Impact of surgical palliation on quality of life in patients with advanced malignancy: results of the decisions and outcomes in palliative surgery (DOPS) trial.
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Biomedical subjects
Gloria Juarez
Publications and source records attributed to Gloria Juarez.
Perspectives on the impact of ovarian cancer: women's views of quality of life.
PURPOSE/OBJECTIVES: To describe quality-of-life (QOL) concerns particular to women with ovarian cancer and to examine whether subgroups of patients with ovarian cancer have significantly different QOL concerns. DESIGN: Mailed survey. SAMPLE: Readership of an ovarian cancer newsletter. METHODS: A total of 1,383 surveys were received in response to the survey's inclusion in the November 2002 issue of Conversations! The International Newsletter for Those Fighting Ovarian Cancer, a monthly newsletter circulated to 3,300 women with ovarian cancer (response rate = 42%). Women were asked to complete the 45-item City of Hope QOL Ovarian Cancer Tool (QOL-OVCA) and a short demographic questionnaire. MAIN RESEARCH VARIABLES: Patients' QOL-OVCA scores were compared across six independent variables, including disease status, age at diagnosis, stage at diagnosis, marital status, household income, and use of alternative therapy, controlling for survival time. FINDINGS: Ovarian cancer survivors reported significant QOL concerns across dimensions of physical, psychological, social, and spiritual well-being. CONCLUSIONS: Patients with ovarian cancer experience particular QOL concerns requiring support. Future research is needed to describe the needs of survivors in more diverse populations and to develop and test interventions that can address these QOL concerns. IMPLICATIONS FOR NURSING: Women with ovarian cancer experience QOL concerns common to other patients with cancer and some that are particular to ovarian cancer. Nurses should assess for and aggressively address these QOL concerns.
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Management of pain and nausea in outpatient surgery.
The cost associated with surgical procedures has been dramatically decreased by the ability to perform these procedures on an outpatient basis. Pain and nausea, two common symptoms after anesthesia and surgical procedures, are among the greatest concerns for patients and their family members. As a result of the distress and sequelae associated with these symptoms, clinicians have attempted to determine the optimal intraoperative and postoperative symptom management for patients. The purpose of this quality improvement project was to describe the incidence of these symptoms and their management in patients who underwent planned outpatient surgical procedures in a cancer center. A sample of 39 patients were accrued at a comprehensive cancer center over a 3-month period. Data were collected at three specific time points (i.e., preoperatively, at 24 hours and at 7 days postoperatively). Postoperative pain and nausea were generally well managed, but improvement was needed in preoperative patient teaching, including the topics of drug and nondrug interventions. The methods used in this project have potential application for the measurement of other clinical outcomes after outpatient surgical procedures.
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A prospective evaluation of palliative outcomes for surgery of advanced malignancies.
BACKGROUND: We prospectively evaluated the effectiveness of major surgery in treating symptoms of advanced malignancies. METHODS: Fifty-nine patients were evaluated for major symptoms of intent to treat and were followed up until death or last clinical evaluation. Surgeons identified planned operations before surgery as either curative or palliative and estimated patient survival time. An independent observer assessed symptom relief. A palliative surgery outcome score was determined for each symptomatic patient. RESULTS: Surgeons identified 22 operations (37%) as palliative intent and 37 (63%) as curative intent. The median overall survival time was 14.9 months and did not differ between curative and palliative operations. Surgical morbidity was high but did not differ between palliative (41%) and curative (44%) operations. Thirty-three patients (56%) were symptomatic before surgery, and major symptom resolution was achieved after surgery in 26 (79%) of 33. Good to excellent palliation, defined as a palliative surgery outcome score >70, was achieved in 64% of symptomatic patients. CONCLUSIONS: Most symptomatic patients with advanced malignancies undergoing major operations attained good to excellent symptom relief. Outcome measurements other than survival are feasible and can better define the role of surgery in multimodality palliative care. A new outcome measure to evaluate major palliative operations is proposed.
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Cancer pain education for patients and the public.
Pain education for patients and the public is an essential element of improved pain management. This article reports on the implementation of a national training project, Cancer Pain Education for Patients and the Public (CPEPP). The CPEPP curriculum was designed to address the multiple opportunities for pain education and to provide resources and support for successful implementation.
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Decision making in palliative surgery.
