Journal of pain and symptom management最新文献

Context: In low-resource settings like Northern India, palliative care providers often lack adequate training, institutional support, and interdisciplinary collaboration that are indispensable for effective implementation.

Objectives: This article highlights strategies to build palliative care capacity through education, interdisciplinary collaboration, and system-level interventions in Northern India. The article describes a palliative care capacity-building project executed from 2023 through 2025. It presents scalable approaches to overcome barriers to palliative care, enhance palliative care competencies, and expand palliative care infrastructure.

Material and method: The project proceeded in three phases and began with the selection and development of nine centers of excellence (Phase I), followed by associating each center with ten district hospitals to embed palliative care within the region (Phase II). Phase III focused on palliative care training for providers in 90 district hospitals. The project assessed capacity and quality improvements at the centers and evaluated providers' palliative care knowledge post-training in the district hospitals.

Results: The centers of excellence reported substantial capacity and continued improvements in palliative care delivery throughout the project. Physicians and nurses affiliated with the district hospital showed significant and lasting knowledge gains after palliative care training.

Conclusion: These results demonstrate significant progress in palliative care capacity with the region, but they, also, underscore the need for ongoing efforts in training, research, and systematic record-keeping. The project's success in its three phased approach illustrates the potential for education, collaboration, and system-level support to strengthen palliative care capacity.

Context: Chronic dyspnea is subjective but with objective (measurable) consequences. It is often poorly assessed because people have modified their lifestyles to avoid exertion that generates dyspnea.

Objectives: This study sought any relationship between respondents' self-reported long-term breathlessness limiting exertion (hereafter chronic dyspnea) and distance travelled from the room in which they slept, frequency of mobilizing, and any assistance required.

Methods: This was a national, cross-sectional, online survey of 10,033 Australian adults conducted using the Qualtrics platform, reflecting the most recent national census. Demographic data were collected in addition to the modified Medical Research Council (mMRC) breathlessness scale, duration of dyspnea in people with mMRC ≥ 1 and the Life-Space Assessment scores (0-120 with higher scores reflecting three factors combined: frequency with which a person moves from the room in which they sleep, the furthest distance they achieve and whether they need assistance to achieve this). A regression model adjusted for age, sex, rurality, socio-economic status, and smoking.

Results: A total of 8181 respondents had valid data: mean age 46.0 years (standard deviation ± 18.6); 29.3% mMRC ≥ 1, with more women reporting more intense dyspnea. Respiratory conditions were the most prevalent underlying cause. Using ANOVA, mean Life-Space Assessment scores reduced significantly as dyspnea increased (mMRC 0, 69.2; mMRC 1, 59.1; mMRC 2, 47.1; mMRC 3-4, 38.9; P < 0.0001). The regression model revealed an association (P < 0.001) between dyspnea and Life-Space Assessment scores decreasing from mMRC 0 by a mean of 9.3 (standard error [SE] 0.83) to mMRC 1; 20.3 (SE 1.2) to mMRC 2; and 27.9 (SE 1.8) to mMRC 3-4.

Discussion: Although potentially intuitive, this study quantified the association of people's reduced spatial footprints at each level of self-reported chronic dyspnea severity, reflecting their shrinking worlds.

Context: Communication skills are essential in cancer care, and international guidelines recommend communication training for all cancer care providers. Both clinical communication and training methods are influenced by culture. As oncology and palliative care expand globally, procedures are needed to adapt evidence-based communication training for diverse contexts.

Objective: To adapt a serious illness communication training intervention in Rwanda.

Methods: Guided by the Cultural Adaptation Process model, we conducted focus groups to understand communication training needs and gather feedback on a U.S. tool, the Serious Illness Conversation Guide (SICG). Based on identified needs, we made initial adaptations to an SICG-based training, incorporating tools from another U.S. program (VitalTalk). We piloted this training with 14 clinical psychologists, using lecture, demonstration, scripted roleplay, and small group discussion. Effectiveness was assessed through 5-point scales and qualitative feedback.

Results: Seventeen interdisciplinary oncology providers participated in one of three focus groups. While some had received lectures on communication, all believed additional training is needed. They endorsed the approach of adapting an international program rather than creating a Rwandan training de novo. Based on their input, we adapted and piloted a training that focused on three skills: 1) Set up the conversation and assess understanding; 2) Share information via a succinct "headline;" 3) Respond to emotion. Training methods received mean scores of 4.0 to 4.33 (5 = most effective). Further modifications were suggested to improve cultural concordance.

Conclusion: Despite vast cultural differences, communication training interventions developed in the U.S. can be effectively adapted in African contexts through co-creation with local providers.

Context: Family caregivers (FCs) of terminally ill cancer patients face substantial strain that can impair quality of life (QoL). However, how spiritual status affects QoL, and whether these relationships differ by religious affiliation, remains unclear.

Objectives: This study examines the association between spiritual status and QoL among FCs of terminally ill cancer patients METHODS: A cross-sectional survey was conducted at nine hospice care units in South Korea (n = 170 FCs). Spiritual status was addressed using the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being questionnaire (FACIT-Sp-12) and three self-rated questions that addressed spirituality, religiosity, and spiritual pain. QoL was measured using the Korean version of the Caregiver Quality of Life Index-Cancer (CQOLC-K) questionnaire. Multivariate regression analysis, adjusted for covariates via stepwise selection, was used to examine the associations between spiritual variables and CQOLC-K total and each subscale.

Results: In adjusted analyses, Positive Adaptation was the only CQOLC-K subscale associated with all spiritual measures, including Meaning/peace, Faith of FACIT-Sp-12, self-rated spirituality, religiosity, and spiritual pain. No consistent independent association was observed with the CQOLC-K total. In stratified models, these associations were confined to caregivers with a religious affiliation. Spiritual pain showed subgroup-specific patterns: among religious caregivers it coexisted with higher positive adaptation and greater burden, while among non-religious caregivers it was related to worse financial concerns.

Conclusion: In this cohort, spirituality aligned with domain-specific adaptation, and this linkage was limited to caregivers with a religious affiliation. Brief screening for spiritual pain and religious affiliation may help tailor meaning-focused or practical support accordingly.

Context: Even as health care institutions seek to promote culturally attuned care, clinicians may struggle when cultural norms and practices contradict established clinical practices.

Objectives: To explore sources of moral distress among clinicians treating the growing population of South Asian breast cancer survivors.

Methods: We report secondary analyses from a mixed methods study that aimed to understand the barriers and facilitators to providing culturally attuned care to South Asian breast cancer survivors. We conducted 30-minute virtual semi-structured interviews with multidisciplinary clinicians involved in cancer care. Interviews were guided by the Consolidated Framework of Implementation Research (CFIR). For this study, we used a thematic analysis approach to examine the sources of moral distress, and potential solutions to address it.

Results: 14 clinicians (8 physicians; 41.6 ± 9.8 years; 9 women; 4 South Asian) were interviewed. We identified the following themes: 1) Clinicians experienced moral distress when South Asian cultural norms conflicted with pillars of biomedical ethics; 2) Moral distress was exacerbated by individual and system-level barriers; and, 3) Solutions may necessitate change across individual, inner setting (e.g., clinics), and outer setting (e.g., health care systems) domains of CFIR.

Conclusions: Clinicians may experience moral distress when their evidence-based and ethical care approaches conflict with cultural norms. Health care systems should provide programs that support clinicians who encounter these dilemmas to ensure high quality clinical care that respects the cultural norms of South Asian breast cancer survivors.