Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus.

OBJECTIVES: Despite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and management of opioid-related harms. The Delphi technique was used to develop expert consensus recommendations about how to promote opioid safety in adults receiving PC in Canada and the USA. METHODS: Through a Delphi process comprised of two rounds, USA and Canadian panellists in PC, addiction and pain medicine developed expert consensus recommendations. Elected Canadian Society of Palliative Care Physicians (CSPCP) board members then rated how important it is for PC physicians to be aware of each consensus recommendation.They also identified high-priority research areas from the topics that did not achieve consensus in Round 2. RESULTS: The panellists (Round 1, n=23; Round 2, n=22) developed a total of 130 recommendations from the two rounds about the following six opioid-safety related domains: (1) General principles; (2) Measures for healthcare institution and PC training and clinical programmes; (3) Patient and caregiver assessments; (4) Prescribing practices; (5) Monitoring; and (6) Patients and caregiver education. Fifty-nine topics did not achieve consensus and were deemed potential areas of research. From these results, CSPCP identified 43 high-priority recommendations and 8 high-priority research areas. CONCLUSIONS: Urgent guidance about opioid safety is needed to address the opioid crisis. These consensus recommendations can promote safer opioid use, while recognising the importance of these medications for PC symptom management.

Assessment tools for problematic opioid use in palliative care: A scoping review.

BACKGROUND: Screening for problematic opioid use is increasingly recommended in patients receiving palliative care. AIM: To identify tools used to assess for the presence or risk of problematic opioid use in palliative care. DESIGN: Scoping review. DATA SOURCES: Bibliographic databases (inception to January 31, 2020), reference lists, and grey literature were searched to find primary studies reporting on adults receiving palliative care and prescription opioids to manage symptoms from advanced cancer, neurodegenerative diseases, or end-stage organ diseases; and included tools to assess for problematic opioid use. There were no restrictions based on study design, location, or language. RESULTS: We identified 42 observational studies (total 14,431 participants) published between 2009 and 2020 that used questionnaires (n = 32) and urine drug tests (n = 21) to assess for problematic opioid use in palliative care, primarily in US (n = 38) and outpatient palliative care settings (n = 36). The questionnaires were Cut down, Annoyed, Guilty, and Eye-opener (CAGE, n = 8), CAGE-Adapted to Include Drugs (CAGE-AID, n = 6), Opioid Risk Tool (n = 9), Screener and Opioid Assessment for Patients with Pain (SOAPP; n = 3), SOAPP-Revised (n = 2), and SOAPP-Short Form (n = 5). Only two studies' primary objectives were to evaluate a questionnaire's psychometric properties in patients receiving palliative care. There was wide variation in how urine drug tests were incorporated into palliative care; frequency of abnormal urine drug test results ranged from 8.6% to 70%. CONCLUSION: Given the dearth of studies using tools developed or validated specifically for patients receiving palliative care, further research is needed to inform clinical practice and policy regarding problematic opioid use in palliative care.

"It's More Difficult ": Clinicians' Experience Providing Palliative Care to Adolescents and Young Adults Diagnosed With Advanced Cancer.

PURPOSE: Adolescents and young adults (AYAs; age 15-39 years) with advanced cancer are a population in whom quality of life is uniquely affected because of their stage of life. However, training focused on palliative care for AYAs is not routinely provided for health care providers (HCPs) in oncology. This study aims to explore the experiences of HCPs involved in introducing and providing palliative care caring for AYAs with advanced cancer and their families to understand the unique challenges HCPs experience. METHODS: Using a qualitative descriptive design, semistructured interviews were conducted with medical and radiation oncologists, palliative care physicians, psychiatrists, and advanced practice nurses involved in caring for AYAs diagnosed with advanced cancer (N = 19). Interviews were transcribed verbatim and analyzed using thematic analysis in combination with constant comparative analysis and theoretical sampling. RESULTS: There were 19 participants, 9 men and 10 women, with a median age of 45 years (range, 24-67 years). Six were palliative care physicians, 5 medical oncologists, 4 nurse practitioners, and 2 each radiation oncologists and psychiatrists. Overall, participants perceived the provision of palliative care for AYAs to be more difficult compared with older adults. Four themes emerged: (1) challenges helping AYAs/families to engage in and accept palliative care, (2) uncertainty regarding how to involve the family, (3) HCP sense of tragedy, and (4) HCP sense of emotional proximity. CONCLUSION: Findings from this study support the development of dedicated training for HCPs involved in palliative care for AYA.

