Palliative Care Consultation

Palliative Care Consultation

PEP Topic 
Chronic Pain
Description 

Consultation by palliative care providers has been examined for effectiveness in symptom management in patients with cancer. Palliative care generally involves focus on symptom management and holistic care. Palliative care consultation involves patient assessment and recommendations for care by individuals specialized in palliative care, but does not involve ongoing direct patient management by a palliative care service or team.

Effectiveness Not Established

Research Evidence Summaries

Bandieri, E., Sichetti, D., Romero, M., Fanizza, C., Belfiglio, M., Buonaccorso, L., . . . Luppi, M. (2012). Impact of early access to a palliative/supportive care intervention on pain management in patients with cancer. Annals of Oncology, 23, 2016–2020.

doi: 10.1093/annonc/mds103
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Study Purpose:

To investigate the impact of early integration of palliative and supportive care on pain management

Intervention Characteristics/Basic Study Process:

Patients involved in the palliative care group were seen within two to three weeks of the cancer diagnosis. Services provided by the palliative and supportive care team were individualized, but included comprehensive symptom management, psychosocial, spiritual, and emotional support to patients and families, as well as assistance with treatment choice and coping. Patients in the comparison group received standard care provided by primary specialists. Data were collected from medical records. Patients were interviewed by a pharmacist regarding perception of pain control and pain intensity on a verbal rating scale.

Sample Characteristics:

  • The study reported on a sample of 1,450 patients.
  • Mean patient age was 65.05 years.
  • The sample was 56% male and 44% female.
  • Of the sample, 81% had metastatic disease. Specific sites were not described.
  • A significantly larger percentage of patients receiving palliative care were receiving opioids and strong opioids for pain.

Setting:

  • Multisite
  • Inpatient setting
  • Italy

Phase of Care and Clinical Applications:

The study has clinical applicability for palliative care.

Study Design:

A descriptive, two-group comparison design was used.

Measurement Instruments/Methods:

Verbal rating scale (five-point)

Results:

Use of morphine and oxycodone were higher in the palliative care group (p < 0.0001). Transdermal fentanyl was used more often in the usual care group (p < 0.0001). Results from the interview showed that the percentage of patients with no pain and mild pain were significantly higher in the palliative care group (p < 0.0001). Care model and gender were the only predictive variables for pain outcomes, with male patients reporting lower pain severity (p = 0.003). Type of analgesics used was not a significant predictor of pain scoring results.

Conclusions:

Findings suggest that provision of early palliative and supportive care is associated with lower pain severity than provision of standard care. There were significant differences in the types of analgesics used between care models, but this factor was not predictive of measured pain severity.

Limitations:

  • The study has baseline sample and group differences of import.  
  • The study has risk of bias due to no control group, no blinding, no random assignment, and no appropriate attentional control condition.
  • Measurement validity and reliability are questionable.
  • Pain was measured at only a single time point.
  • Duration of palliative care and time since diagnosis for the entire sample are not described.
  • There is limited information about content of standard care as well as overall pain management approaches in all patients.

Nursing Implications:

This study design is associated with multiple limitations and threats to validity, so results cannot be seen as conclusive. Findings do suggest that an integrated care delivery model, incorporating holistic palliative and supportive care that is initiated early in the course of cancer care, may be associated with greater control of cancer-related pain.

Bischoff, K., Weinberg, V., & Rabow, M.W. (2013). Palliative and oncologic co-management: Symptom management for outpatients with cancer. Supportive Care in Cancer, 21, 3031–3037.

doi: 10.1007/s00520-013-1838-z
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Study Purpose:

To assess the association between palliative care management, symptoms, and quality of life

Intervention Characteristics/Basic Study Process:

Clinical records of patients referred for outpatient palliative care who had follow-up visits within 120 days of initial referral were included. Retrospective analysis of clinical data was done.

Sample Characteristics:

  • N = 266
  • MEAN AGE = 57.2 years (SD = 13.8 years)
  • MALES: 46%, FEMALES: 54%
  • KEY DISEASE CHARACTERISTICS: 59% had metastatic disease. Multiple cancer sites were included, and 68% were on active treatment. Median time since diagnosis was 17 months. Mean time of follow-up after initial visit was 41 days.

Setting:

  • SITE: Single site 
  • SETTING TYPE: Outpatient 
  • LOCATION: California

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Palliative care

Study Design:

  • Retrospective, descriptive

Measurement Instruments/Methods:

  • Edmonton Symptom Assessment Scale

Results:

At the time of initial visit, average symptom scores were 2.9–5.8 (10-point scale). At the first follow-up visit, there was an average 0.67-point improvement in pain (p < .001), a 0.67-point improvement in fatigue (p < .001), a 0.94-point improvement in depression (p < .001), and a 0.89-point improvement in anxiety (p < .001). At least 50% of patients reported a greater than one-point improvement in symptoms by the first follow-up visit, and 16%–25% reported a one-point or greater worsening of symptoms. Among 142 patients who had a second follow-up visit, there was continued significant improvement from baseline symptom scores. Patients on active treatment had less improvement in fatigue than others (p = .02).

