The National Academy of Sciences through its Institute of Medicine (IOM) has produced a major scholarly assessment of pain in America. This document is a tremendous contribution to the evolving nec...

Relieving pain in america: a blueprint for transforming prevention, care, education, and research

Context There are few randomized controlled trials on the effectiveness of palliative care interventions to improve the care of patients with advanced cancer. Objective To determine the effect of a nursing-led intervention on quality of life, symptom intensity, mood, and resource use in patients with advanced cancer. Design, Setting, and Participants Randomized controlled trial conducted from November 2003 through May 2008 of 322 patients with advanced cancer in a rural, National Cancer Institute–designated comprehensive cancer center in New Hampshire and affiliated outreach clinics and a VA medical center in Vermont. Interventions A multicomponent, psychoeducational intervention (Project ENABLE [Educate, Nurture, Advise, Before Life Ends]) conducted by advanced practice nurses consisting of 4 weekly educational sessions and monthly follow-up sessions until death or study completion (n = 161) vs usual care (n = 161). Main Outcome Measures Quality of life was measured by the Functional Assessment of Chronic Illness Therapy for Palliative Care (score range, 0-184). Symptom intensity was measured by the Edmonton Symptom Assessment Scale (score range, 0-900). Mood was measured by the Center for Epidemiological Studies Depression Scale (range, 0-60). These measures were assessed at baseline, 1 month, and every 3 months until death or study completion. Intensity of service was measured as the number of days in the hospital and in the intensive care unit (ICU) and the number of emergency department visits recorded in the electronic medical record. Results A total of 322 participants with cancer of the gastrointestinal tract (41%; 67 in the usual care group vs 66 in the intervention group), lung (36%; 58 vs 59), genitourinary tract (12%; 20 vs 19), and breast (10%; 16 vs 17) were randomized. The estimated treatment effects (intervention minus usual care) for all participants were a mean (SE) of 4.6 (2) for quality of life (P = .02), −27.8 (15) for symptom intensity (P = .06), and −1.8 (0.81) for depressed mood (P = .02). The estimated treatment effects in participants who died during the study were a mean (SE) of 8.6 (3.6) for quality of life (P = .02), −24.2 (20.5) for symptom intensity (P = .24), and −2.7 (1.2) for depressed mood (P = .03). Intensity of service did not differ between the 2 groups. Conclusion Compared with participants receiving usual oncology care, those receiving a nurse-led, palliative care–focused intervention addressing physical, psychosocial, and care coordination provided concurrently with oncology care had higher scores for quality of life and mood, but did not have improvements in symptom intensity scores or reduced days in the hospital or ICU or emergency department visits. Trial Registration clinicaltrials.gov Identifier: NCT00253383

https://jamanetwork.com/journals/jama/articlepdf/184422/joc90071_741_749.pdf

Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced Cancer: The Project ENABLE II Randomized Controlled Trial

Purpose To provide evidence-based recommendations to oncology clinicians, patients, family and friend caregivers, and palliative care specialists to update the 2012 American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) on the integration of palliative care into standard oncology care for all patients diagnosed with cancer. Methods ASCO convened an Expert Panel of members of the ASCO Ad Hoc Palliative Care Expert Panel to develop an update. The 2012 PCO was based on a review of a randomized controlled trial (RCT) by the National Cancer Institute Physicians Data Query and additional trials. The panel conducted an updated systematic review seeking randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of RCTs in the 2012 PCO, published from March 2010 to January 2016. Results The guideline update reflects changes in evidence since the previous guideline. Nine RCTs, one quasiexperimental trial, and five secondary analyses from RCTs in the 2012 PCO on providing palliative care services to patients with cancer and/or their caregivers, including family caregivers, were found to inform the update. Recommendations Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs. Providers may refer family and friend caregivers of patients with early or advanced cancer to palliative care services.

https://ascopubs.org/doi/pdfdirect/10.1200/JCO.2016.70.1474

Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update

CONTEXT
There are few randomized controlled trials on the effectiveness of palliative care interventions to improve the care of patients with advanced cancer.


OBJECTIVE
To determine the effect of a nursing-led intervention on quality of life, symptom intensity, mood, and resource use in patients with advanced cancer.


DESIGN, SETTING, AND PARTICIPANTS
Randomized controlled trial conducted from November 2003 through May 2008 of 322 patients with advanced cancer in a rural, National Cancer Institute-designated comprehensive cancer center in New Hampshire and affiliated outreach clinics and a VA medical center in Vermont.


INTERVENTIONS
A multicomponent, psychoeducational intervention (Project ENABLE [Educate, Nurture, Advise, Before Life Ends]) conducted by advanced practice nurses consisting of 4 weekly educational sessions and monthly follow-up sessions until death or study completion (n = 161) vs usual care (n = 161).