Palliative care for patients with communication and cognitive difficulties.

OBJECTIVE: To help increase the confidence of both caregivers and clinicians in providing palliative care to adults with intellectual and developmental disabilities (IDD) using an easy-to-follow framework to improve and overcome barriers to effective palliative care in this population. QUALITY OF EVIDENCE: A literature review was conducted to explore recent best evidence to address these palliative care needs and to allow for a focused opportunity to consider the details of implementing clinical practice guidelines in the palliative care context. Evidence ranges from level I to level III. MAIN MESSAGE: Pain and psychological and emotional distress are important issues for individuals with IDD, as they can be difficult to assess and measure, and often present atypically, especially in those with limited communication skills. Further, little is known about end-of-life needs in the adult population with IDD, especially for those living in community residences. The conducted literature review of patient, caregiver, and clinician experiences exposed considerable barriers, including incorrect assumptions about patients' capacity to understand and discomfort of both caregivers and clinicians with open communication. This has resulted in exclusion of adults with IDD from their own care, which has proven harmful. Maximizing time in familiar surroundings and establishing trust and continuity are crucial. Sometimes trial and error with empiric use of comfort medications is necessary, but this can be mitigated with careful examination of distress patterns and judicious use of diagnostic testing. It is always best to integrate the palliative approach into the existing pattern of care. CONCLUSION: The validated tools and recommendations provided will assist with communication, symptom interpretation, treatment decisions, advanced care planning, addressing grief, and important considerations in end-of-life care.

Enhancing communication in end-of-life care: a clinical tool translating between the Clinical Frailty Scale and the Palliative Performance Scale.

OBJECTIVES: To create a clinical tool to translate between the Clinical Frailty Scale (CFS), which geriatrics teams use, and Palliative Performance Scale (PPS), which palliative care teams use, to create a common language and help improve communication between geriatric and palliative care teams. DESIGN: Cross-sectional. SETTINGS: Two academic health centers: inpatient palliative care and chronic care units, an outpatient geriatric clinic, and inpatient referrals to a palliative care consultation service. PARTICIPANTS: Older adults (≥65) aged 80.9±8.0, with malignant (51%) and nonmalignant (49%) terminal diagnoses (N=120). MEASUREMENTS: Each participant was assigned four scores: a CFS score each from a geriatric physician and nurse and a PPS score each from a palliative care physician and nurse. Interrater reliability of each measure was calculated using kappa coefficients. For each measure, the mean of physician and nurse scores was used to calculate every possible combination of CFS and PPS scores to determine the combination with maximum agreement. RESULTS: Interrater reliability of each measure was very high for the CFS (weighted κ=0.92) and PPS (weighted κ=0.80). The CFS-PPS score matching that achieved maximum agreement (weighted κ=0.71) was used to create a conversion chart between the two measures. CONCLUSION: This conversion chart is a reliable means of translating scores between the CFS and PPS and is useful for geriatric and palliative care teams collaborating in the care of elderly adults.

Oncologists' strategies and barriers to effective communication about the end of life.

PURPOSE: Communicating about the end of life with patients has been reported as one of the most difficult and stressful part of the work of oncologists. Despite this fact, oncologists receive little training in this area, and many do not communicate effectively with patients. The purpose of this analysis, part of a larger study examining oncologists' experiences of patient loss, was to explore oncologists' communication strategies and communication barriers when discussing end-of-life issues with patients. METHODS: Twenty oncologists were interviewed at three hospitals about their communication strategies on end-of-life issues with patients. The data were analyzed using the grounded theory method. RESULTS: The findings revealed the strategies to effective communication about the end of life included: being open and honest; having ongoing, early conversations; communicating about modifying treatment goals; and balancing hope and reality. Barriers to implementing these strategies fell broadly into three domains, including physician factors, patient factors, and institutional factors. Physician factors included difficulty with treatment and palliation, personal discomfort with death and dying, diffusion of responsibility among colleagues, using the "death-defying mode," lack of experience, and lack of mentorship. Patient factors included, patients and/or families being reluctant to talk about the end of life, language barriers, and younger age. Institutional factors included stigma around palliative care, lack of protocol about end-of-life issues; and lack of training for oncologists on how to talk with patients about end-of-life issues. CONCLUSION: We conclude by drawing implications from our study and suggest that further research and intervention are necessary to aid oncologists in achieving effective communication about end-of-life issues.