Conclusions:

Most patients who continued follow-up by palliative care demonstrated improvement in pain, fatigue, anxiety, and depression.

Limitations:

  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Risk of bias (sample characteristics)
  • Other limitations/explanation: The study only included those patients referred who had follow-up visits in the palliative care clinic. It is possible that at least some of those who did not come back for another visit did not have symptom improvement, so results may be overestimated. The opposite also is possible. There was a lot of variability in the timing of follow-ups. A single symptom measure was used repeatedly; it is possible that the study had threats to validity because of testing effect and patient expectations. It is not known if oncologic providers made any changes in medications for symptom management, as palliative care follow-up visits were relatively infrequent.

Nursing Implications:

Palliative care, with attention to symptom management, has been shown to be effective in reducing symptom severity for the majority of patients. It is not clear, however, if formal palliative care services result in better outcomes than attention to symptom management in general. It would be expected that, whether provided by oncology or palliative care providers, focused attention on symptom management would result in improvement of symptoms. The optimum frequency of follow-up and timing for optimal symptom control has not been determined.

Gagnon, B., Murphy, J., Eades, M., Lemoignan, J., Jelowicki, M., Carney, S., . . . Macdonald, N. (2013). A prospective evaluation of an interdisciplinary nutrition-rehabilitation program for patients with advanced cancer. Current Oncology, 20, 310-318.  

doi: 10.3747/co.20.1612
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Study Purpose:

To evaluate the degree to which a multi-component rehabilitation program improves symptom control and quality of life in patients with advanced cancer

Intervention Characteristics/Basic Study Process:

The intervention was a 10-12 week program offered by a multidisciplinary team, consisting of nutritional counseling, a collaborative care plan based on patient goals, a palliative care physician specialist focused on symptom-related medical interventions, a pivot nurse for care coordination and case management, and an exercise component with semi-weekly exercise sessions with a physical therapist and a home exercise plan. Occupational therapy was provided and focused on self care, leisure, and productivity. Patients were assessed at baseline and during their final clinic visit at the end of the study.

Sample Characteristics:

  • N = 131  
  • MEAN AGE = 59.9 years (SD = 13.0 years)
  • MALES: 50.4%, FEMALES: 49.6%
  • KEY DISEASE CHARACTERISTICS: All had stage III and IV disease with a variety of primary tumor types including both hematologic and sold tumors.
  • OTHER KEY SAMPLE CHARACTERISTICS: 38% were on current chemotherapy; most had ECOG performance status of 1 or 2.

Setting:

SITE: Single site  

SETTING TYPE: Outpatient  

LOCATION: McGill University Cancer Center, Montreal, Canada

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship
 
APPLICATIONS: Palliative care 

Study Design:

Quasi-experimental

Measurement Instruments/Methods:

Edmonton Symptom Assessment Scale (ESAS)
Multidimensional Fatigue Inventory
Distress Thermometer
Coping Thermometer
Six Minute Walk Test

Results:

Change in symptom severity was analyzed and Cohen’s d was used to calculate effect size. Severity of depression from ESAS declined (p <. 0001, d = 0.7); anorexia declined (p < .0001, d = .4);  pain declined (p < .0001, d = .4); physical and general fatigue declined (p < .0001, d = .7); mental fatigue declined (p < .0005, d = .4); and level of distress and difficulty coping declined (p < .0001).

Conclusions:

The multi-component rehabilitation program provided here resulted in a significant improvement in multiple symptoms and a reduction in distress and difficulty coping.

Limitations:

  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)  
  • Unintended interventions or applicable interventions not described that would influence results
  • Subject withdrawals ≥ 10%
  • Other limitations/explanation: 30% of patients withdrew from the study–the majority of these were due to death or disease progression. No information is provided about medication changes over the course of the study that might affect outcomes measured. The report states some different results in the body of the article versus tables provided.

Nursing Implications:

A multi-component, multi-disciplinary rehabilitation and palliative care program can provide effective improvement of multiple symptoms in patients with advanced disease.

Kang, J.H., Kwon, J.H., Hui, D., Yennurajalingam, S., & Bruera, E. (2013). Changes in symptom intensity among cancer patients receiving outpatient palliative care. Journal of Pain and Symptom Management, 46, 652–660.

doi: 10.1016/j.jpainsymman.2012.11.009
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Study Purpose:

To determine symptom changes after outpatient palliative care

Intervention Characteristics/Basic Study Process:

Patients who were seen in outpatient palliative care and had completed a symptom assessment scale were included in retrospective review of medical records. Only patients who completed the assessment and had at least one follow-up visit were included. The outpatient palliative care service was provided by an interdisciplinary team. Baseline symptom severity was compared to findings on an initial follow-up—usually in 15 days—and compared to a group of patients not eligible for study inclusion.

Sample Characteristics:

  • N = 1,612 
  • MEAN AGE = 59.2 years (SD = 13.2 years)
  • MALES: 52%, FEMALES: 48%
  • KEY DISEASE CHARACTERISTICS: Multiple disease types; lung, gastrointestinal, and genitourinary cancers were most frequent.
  • OTHER KEY SAMPLE CHARACTERISTICS: 73% were Caucasian.

