Biomedical subjects
Publications and source records attributed to Declan Walsh.
Although many patients are advised to follow a high-fiber diet to avoid constipation, it seems that a soft diet such as that recommended after bowel surgery may well be more helpful in avoidance of intestinal obstruction.
For the patient with advanced pancreatic cancer, curative strategies may not be appropriate, and palliative symptom management may be the best approach to patient care. Oncologists, who have been trained to concentrate on curing cancer, must shift focus when caring for these patients and consider palliative treatment strategies. Pancreatic cancer patients are multisymptomatic and may require treatment for such conditions as pain, bowel obstruction, anorexia, early satiety, cachexia, nausea and vomiting, constipation, diarrhea, ascites, and dyspnea, among others. These patients may be most effectively managed in a hospice care center, which can provide comprehensive care. Alternatively, new programs, such as the Cleveland Clinic Palliative Care Program, provide a unique setting for the patient with advanced cancer that integrates the qualities of hospice care into the acute medical care system.
PURPOSE: Cough is a common symptom in advanced cancer. The use of hydrocodone as an antitussive has not been studied previously in this setting. This study evaluates hydrocodone for cough in advanced cancer METHODS: The results presented are from a phase II study with dose titration. SETTING: Palliative medicine program in a tertiary referral center PATIENTS: 25 consecutive patients with cough from irreversible causes, on a stable opioid regimen for the prior 24 hours, and no previous or current use of hydrocodone for cough. INTERVENTION: 5 mg hydrocodone was administered twice daily. The dose was then titrated daily (maximum: 60 mg/24 h), if needed, until a > or = 50 percent improvement of the frequency of cough was achieved and then maintained for three consecutive days. MEASUREMENTS: Cough severity, frequency, complications, and hydrocodone side effects. RESULTS: 20 persons (10 women and 10 men) completed study evaluation. Median age was 63 years (range: 42-82). Nine patients had lung cancer and seven had lung or pleura metastases; 19 patients had at least 50 percent improvement of their cough frequency. The median best response was 70 percent improvement in the cough frequency (range: 50-90 percent). Median hydrocodone dose associated with the best response was 10 mg/day (range: 5-30 mg/day). Cough severity, frequency, associated symptoms and complications, and activities of daily living improved significantly. Side effects of hydrocodone (dry mouth, nausea, and drowsiness) were tolerable and rated as mild. CONCLUSIONS: Hydrocodone is effective and safe to treat cough in advanced cancer A starting dose of 10 mg per day in divided doses seems effective. Dose escalation may be required. Most improved within one day.
Economic feasibility is a major factor in the viability of established acute inpatient palliative medicine. Several clinical, administrative, and financial parameters determine the financial health of inpatient care. Financial management metrics include case mix index (CMI) (as determined by the Federal Register as an assigned relative weight to the diagnosis-related group (DRG) reflecting resource consumption), direct costs, indirect costs, contribution margin, and in the future of all patient revised-DRG (APR-DRG). Both census and length of stay will have a major impact on these financial metrics. The type of patient referral and clinical decisions will influence direct costs and revenues. In the future, an international CMI or APR-DRG will allow palliative inpatient units to compare disease severity, resource utilization, and outcome measures.
Anorexia is a common problem in advanced cancer. Low-dose megestrol acetate, a semi-synthetic progesterone, given twice daily, is an effective appetite stimulant in advanced cancer patients. There was an excellent correlation between patient satisfaction and the primary response criteria (appetite improvement). Given cost, side-effect profile, ease of administration, and efficacy, 80 mg twice daily after meals is an appropriate starting dose of megestrol acetate for anorexia in advanced cancer. If this is not effective, considerable dose escalation is possible.
PURPOSE: (a) To report the medical complexity of cancer and noncancer patients receiving palliative medicine (PM) consultation at a tertiary medical center and (b) to describe the consult recommendations madefor this group. PATIENTS AND METHODS: Prospective data collection was performed on all consultations (cancer, n = 175; noncancer, n = 35) done by first author (JDC) as a PM fellow at the Cleveland Clinic Foundation between July 1998 and April 1999. A computer database was used to query for demographics, complexity of medical problems, current medications, mortality, symptoms, nursing problems, and consult recommendations. RESULTS: A median of three (range, 0-12) acute medical problems and three (range, 0-16) chronic medical problems were identified for each patient. Patients were taking a median of six medications (range, 0-20). They had a median of five symptoms (range, 0-13) with pain (73 percent) being most common, followed by weakness (40 percent) and shortness of breath (40 percent). Cancer patients were twice as likely to have more than five symptoms (48 percent versus 23 percent) (chi-square = 0.006). The most common nursing problems were ambulation or fall risk (15 percent) and skin integrity (11 percent). A median of five (range, 1-11) management recommendations were made as part of each consultation. These included medication changes in 81 percent, nonmedication changes in 53 percent, andfollow-up services in 100 percent. The median survivalfrom the time of consultation for the known dead was 29 days with 65 percent living more than 14 days. CONCLUSION: Multiple recommendations were made with most patients surviving long enough potentially to benefit. Consultation in palliative medicine is a sophisticated intervention involving considerable acuity and complexity of care.
