; (2) Common symptom profile-agitation, confusion, hallucinations, and constant movement; (3) Temporal association with active dying process-terminal restlessness was viewed as a sign of imminent death; (4) Ruling out reversible causes-pain, urinary retention, or other modifiable factors; and (5) Treatment variability-approaches varied, though most clinicians were more comfortable using sedating medications once death was perceived to be imminent.

Conclusion: Hospice clinicians encounter uncertainty when diagnosing and managing terminal restlessness. Although common symptom patterns and care considerations were shared, variability in clinical approach and lack of standardized treatment were prominent. Additional research is needed to further characterize the syndrome, refine diagnostic criteria, and identify treatment strategies.

Context: Documented goals of care conversations (GOCC) are associated with positive outcomes. Little is known about how specific content documented within GOCC notes may be associated with patient care plan decisions.

Objectives: To assess the content of documented GOCC notes and identify how this content is associated with care plan decisions following the GOCC.

Methods: This cross-sectional, multihospital study assessed GOCC notes documented for seriously ill hospitalized patients between 2021 through 2023. We quantitatively assessed completion of check boxes in a standardized GOCC note template to identify content within GOCC notes. We used multivariable logistic regression to assess how content within GOCC notes was associated with patient care plan decisions.

Results: Five thousand four hundred seventy five patients across twenty-one hospitals had a documented GOCC during the study period. These patients had median age 76, were 48% female, and were 11% Black, 2% Other and 87% White. About half (55%) of GOCC notes documented a surrogate decision-maker. Two-thirds documented patient prognosis (66%) or patient values (68%). Documentation of patient prognosis or patient values was associated with a change in code status (aOR 2.2 95% CI 1.9-2.5; aOR 2.2, 95% CI 1.9-2.5), transition to comfort measures only status (aOR 2.8, 95% CI 2.4-3.4; aOR 2.0, 95% CI 1.6-2.4), and discharge with hospice (aOR 1.9, 95% CI 1.6-2.2; aOR 1.4, 95% CI 1.2-1.6).

Conclusions: This multicenter study identified that documentation of patient prognosis or patient values in GOCC notes was often associated with comfort focused care decisions. Future research should explore the reasons for these findings.

Context: Chronic pain affects many cancer survivors yet remains underdiagnosed and inadequately managed. Existing treatments (e.g., opioids, NSAIDs) carry risks like addiction and limited long-term relief, while non-pharmacological options show modest effectiveness. Given these limitations innovative, evidence-based interventions are needed. Mindfulness-Oriented Recovery Enhancement (MORE), a multimodal intervention targeting neurocognitive mechanisms underlying chronic pain, has demonstrated effectiveness in noncancer populations but has not been studied in cancer survivors.

Objective: This pilot randomized controlled trial evaluated the feasibility, acceptability, and explored preliminary efficacy of MORE on pain interference and severity in cancer survivors.

Methods: Sixty patients with history of any type of cancer living with no evidence of disease or stable oncological disease with moderate-to-severe pain (mean age 60.3 ± 11.8 years; 75% female) were randomized 3:1 to one of three MORE formats (16-hour, 8-hour, or 2-hour) or waitlist control (WLC). Feasibility was assessed through enrollment, assessment completion, and adverse events rates. Acceptability was evaluated by treatment adherence, at-home practice, and satisfaction (Net Promoter Score). Pain interference and pain severity were measured with the Brief Pain Inventory at baseline and weeks 1, 4, 8, and 12. Descriptive statistics summarized feasibility and acceptability; constrained linear mixed models tested efficacy and dose-response effects.

Results: MORE demonstrated feasibility with high enrollment (70.6%) and assessment completion (91%) rates. Treatment adherence was high (16-hour: 64.3%; 8-hour: 81.3%; 2-hour: 100%), with satisfaction highest in the 16-hour format. Within-group reductions in pain interference (-1.22 vs. -0.81) and severity (-1.31 vs. -0.85) favored MORE over WLC, though not significant. A dose-response effect was observed, with all MORE formats yielding significant reductions in pain interference and severity.

Conclusions: These findings support the feasibility and acceptability of MORE for cancer survivors and suggest potential efficacy in reducing chronic pain among cancer survivors.

Trial registry/number: ClinicalTrials.gov/ NCT05877521.

Context: Effective prediction of short survival allows clinicians to coordinate care appropriately. The Palliative Prognostic Score (PaP) is a multivariable prognostication tool to identify shorter survival.

Objective: To test predictive accuracy of PaP to identify patients with 4 weeks or less of survival.

Methods: A retrospective study of 855 consecutive patients with advanced cancer seen in initial consultation at a palliative care clinic in a tertiary cancer center (November 2016-March 2019). The data were assessed by Cox proportional survival statistics, area under the receiver operating curve (AUROC) statistics and cross tabulation of Clinical Prediction of Survival (CPS) scores against the actual survival of patients in the cohort.

Results: Median survival was 85 days (95% CI 75-95). The AUROC of the total PaP score was 0.810 (95% CI 0.774-0.847), while that of the CPS domain alone was 0.800 (95% CI 0.760-0.840); thus, other PaP elements (laboratory values, clinical symptoms, Karnofsky Performance Status) contributed little to the prognostic discrimination of the tool. Of 177 patients who died in 4 weeks or less, only 21 (11.9%) were assigned the correct CPS sub-categories; in the rest, survival was over-predicted.

Conclusion: CPS is a highly weighted element of the PaP. Consequently, the prognostic discrimination of the tool is reliant on correct CPS. The other elements of the score do not have enough cumulative weight to correct over-predictive CPS. Shorter survival CPS categories were underutilized, undermining the PaP for the intended outcome of identifying patients with 4 weeks or less of survival in the study setting.

Difficult encounters between patients and clinicians impact all areas of medical care, yet how to manage them is not routinely taught in medical training. This paper presents a case of a patient with cancer who struggled with emotional outbursts and impulsive behaviors. In the context of the racial trauma and socioeconomic challenges that the patient also experienced, the team struggled with boundary setting. We will review both traditional and contemporary approaches to the management of difficult clinician-patient interactions, while also addressing some of the limitations of existing frameworks. We will explore the role of bias in boundary setting and make suggestions for individual-, team-, and system-level approaches.