MAIN OUTCOME MEASURES
Quality of life was measured by the Functional Assessment of Chronic Illness Therapy for Palliative Care (score range, 0-184). Symptom intensity was measured by the Edmonton Symptom Assessment Scale (score range, 0-900). Mood was measured by the Center for Epidemiological Studies Depression Scale (range, 0-60). These measures were assessed at baseline, 1 month, and every 3 months until death or study completion. Intensity of service was measured as the number of days in the hospital and in the intensive care unit (ICU) and the number of emergency department visits recorded in the electronic medical record.


RESULTS
A total of 322 participants with cancer of the gastrointestinal tract (41%; 67 in the usual care group vs 66 in the intervention group), lung (36%; 58 vs 59), genitourinary tract (12%; 20 vs 19), and breast (10%; 16 vs 17) were randomized. The estimated treatment effects (intervention minus usual care) for all participants were a mean (SE) of 4.6 (2) for quality of life (P = .02), -27.8 (15) for symptom intensity (P = .06), and -1.8 (0.81) for depressed mood (P = .02). The estimated treatment effects in participants who died during the study were a mean (SE) of 8.6 (3.6) for quality of life (P = .02), -24.2 (20.5) for symptom intensity (P = .24), and -2.7 (1.2) for depressed mood (P = .03). Intensity of service did not differ between the 2 groups.


CONCLUSION
Compared with participants receiving usual oncology care, those receiving a nurse-led, palliative care-focused intervention addressing physical, psychosocial, and care coordination provided concurrently with oncology care had higher scores for quality of life and mood, but did not have improvements in symptom intensity scores or reduced days in the hospital or ICU or emergency department visits.


TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT00253383.

/pdf/effects-of-a-palliative-care-intervention-on-clinical-1fj5fa7hnv.pdf

Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced Cancer

In 2009, 28.4% (95% CI, 27.9%-28.5%) of hospice use at the time of death was for 3 days or less. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. Conclusion and Relevance Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.

https://jamanetwork.com/journals/jama/articlepdf/1568250/joc120140_470_477.pdf

Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009

https://www.legacy-hospice.com/media/Healthcare%20Pros/Comparing%20Hospice%20and%20Non%20Hospice%20Patient%20Survival%20Among%20Patients%20who%20Die%20Within%20a%20Three%20Year%20Window.pdf

Comparing Hospice and Nonhospice Patient Survival Among Patients Who Die Within a Three-Year Window

https://www.legacy-hospice.com/media/Healthcare%20Pros/Timing%20of%20Referral%20to%20Hospice%20&%20Qaulity%20of%20Care.pdf

Timing of Referral to Hospice and Quality of Care: Length of Stay and Bereaved Family Members' Perceptions of the Timing of Hospice Referral

https://www.jpsmjournal.com/article/S0885-3924(05)00243-5/pdf

Family Evaluation of Hospice Care: Results from Voluntary Submission of Data Via Website

https://www.jpsmjournal.com/article/S0885-3924(06)00547-1/pdf

Opioid use and survival at the end of life: a survey of a hospice population.

OBJECTIVES: To examine the effectiveness of hospice services for persons dying from dementia from the perspective of bereaved family members.
DESIGN: Mortality follow-back survey.
SETTING: Death certificates were drawn from five states (AL, FL, TX, MA, and MN).
PARTICIPANTS: Bereaved family members listed as the next of kin on death certificates when dementia was listed as the cause of death.
MEASUREMENTS: Ratings of the quality of end-of-life care, perceptions of unmet needs, and opportunities to improve end-of-life care. Two questions were also asked about the peacefulness of dying and quality of dying.
RESULTS: Of 538 respondents, 260 (48.3%) received hospice services. Family members of decedents who received hospice services reported fewer unmet needs and concerns with quality of care (adjusted odds ratio (AOR)=0.49, 95% confidence interval (CI)=0.33�0.74) and a higher rating of the quality of care (AOR=2.0, 95% CI=1.53�2.72). They also noted better quality of dying than those without hospice services.
CONCLUSION: Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying.

Carol Spence

Papers

Comparing Hospice and Nonhospice Patient Survival Among Patients Who Die Within a Three-Year Window

Timing of Referral to Hospice and Quality of Care: Length of Stay and Bereaved Family Members' Perceptions of the Timing of Hospice Referral

Family Evaluation of Hospice Care: Results from Voluntary Submission of Data Via Website

Opioid use and survival at the end of life: a survey of a hospice population.

Does Hospice Improve Quality of Care for Persons Dying from Dementia