Morphine is the strong opioid of choice in the management of moderate-to-severe chronic cancer pain. The preferred route of administration is oral, in individually titrated doses, regularly scheduled around the clock We conducted a retrospective study of continuous intravenous morphine (CIVM) in a palliative medicine program in 107 consecutive patients. The results suggest CIVM is an effective, safe, and versatile method of morphine administration when used with a defined protocol. Efficacy was similar to that obtained by others with intravenous morphine sulfate and also for oral morphine. Safety was suggested by the low incidence of dose-limiting side effects, most of which responded to dose reduction. Particularly noteworthy was the flexibility of CIVM with dose reduction in 20 percent.
Nearly one-half of the most frequently reported and most distressing symptoms in patients with advanced cancer are gastrointestinal in nature. This prospective study was designed to assess the frequency of gastrointestinal symptoms among inpatients admitted to a palliative medicine program with advanced cancer. Twenty-nine men and 2l women, with a median age of 64 years (range, 35-84), were interviewed about 17 gastrointestinal symptoms. Age, gender, diagnosis, and medication use were also recorded The most common diagnoses were cancers of the lung (n = 14), breast (n = 6), and prostate (n = 4). Dry mouth (84 percent), weight loss (76 percent), early satiety (71 percent), taste change (60 percent), constipation (58 percent), anorexia (56 percent), bloating (50 percent), nausea (48 percent), abdominal pain (42 percent), and vomiting (34 percent) were the 10 most common gastrointestinal symptoms. Women had more gastrointestinal symptoms than men (median 8 vs. 6, p = 0.018), although this finding was not statistically significant (p = 0.11) after excluding gender-specific cancers. Women had more taste change and diarrhea than men after excluding gender-specific cancers (p = 0.036 and p = 0.046, respectively). Those with primary gastrointestinal cancers (n = 8) had more indigestion and hiccups than those with nongastrointestinal cancers (n = 39). There was no age difference in symptomatology. The drugs prescribed most commonly were opioids (n = 40), laxatives (n = 38), H2 blockers (n = 29), appetite stimulants (n = 29), and antiemetics (n = 29). Findings support that gastrointestinal symptoms are very common in hospitalized patients with advanced cancer and that the frequency and type of symptoms differ with gender and gastrointestinal vs. nongastrointestinal primary site.
The family is essential to patients with advanced cancer. Family and caregiver distress, however, can impair optimal care and support of the patient. A five-item questionnaire, the Family APGAR Scale, was evaluated to determine family functioning levels of selected patients. The APGAR Scale has five components for measuring family functioning: Adaptation, Partnership, Growth, Affection, and Resolve. Fifty consecutive patients admitted to a palliative medicine inpatient unit were reviewed for a pilot study. Eligibility requirements included admission to the unit for the first time, and the ability to speak English and give informed consent. Fifteen patients and 11 primary caregivers participated. Despite the small sample, some significant family functioning issues were identifed. Completing the study later with a larger sample will provide information that will help the multidisciplinary team better meet the needs of both patient and family.
Persistent bleeding from superficial malignant tumors, although uncommon, can be a major and distressing problem. Management includes frequent skilled dressing changes, correction of clotting abnormalities, and maintaining blood volume by repeated transfusions. We report a case where application of oxidized regenerated cellulose surgical dressing appeared to contribute to successful hemostasis.
Fifty consecutive cancer patients cared for by a palliative medicine program were interviewed concerning the initial communication of their diagnosis. The majority of patients were satisfied with the manner and the circumstances in which the information was imparted. A minority of women were significantly more unhappy than men about the manner in which they were told. Sophisticated techniques are available to help physicians impart bad news effectively and humanely.
Dyspnea, the sensation of difficult breathing, is a common debilitating symptom in advanced cancer and chronic progressive cardiopulmonary disease. Primary treatment is correction of the underlying etiology. In incurable illness wherein the cause is irreversible and the goal is palliation, opioids are the drugs of choice for symptomatic relief. This article reviews current knowledge in the pathophysiology of dyspnea, proposed opioid mechanism of action, and evidence of efficacy.
We developed a Bereavement Risk Questionnaire to rate 19 possible factors for assessing complicated bereavement. A four-point scale was used (0 = no risk, 3 = significant risk). The questionnaire was mailed nationwide in the United States to 508 hospice bereavement coordinators, and 262 responded. Most rated the following as significant risks: perceived lack of caregiver social support (70 percent), caregiver history of drug/alcohol abuse (68 percent), caregiver poor coping skills (68 percent), caregiver history of mental illness (67 percent), and patient is a child (63 percent). Overall, 61 percent chose perceived lack of social support, and 47 percent chose poor coping skills, as one of the top three risk factors. There was no relationship between professional discipline and responses. We found a consensus among bereavement professionals regarding important indicators in assessing bereavement risk. We conclude that it is possible to assess bereavement risk in caregivers of seriously ill patients, prior to the death of the patient. This would allow palliative care teams to allocate resources and services to those at the greatest risk for complicated bereavement.