BACKGROUND: Palliative surgery for advanced cancer patients involves complex decision making. Surgeons with a cancer-focused practice were surveyed to determine the extent to which palliative surgery was currently practiced, to identify ethical dilemmas and barriers they faced in performing palliative surgery, and to evaluate their treatment choices in four different clinical scenarios. STUDY DESIGN: A 110-item survey was devised after extensive review of the palliative care and palliative surgery literature to evaluate current practices and attitudes regarding palliative surgery. Case vignettes were devised to evaluate dinical factors influencing surgeons' selection of treatment for symptomatic patients with advanced malignancy. RESULTS: Survey response rate was 24% (419 of 1,740). Respondents reported 74% of their surgery caseload as cancer related, and 21% of these as palliative. On a scale of 1 (uncommon problem) to 7 (common problem), surgeons reported that the most common ethical dilemmas in palliative surgery were providing patients with honest information without destroying hope (5.6 +/- 1.4) (mean +/- standard deviation), and preserving patient choice (5.0 +/- 1.7). Bound on error of the average frequency estimate for ethical dilemmas, based on response rate, was 0.08. On a scale of 1 (not a barrier) to 7 (a severe barrier), surgeons rated the most severe barriers to optimum use of palliative surgery as limitations of managed care (4.1 +/- 2.0) and referral to surgery by other specialists (3.9 +/- 1.8). Bound on error of the estimate for average severity of barriers, based on response rate, was 0.09. They rated the least severe barriers to palliative surgery as surgeon avoidance of dying patients (3.0 +/- 1.8) and surgery department reluctance to perform palliative surgery (2.6 +/- 1.6). Analysis of surgeons' treatment selection in case vignettes indicated that patient age, aggressiveness of tumor biology, local extent of disease, and severity of patient symptoms were all variables of influence for treatment selection in patients with advanced malignancies. CONCLUSIONS: Palliative surgery involves numerous ethical dilemmas, the most prominent being providing honest information to patients without destroying hope, and complex treatment decision making. We have identified variables of major influence to surgeons in the palliative treatment selection for patients with advanced, solid malignancies. Validation of these variables as meaningful will require future studies focusing on patient outcomes.
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Strategies for effective continuing education by oncology nurses.
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Education, Nursing, Continuing↗
Meaning of illness and spirituality in ovarian cancer survivors.
PURPOSE/OBJECTIVES: To describe spirituality and meaning of illness in survivors of ovarian cancer. DESIGN: Ethnographic study based on seven years of natural correspondence among survivors of ovarian cancer and a support newsletter. SAMPLE: 21,806 letters, cards, and e-mails received from survivors of ovarian cancer from 1994-2000. METHODS: Analysis was based on the Quality of Life (QOL) Ovarian Cancer Instrument. Data were bracketed and assigned within a table according to QOL themes. MAIN RESEARCH VARIABLES: Spirituality, meaning, QOL, and cancer survivorship. FINDINGS: Spirituality was relied on heavily as a coping mechanism, as well as a method of deriving meaning from the cancer experience. Data from survivors of ovarian cancer validated previously established meaning in cancer themes and identified eight new themes specific to meaning in ovarian cancer survivorship. CONCLUSIONS: The nature of ovarian cancer implicates specific characteristics that alter the meaning of QOL and survivorship. Spirituality is an important component of QOL and contributes to the process of deriving meaning from the ovarian cancer experience. IMPLICATIONS FOR NURSING: Knowledge of the unique survivorship issues of patients with ovarian cancer can enable nurses to improve their care for these women.
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Concerns of family caregivers of patients with cancer facing palliative surgery for advanced malignancies.
PURPOSE/OBJECTIVES: To describe the concerns of family caregivers of patients undergoing palliative surgeries for advanced malignancies. DESIGN: Descriptive study with repeated measures. SETTING: A National Cancer Institute-designated Comprehensive Cancer Center in the western United States. SAMPLE: Family caregivers (N = 45) of patients with cancer. METHODS: Family caregivers were assessed prior to planned palliative surgery and at two weeks and six weeks postsurgery. Quantitative assessment of caregiver quality of life (QOL) occurred at each interval. A subset of nine caregivers also participated in a structured interview presurgery and at two weeks postsurgery. MAIN RESEARCH VARIABLES: Caregiver concerns, QOL, decision making. FINDINGS: Family caregivers have important QOL concerns and needs for support before and after surgery for advanced disease. Psychological issues were most pronounced, and common concerns included uncertainty, fears regarding the future, and loss. Family caregivers have concerns about surgical risks and care after surgery and voiced recognition of the declining status of patients. CONCLUSIONS: Surgery is an important component of palliative care and profoundly impacts family caregivers of patients with cancer. The needs of family caregivers are multiple and complex, requiring ongoing assessment to provide interventions that help them cope and ultimately improve their QOL. This important topic requires further research and clinical attention. IMPLICATIONS FOR NURSING: Findings suggest that family caregivers experience their own trajectory during the course of their loved ones' cancer, with surgery being a part of the course. This includes their profound emotions that may swing like a pendulum from one minute to the next. Nurses need to assess family caregivers in addition to patients to provide support and resources that will help increase caregivers' QOL.