Oncologists' protocol and coping strategies in dealing with patient loss.

To identify what protocol and coping strategies oncologists turn to cope with patient loss, the authors interviewed 20 oncologists at 3 hospitals. Using the grounded theory method, findings revealed that their protocol may include meeting with families, participating in bereavement rituals, making a phone call, or sending a condolence card. Coping strategies included social support, activity-oriented coping, turning to faith, compartmentalization, and withdrawing from patients and families. The authors conclude by offering implications from this research on how to address oncologists' grief over patient loss in institutional settings in order to improve bereavement care for families and enhance oncologists' quality of life.

Difficult patient loss and physician culture for oncologists grieving patient loss.

BACKGROUND: While caring for critically ill and terminal patients can elicit grief symptoms in health care professionals, few studies have examined oncologists' grief over patient loss using a qualitative approach to inquiry. OBJECTIVES: To explore what makes patient loss difficult for oncologists and to explore the context in which these losses were occurring. METHOD: Twenty oncologists were interviewed at three oncology centers in Canada about their experiences of grief over patient loss. Exclusion criteria included never having lost a patient in their care and being unable to speak English. Data was analyzed using the grounded theory method. RESULTS: Oncologists found patient loss particularly difficult for relational reasons including instances where they felt close to patients and their families, when they had a transference to the patient, when patients died young, when they had long-term patients, and when deaths were unexpected. Contextual reasons included when patients and their families were unprepared for death, had unrealistic expectations about cure, when excessive treatments were perceived to be used, when physicians were blamed for the loss, or when families were chaotic or had high needs. Findings further revealed that these losses were occurring within a physician culture that had a stigma around death and dying, viewed emotion as weakness, was focused on cure, and was gendered. CONCLUSIONS: Effective interventions to help oncologists cope with grief must identify the expectation gaps between physicians and patients when it comes to end-of-life care.

What do oncologists want? Suggestions from oncologists on how their institutions can support them in dealing with patient loss.

PURPOSE: The purpose of the study was to explore what institutional support(s) oncologists want to help them cope with patient loss. METHODS: The grounded theory method was used. Twenty oncologists were recruited and interviewed between November 2010 and July 2011 from three adult oncology centers in Ontario. Data collection and analysis took place concurrently. Analysis involved line-by-line coding, and was inductive, with codes and categories emerging from participants' narratives. RESULTS: Oncologists suggested institutional supports that fit under four categories that included: (1) training, information and education including fellowship training, grand rounds and the availability of fact sheets; (2) acknowledgment and validation of grief including normalizing grief, having forums to share experiences, supportive mentorship and group debriefing sessions; (3) institutional psychosocial support including access to professional help and the nursing care model; and (4) vacations and sabbaticals. CONCLUSIONS: Institutions such as medical schools and hospitals have both the opportunity and the obligation to support oncologists with this difficult aspect of their work. In addition to offering ongoing education and forums to share experiences, medical institutions can also provide supportive mentorship models to junior oncologists on how to cope with patient loss.

High scores on the Edmonton Symptom Assessment Scale identify patients with self-defined high symptom burden.

The terms symptom burden and symptom distress are frequently seen in palliative care literature yet are used in multiple ways ranging from addition of symptom scores to more in-depth assessments of interference in function. Patient input to date has had little role in these varied definitions yet previous reviews have suggested the importance of such input. This mixed qualitative and quantitative prospective study was conducted to seek patient input into the definition of 'symptom burden' and to correlate burden self-ranked scores with symptom scores on the Edmonton Symptom Assessment Scale (ESAS). Results suggest that patients with advanced disease followed by palliative care providers are a group with a high level of self-defined burden. Further, any patient rating one or more symptoms on the ESAS ≥7 is at high risk of self-defined burden and likely to be experiencing significant impact on physical, emotional and social functioning. Further work should look at which aspects of symptom management best promote a lessening of perceived burden.

Anorexia-cachexia syndrome: a systematic review of the role of dietary polyunsaturated Fatty acids in the management of symptoms, survival, and quality of life.

