Journal of pain and symptom management最新文献

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.

Context: A prenatal diagnosis of complex congenital heart disease (cCHD) introduces significant emotional, social, and financial stress for families. Uncertainty about the future is a central source of distress for parents, particularly surrounding management options and anticipated outcomes. Little is known about how fetal cardiologists present management options, address anticipated outcomes, and offer supportive services.

Objective: To examine how fetal cardiology clinicians discuss management options, anticipated outcomes, and supportive services with parents following a prenatal diagnosis of complex congenital heart disease (cCHD).

Methods: Initial fetal cardiology consultations were audio-recorded, transcribed, and analyzed qualitatively. Deductive coding focused on management options (e.g., invasive intervention, comfort care), anticipated outcomes (e.g., quality of life, mortality risk), and supportive services (e.g., social work, peer support, palliative care).

Results: Five fetal cardiology clinicians from one tertiary care institution participated in 19 initial consultations. Management options discussed included invasive intervention and comfort care. Clinicians frequently described anticipated outcomes involving quality of life and mortality risk but rarely used those terms specifically. Families were most engaged during quality-of-life discussions. Palliative care as a consulting service was selectively introduced, often when the CHD diagnosis carried a higher risk of mortality. The service was frequently described as additional support.

Conclusion: Fetal cardiology consultations offer an important opportunity to support families navigating uncertainty following a prenatal diagnosis of CHD. Clinicians approached these conversations with empathy and a focus on long-term outcomes, though discussions about management options varied. There is an opportunity for increased presentation and integration of palliative care consultants as a longitudinal, family-centered resource, regardless of mortality risk, which may enhance supports available to families during this highly emotional period. Ongoing efforts to improve family-centered counseling and resources, such as access to perinatal palliative care, may help ensure families receive comprehensive, values-aligned information across the spectrum of care pathways.

Palliative care, whether in the form of early Supportive Palliative Care or later in the course of illness with Hospice, serves not only the seriously ill patient, but the patient's family members. When the family includes children associated with the seriously ill patient, the needs of those children often go unmet, especially in adult palliative care. This paper focuses on the work done and the methods used by Certified Child Life Specialists (CCLSs) working in adult palliative care. Using the literature and our 15+ year experience integrating Child Life Services into both community and academic center Supportive Palliative Care services, we argue it is imperative that the core adult palliative care interdisciplinary team include Certified Child Life Specialists trained to help children of the seriously ill adult understand their loved adult's illness, and to help adults communicate effectively with and better support the child.

Context: Pediatric palliative care and complex care programs frequently collaborate when caring for a shared population of children with medical complexity (CMC), despite programmatic heterogeneity across institutions. Yet, scant literature exists documenting the nature of collaboration between these subspecialties.

Objectives: The aim of the present study is to explore perceived facilitators and challenges to collaboration among pediatric complex care and palliative care providers within a subset of Midwest medical institutions.

Methods: Eighteen pediatric complex care and palliative care providers across ten academic medical centers completed semi-structured interviews. In addition to perceived facilitators and challenges, providers were asked to comment on hypothetical changes they would make to enhance future collaboration. Audio recordings were transcribed and qualitatively analyzed using thematic analysis.

Results: Qualitative analysis of provider commentary revealed individual and institution-level facilitators and challenges to collaboration between both teams, descriptions of the collaborative process when facilitators are optimized, and visions for enhancing future collaboration.

Conclusion: Participant responses from both subspecialties identified similar facilitators and challenges to collaboration, and supported greater integration as a means of mitigating collaborative challenges, offering ideas such as embedded programs, shared staff, or merging of divisions, among other interdisciplinary care models Future research is needed to explore methods of capturing outcomes associated with different integrative models, ideally through the incorporation of patient and family voices as a means of evaluating how clinical care is received.

Context: The lack of valid methods to identify specialist palliative care (PC) delivery in population-level data impedes comprehensive understanding of its use.

Objective: To develop and validate a claims-based algorithm to identify receipt of specialist PC in Medicare beneficiaries with metastatic cancer.

Methods: We developed a claims-based algorithm to identify specialist PC, using a physician billing claim from a known PC clinician as the gold standard, retaining candidate variables with a positive predictive value (PPV) >60%. We evaluated algorithm performance and conducted simulation to measure bias resulting from algorithm use when examining the association between specialist PC and outcomes.