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The role of oncology nursing to ensure quality care for cancer survivors: a report commissioned by the National Cancer Policy Board and Institute of Medicine.
PURPOSE: To examine the roles of oncology nurses in improving quality care for cancer survivors. DATA SOURCES: A content analysis of textbooks, journals, and key documents; surveys of graduate oncology nursing programs and the Oncology Nursing Society's Survivorship Special Interest Group; review of the nursing licensure examination and oncology nursing certification; review of undergraduate and graduate nursing standards; and review of currently funded nursing research. DATA SYNTHESIS: Ten critical content areas of cancer survivorship were used for the analysis: description of population of cancer survivors, primary care, short- and long-term complications, prevention of secondary cancer, detecting recurrent and secondary cancers, treatment of recurrent cancer, quality-of-life issues, rehabilitative services, palliative and end-of-life care, and quality of care. Although findings within each source indicated significant information related to the roles of nurses in caring for cancer survivors, deficits also were identified. CONCLUSIONS: Review of key literature and resources suggests significant contributions by oncology nursing over the past two decades to the area of cancer survivorship. IMPLICATIONS FOR NURSING: Support is needed to expand education and research to ensure quality care for future cancer survivors.
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Online exclusive: patient and surgeon decision making regarding surgery for advanced cancer.
PURPOSE/OBJECTIVES: To describe a program of research related to outcomes of palliative surgery and focus on one phase of this research involving decision making by patients and surgeons considering surgery for advanced disease. DESIGN: Descriptive. SAMPLE: 10 patients undergoing surgery and 3 oncology surgeons. METHODS: Qualitative interviews were conducted with patients and their surgeons pre- and postoperatively. Transcripts were content analyzed to identify major themes in patient and surgeon interviews based on study questions. MAIN RESEARCH VARIABLES: Decision making, palliative surgery, quality of life. FINDINGS: The study findings highlight the issues of greatest concern to patients and surgeons considering palliative surgery. This phase was an important component of the overall program of palliative surgery research. CONCLUSIONS: Comprehensive care for patients with advanced cancer seeks to achieve a balance of providing aggressive care, ensuring optimum symptom management, and maintaining a focus on comfort. Further study of palliative surgery as an aspect of interdisciplinary care is warranted. IMPLICATIONS FOR NURSING: Patients undergoing surgery for advanced disease require expert nursing care to address quality-of-life concerns. Further research is needed in this area.
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Indications and use of palliative surgery-results of Society of Surgical Oncology survey.
BACKGROUND: Despite increasing attention to end-of-life care in oncology, palliative surgery (PS) remains poorly defined. A survey to test the definition, assess the extent of use, and evaluate attitudes and goals of surgeons regarding PS was devised. METHODS: A survey of Society of Surgical Oncology (SSO) members. RESULTS: 419 SSO members completed a 110-item survey. Surgeons estimated 21% of their cancer surgeries as palliative in nature. Forty-three percent of respondents felt PS was best defined based on pre-operative intent, 27% based on post-operative factors, and 30% on patient prognosis. Only 43% considered estimated patient survival time an important factor in defining PS, and 22% considered 5-year survival rate important. The vast majority (95%) considered tumor still evident following surgery in a patient with poor prognosis constituted PS. Most surgeons felt PS could be procedures due to generalized illness related to cancer (80%) or related to cancer treatment complications (76%). Patient symptom relief and pain relief were identified as the two most important goals in PS, with increased survival the least important. CONCLUSION: PS is a major portion of surgical oncology practice. Quality-of-life parameters, not patient survival, were identified as the most important goals of PS.
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