To provide a systematic review on the clinical utility of anti-inflammatory polyunsaturated fatty acids (PUFAs) in cancer-associated anorexia-cachexia syndrome (ACS), clinical trials involving eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) for the management of ACS were identified in the medical literature using MEDLINE (1966 to October 2006) and EMBASE (1980 to October 2006). Review Manager 4.1 was used to compare trials based on outcome measures of interest, including weight change, lean muscle mass change, survival, and quality of life (QoL). Seven randomized controlled trials (RCTs) were identified. Various outcome measures were used in each study. Variability in study populations, dose of EPA and DHA, and standardized scales did not allow for analysis using Review Manager 4.1. Therefore, trials were summarized based on their individual outcomes. Except for one trial showing a positive effect on weight, none of the trials found a clinically or statistically significant difference in outcome measures reviewed. EPA and DHA alone have not shown significant clinical effect in altering weight, lean muscle mass, survival, or QoL in patients with ACS associated with cancer.

Fetal safety of drugs used in the treatment of allergic rhinitis: a critical review.

Allergic rhinitis is the most common allergic disease. Pharmacological interventions are often not used in pregnancy because of alarming information in drug labels and patient information, even when evidence for safety exists.Low-risk therapies could include immunotherapy, intranasal sodium cromoglycate (cromolyn sodium), beclometasone, budesonide and first-generation antihistamines. In a meta-analysis examining the safety of first-generation antihistamines in pregnancy, 200 000 first trimester exposures failed to show increased teratogenic risk. Loratadine is the most studied second-generation antihistamine (with a total patient cohort of 2147 women who were exposed) and does not appear to increase the risk of major congenital malformations; however, it has not been as well studied as the earlier antihistamines. Since desloratadine is the principal metabolite of loratadine, it can be assumed that a similar safety profile would fit for desloratadine as was described for loratadine although no direct human studies have been done. Decongestants have not been conclusively proven to affect the fetal outcome and may be used for short-term relief when no other safer alternatives are available. Intranasal corticosteroids have not been associated with an increase in congenital malformations in humans. Based on efficacy and the fact that there would be little systemic absorption, they can be considered a first-line treatment over oral antihistamines, decongestants and mast cell stabilisers; however, the number of controlled trials in pregnancy is limited. Intranasal corticosteroids are associated with minimal systemic effects in adults and are the most effective therapy for allergic rhinitis. Benefit-risk considerations must, therefore, be done but favour their first-line use during pregnancy. Because fetal safety is paramount, recommendations should be based both on the safety of the drugs during pregnancy and the comparative efficacy of the agent in the treatment of the underlying condition. This review exemplifies the fact that there are many safe treatment options for the clinician when dealing with allergic rhinitis during pregnancy.

GABAergic function in Alzheimer's disease: evidence for dysfunction and potential as a therapeutic target for the treatment of behavioural and psychological symptoms of dementia.

Alzheimer's disease (AD) is characterized by disruptions in multiple major neurotransmitters. While many studies have attempted to establish whether GABA is disrupted in AD patients, findings have varied. We review evidence for disruptions in GABA among patients with AD and suggest that the variable findings reflect subtypes of the disease that are possibly manifested clinically by differing behavioural symptoms. GABA, the major inhibitory neurotransmitter, has long been a target for anxiolytics, hypnotic sedatives, and anticonvulsants. We review the clinical use of GABAergic agents in treating persons with AD symptoms. While newer generation GABAergic medications are now available, they have yet to be evaluated among patients with AD.

Evidence-based view of safety and effectiveness of pharmacologic therapy for nausea and vomiting of pregnancy (NVP).

OBJECTIVE: Our goal was to review the safety and effectiveness of available antiemetics for treatment of nausea and vomiting of pregnancy. STUDY DESIGN: We performed a quantitative and qualitative overview of observational controlled studies for drug safety in pregnancy and randomized controlled trials for drug effectiveness for nausea and vomiting in pregnancy. RESULTS: All of the following are safe and effective for treatment of varying degrees of nausea and vomiting in pregnancy: Bendectin/Diclectin (doxylamine, pyridoxine, dicyclomine), antihistamine (H(1)) blockers, and phenothiazines; however, the magnitude of effect, particularly for phenothiazines, is in question and may differ among individual agents. Pyridoxine and vitamin B(12)are safe and may be effective. Metoclopramide, droperidol, and ondansetron may be effective, but safety data are insufficient to recommend them as first-line agents. Corticosteroids may not be as beneficial as first thought, and there may be a small teratogenic risk. The relative effectiveness of various agents is largely unknown. CONCLUSION: Many medications, particularly H(1)-antagonists and phenothiazines, are safe and effective for treatment of varying degrees of NVP.