Comprehensive pain evaluation is requisite for optimal management. Few studies have evaluated pain syndromes and adequacy of associated analgesic regimens in one population. Available studies in cancer populations have focused on ambulatory patients or hospice-type inpatients. This study was designed to evaluate multiple characteristics of pain and adequacy of therapy in a broad spectrum of patients with advanced cancer presenting to a palliative medicine service. One hundred pain patients (95 with cancer) underwent a comprehensive pain evaluation consisting of history, physical examination, review of available diagnostics, and a pain assessment tool designed for routine clinical use. Seventy-one percent of 141 evaluable patients reported pain in the month before referral. In these 100 patients, 158 distinct sites of pain were reported, with 88 percent reporting a maximum of 2. Pain due to tumor was the most common cause (68 percent), and the most common pathophysiologic mechanism, somatic (52 percent). Pain was almost equally divided between continuous (48 percent) and intermittent (52 percent). Breakthrough pain occurred in 75 percent of continuous pains. Of these, 30 percent were exclusively incidental, 26percent nonincidental, and 16 percent due to end-of-dose failure. The remainder was of mixed etiology, but almost always with an incidental component. Of intermittent pain syndromes, 61 percent were incidental. On referral, analgesic dosing was inadequate and was compounded by use of regimens that typically did not meet peer-reviewed guidelines. Comprehensive studies rigorously evaluating characteristics of pain and response to treatment are a necessary first step toward more effective treatments for difficult pain syndromes.
Recent years have seen significant growth in palliative medicine training programs and positions. There are plans to pursue palliative medicine specialty status with the American Board of Medical Specialties and accreditation of fellowship programs with the American College of Graduate Medical Education. A work group of program directors, supported initially by the Cleveland Clinic and then by the American Board of Hospice and Palliative Medicine, has recently published standards for fellowship training. Despite this, fundamental questions remain about defining the field and delineating the knowledge and skills expected following completion of specialty training. In this article, we describe the first fellowship program in palliative medicine (PMP) in the United States, developed and supported by the Cleveland Clinic Foundation. The program has been implemented as part of the Harry R. Horvitz Center for Palliative Medicine, founded in 1987 as the first comprehensive integrated US program in this field. This training program, in existence since 1989, features a traditional rotational structure with an inpatient primary care service, inpatient consult services, and an outpatient consult/hospice service. This article outlines the syllabus developed for this fellowship, given what we believe to be the essential knowledge base for the field of palliative medicine.
Palliative medicine is the total continuing care of patients with cancer. Most resources for cancer care focus on curative attempts while often ignoring the symptoms created by the disease and its treatment. Attempts at curative treatment of the malignancy must be coupled with pain and symptom relief psychosocial and spiritual care, and support for the patient and family extending from the time of diagnosis through the bereavement period. To accomplish this important goal, we must establish comprehensive palliative medicine programs in cancer centers throughout the world. These programs must include education, research, and patient care and must work through an interdisciplinary team. The Cleveland Clinic Foundation palliative medicine program (PMP) is composed of a primary inpatient service, consult service, outpatient clinic, hospice homecare, and cancer homecare services. In this article, we describe the structure and development of the program and suggest future avenues for growth.
Pain is one of the most commonly experienced and feared symptoms of advanced cancer. Most cancer patients experience pain, usually of moderate to severe intensity, and most also have a number of distinct pains. The most common type of pain is related to bone metastases. Neuropathic pain occurs in one-third of patients, alone, or as a mix of nociceptive and neuropathic pain. The failure to manage pain properly is due to several factors. In developing countries, it is likely to be related to geography and limited resources. Legal restrictions also present barriers. In developed countries, failure to manage pain properly is usually related to a "disease" rather than a "symptom" model of care, which minimizes symptom management. Other factors include lack of physician education and failure to follow existing guidelines. Patients fear addiction, drug tolerance, and side effects. Despite adequate resources, pain is still undertreated.
In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes. A large heterogenous population, comprising up to 40 percent of annual discharges from the Hematology/Oncology service, was identified. If management decided to add an acute-care, palliative medicine unit to the hospital, these are the patients who would benefit. The study predicted a significant change in patient profile, acuity, complexity, and resource utilization in current palliative care services. This study technique predicted the actual clinical load of the acute-care unit when it opened and was very helpful in program development. Our model predicted that 695 patients would be admitted to the acute-care palliative medicine unit in the first year of operation; 655 patients were actually admitted during this time.