Results: We identified 1,384,750 claims from 68,121 patients. The prevalence of specialist PC was 3.8% on the claim-level and 26.8% on the patient-level. The provider specialty code for "hospice and palliative care" (PPV 80.4%) and the diagnosis code Z51.5 for "encounter for palliative care" (PPV 67.5%) were included, where claims were counted as specialist PC if they had either variable. PPV and sensitivity of the algorithm were 68.0% and 83.0% respectively on a claim-level, and 78.4% and 88.3% respectively on a patient-level. Percent bias differed by outcome (hospice 4.2%, hospice enrollment ≥3 days 5.3%, intensive care unit use in the last 30 days of life -1.7%, chemotherapy use in the last 14 days of life -1.3%).

Conclusions: A simple algorithm can identify receipt of specialist PC care in Medicare claims for patients with metastatic cancer with reasonable accuracy. Algorithm use results in potentially acceptable amounts of bias, depending on study aims.

Context: Depression is prevalent and often undertreated in people living with advanced cancer. Methylphenidate (MPH) has been proposed as a faster-acting pharmacologic intervention in this setting, yet evidence remains limited.

Objectives: To evaluate MPH's efficacy and safety for depression management in adults with advanced malignancies.

Methods: We conducted a pairwise systematic review and meta-analysis of double-blind, placebo-controlled randomized trials following Cochrane and PRISMA standards. PubMed, Embase, and CENTRAL were searched through April 04, 2025. The primary outcome was between-group change in depressive scores at 2 ± 1 weeks, expressed as standardized mean difference (SMD). Secondary outcomes included depression remission at 2 ± 1 weeks, expressed as risk ratio (RR) and risk difference (RD), and treatment-emergent adverse events (TEAEs). Random-effects models were applied.

Results: Three studies were included (MPH, n = 90; control, n = 99). Compared with placebo, MPH (10-45 mg/day as monotherapy or 10-20 mg/day as augmentation to conventional antidepressants) reduced depressive symptom severity (SMD, -0.81; 95%CI, -1.22 to -0.39; P < 0.001; I² = 32%). While relative risk for depression remission narrowly missed significance (RR, 1.69; 95%CI, 0.97 to 2.96; P = 0.07; I² = 50%), MPH increased the absolute probability of remission (RD, 0.22; 95%CI, 0.09 to 0.34; P < 0.001; I² = 0%; number needed to treat ≈ 5). Incidence of all analyzed TEAEs was similar between groups.

Conclusions: MPH may provide rapid, potentially meaningful improvement in depressive symptoms for people living with advanced cancer, while maintaining a favorable safety profile. Considering the small sample sizes and short follow-up durations across studies included in this exploratory meta-analysis, future large-scale trials are needed to confirm efficacy and define optimal candidates.

Context: Physician-assisted dying (PAD) is legal in a growing number of U.S. states, with access expanding nationally due to recent legislative changes. Despite this, how to address PAD in hospice and palliative medicine (HPM) fellowship programs remains undefined. The perspectives of HPM fellows regarding PAD education have not been studied.

Objectives: To assess HPM fellows' experiences and interest in a formal PAD curriculum, including preferred content areas and anticipated relevance to future practice.

Methods: An anonymous nine-item survey was sent to all HPM fellows (N = 21) at the Icahn School of Medicine at Mount Sinai. Survey domains included prior exposure to PAD, attitudes toward PAD education, and intention to provide PAD in future clinical practice.

Results: The response rate was 100%. Most fellows (81%) had no formal education on PAD. All respondents agreed that learning about PAD in fellowship is important. Topics of interest included ethical considerations (95%), legal criteria (86%), responding to requests in serious illness conversations (86%), navigating requests (76%), and pharmacology/modes of ingestion (71%). A majority (62%) were interested in an away elective with a PAD provider. While only 10% intended to provide PAD in future practice, 57% were unsure or had not thought about it, and 33% were not considering it.

Conclusion: Fellows unanimously supported including PAD education in HPM training, regardless of intent to participate in the practice. These findings underscore a clear educational need and may guide curriculum development. To our knowledge, this is the first survey assessing HPM fellows' views on PAD.