Symptom burden at the end of life: hospice providers' perceptions.

To describe symptom prevalence, frequency, and severity among hospice patients, from the perspective of hospice providers, a cross-sectional study was conducted among 16 hospices participating in the Population-based Palliative Care Research Network (PoPCRN). Hospice staff estimated symptom presence, frequency, and severity, using the Memorial Symptom Assessment Scale. Among the 348 patients (median age 78 years, 55% female, 55% cancer diagnosis), the most common symptoms noted by hospice staff were lack of energy (83%), pain (76%), lack of appetite (63%), drowsiness (61%), difficulty concentrating (60%), and sadness (51%). When present, lack of energy was rated by hospice providers as both frequent (75% "frequently" or "almost constantly") and severe (46% "severe" or "very severe"). Symptoms varied by care setting and by diagnosis. Hospice staff often lacked sufficient information to rate potentially important symptoms, such as problems with sexual interest or activity (63%), change in self image (30%), and worrying (26%). This study identifies a significant burden of unrelieved symptoms among hospice patients, suggesting a need for more widespread institution of symptom management strategies with proven effectiveness and additional investigation into treatment of common symptoms for which few effective treatment strategies are known.

Colorado family practice graduates' preparation for and practice of emergency medicine.

BACKGROUND: Family physicians provide care in emergency departments, especially in rural areas; however, no published data describe how they perceive their preparation for emergency practice. We surveyed graduates of Colorado family practice residencies concerning their emergency medicine practice, their comfort working in emergency departments, and their perceived preparation for practicing emergency medicine. METHODS: Seventy recent graduates of Colorado residencies were surveyed regarding their location, work in emergency departments, contact with emergency medical services (EMS) personnel, and perceptions about their emergency medical training. RESULTS: Forty-five percent of respondents practiced in rural settings, 33% worked in emergency departments (56% rural, 14% urban), 60% reported contact with EMS personnel (91% rural, 32% urban), 54% believed their training adequately prepared them for working in emergency departments (82% rural vs 32% urban), 63% of rural and 22% of urban respondents indicated they wanted more major trauma experience during training, 70% reported discomfort with managing trauma, and 44% were interested in a 6-month emergency medicine fellowship. CONCLUSIONS: Most respondents believed their training in emergency medicine was adequate; however, most also reported discomfort with trauma management. Improved training for family physicians who provide emergency care could include expanded trauma care opportunities, increased work with EMS personnel, and postresidency training.

Cancer pain management in home hospice settings: a comparison of primary care and oncologic physicians.

We compare the effectiveness of terminal cancer pain management delivered by primary care physicians with that of specialists in home-based hospice settings. Each visit record for 223 outpatients in three hospice programs was abstracted for physician type, patient age, medication usage, level of pain reported, cancer type, and metastatic status. Thirteen percent of patients reported no pain at any visit and 19% reported pain at all visits; half of the patients reported pain at two thirds of their visits. No difference was found in the presence or absence of pain between primary care and oncologic patients. When available, the level of pain reported (0-10 scale) was statistically (p < 0.01) but not clinically different between physician groups; average pain rating for primary care patients was 3.7 while the mean pain rating for oncologic patients was 3.1. The reported pain level varied significantly among facilities, as did physician mix. Multivariate analysis revealed that program and an interaction term between program and physician type, but not physician type independently, explained a significant amount of variation in pain level. Overall, reported pain remained higher than optimal. Research elsewhere has shown that application of the World Health Organization (WHO) cancer pain management guidelines can control 70%-90% of cancer pain. Strategies for implementing pain guidelines that emphasize a systems approach may be effective.