Setting:

  • SITE: Single site 
  • SETTING TYPE: Outpatient 
  • LOCATION: MD Anderson in Texas

Phase of Care and Clinical Applications:

  • APPLICATIONS: Palliative care

Study Design:

  • Retrospective, descriptive

Measurement Instruments/Methods:

  • Edmonton Symptom Assessment Scale

Results:

Of the patients, 52%–74% had improvement in intensity of symptoms of pain, fatigue, depression, anxiety, anorexia, shortness of breath, and sleep disruption. Overall, among patients who had no or mild symptoms at baseline, symptom intensity was worse at follow-up, and among those with moderate or severe symptoms, symptom intensity declined at follow-up. Of patients with moderate or severe symptoms, 48%–80% continued to have clinically significant symptom intensity at follow-up. Median scores for pain, fatigue, depression, anxiety, anorexia, dyspnea, and sleep disturbance improved by at least one point by the first follow-up (p < .001).

Conclusions:

Outpatient palliative care services in this setting were associated with reduced symptom intensity among patients who had moderate to severe symptoms. Findings suggest that the timing of initial follow-up might not be sufficient to significantly reduce symptom burden quickly.

Limitations:

  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Selective outcomes reporting
  • Other limitations/explanation: Retrospective design; no information provided regarding disease stage or phase of cancer care involved; only a single follow-up time point

Nursing Implications:

Findings suggest that provision of outpatient palliative care services can be beneficial in reducing symptom burden among patients with cancer. Because 48%–80% still had relatively high intensity of symptoms at follow-up after 15 days—and those with no or mild symptoms had exacerbation of symptoms at follow-up—a shorter initial follow-up period might achieve more rapid improvement and help to prevent exacerbation of symptoms. Findings also suggest that getting more severe symptoms under control may take longer, pointing to the need for nurses to consider involvement of palliative care specialists early in the course of cancer treatment.

Yennurajalingam, S., Kang, J.H., Hui, D., Kang, D.H., Kim, S.H., & Bruera, E. (2012). Clinical response to an outpatient palliative care consultation in patients with advanced cancer and cancer pain. Journal of Pain and Symptom Management, 44, 340–350.

doi: 10.1016/j.jpainsymman.2011.09.014
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Study Purpose:

To determine response to pain treatment with outpatient palliative care consultation

Intervention Characteristics/Basic Study Process:

Records of consecutive patients referred to an outpatient palliative care consultation program were reviewed for analysis. The palliative care service was provided by an interdisciplinary team led by a board-certified palliative care specialist. Care follows a standardized management plan. Symptoms were evaluated at baseline and follow-up visits. Findings between individuals who had consultation only versus those who had consultation with follow-up were compared.

Sample Characteristics:

  • The study reported on a sample of 1,869 patients.
  • Mean patient age was 59.2 years.
  • The sample was 52% male and 48% female.
  • Multiple different disease types were represented. 
  • The most severe symptoms were pain and fatigue.
  • Patients who had consultation only had significantly lower symptom severity scores.

Setting:

  • Single site
  • Outpatient setting
  • The University of Texas MD Anderson Cancer Center

Phase of Care and Clinical Applications:

  • Patients were undergoing multiple phases of care.
  • The study has clinical applicability for palliative care.

Study Design:

A retrospective, descriptive design was used.

Measurement Instruments/Methods:

  • Edmonton Symptom Assessment Scale
  • Pain “responders” defined as those achieving at least a three-point pain severity reduction

Results:

More than half (53%) of patients did not achieve a pain response, and 70% of those with moderate to severe pain at the initial visit did not respond to palliative care consultation or still had poor pain control at a follow-up visit. Thirty-two percent of those with mild pain and 27% with moderate pain had worse pain at follow-up. Median time to follow-up visits was 15 days. Factors associated with pain treatment response were baseline pain intensity, fatigue, and total symptom burden at baseline (p < 0.04).

Conclusions:

Findings show that pain was not effectively controlled in the short-term with this program. Pain intensity can change quickly in the short-term. Standardized care as examined here may be an insufficient way to effectively manage pain.

Limitations:

  • The study has risk of bias due to no control group, no blinding, no random assignment, and no appropriate attentional control condition.
  • The study has risk of bias due to the sample characteristics.
  • Unintended interventions or applicable interventions are not described that would influence results.
  • Retrospective descriptive nature of the study is limiting but does provide some information regarding this type of program.
  • It is not known if recommendations made from consultation were implemented, such as any changes in pain medications, etc.

Nursing Implications:

This study provides only limited information about effectiveness of outpatient palliative care consultation for pain control; however, it does show that pain can get worse quickly, a large percentage of patients did not have adequate pain control, and the use of standard protocols may not be sufficient. Findings point to the need for aggressive pain management, frequent assessment of pain, and the potential need for very frequent follow-up in initial phases of establishing a pain management plan for the patient in order to quickly achieve pain reduction.


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