Relaxation and Visual Imagery

To evaluate the psychological, endocrine, and immunologic effects of a relaxation and visualization therapy (RVT) in breast cancer patients undergoing radiotherapy

Investigators randomly assigned participants to one of two groups: the relaxation visualization (RVT) group or the control group. The RVT intervention consisted of 30-minute structured group sessions led daily by a trained investigator. Each RVT session took place immediately following radiation. Subjects were also instructed to perform the RVT exercise at home twice a day, with the aid of a telephone-call reminder and a tape. The RVT intervention occurred daily for 24 days. The control group received radiation only. Investigators obtained psychological assessments as well as blood and saliva samples at baseline and after the 24-day intervention.

• The sample was composed of 34 participants; 20 in the experiment (RVT) group and 14 in the control group.
• Mean patient age in the control group was 50.07 years (SD = 2.68 years); the age range in the control group was 36–70 years.
• Mean patient age in the RVT group was 54.20 years (SD = 1.24 years); the age range in the RVT group was 45–65 years.
• Investigators discovered no significant differences between groups in regard to any of the demographic variables, including age.
• All the participants were female; all had stage I or II breast cancer, and all were receiving radiotherapy.

• Single site
• Outpatient
• Brazil

Active treatment

Prospective randomized trial design with randomization and repeated measures

• Lipp Inventory of Stress Symptoms for Adults (ISSL)
• State-Trait Anxiety Inventory (STAI)
• Beck Anxiety Inventory (BAI)
• Beck Depression Inventory (BDI)
• Structured clinical interview to assess psychosocial variables
• Neuroimmunologic parameters: salivary cortisol and peripheral blood cells

At baseline the experimental group was significantly more anxious than the control group, according to the BAI and STAI. Within-group analysis for the control group revealed no significant changes in any of the psychological scores over time. However, the experimental group demonstrated significant declines in levels of stress, anxiety, and depression over time (p < 0.05 for all measures). Interestingly, the mean scores relating to the psychological measures of the experimental group, at the post-time point (after completion of the study), were all higher than the mean post- scores of the control group. Cortisol levels and lymphocyte proliferation did not change over time for either group.

The RVT intervention was effective in reducing psychological distress but did not seem to affect the endocrine (cortisol) or immune measures (lymphocyte proliferation).

• The study had a small sample size, with fewer than 100 participants.
• The study had risks of bias due to no appropriate attentional control condition and because participants' levels of anxiety differed.
• All participants had gone without chemotherapy for two weeks, but this may not have been sufficient for complete immune recovery; the study presents no way to ascertain this because it lacks a \"true\" baseline value.

Use of adjunct therapies, such as relaxation and visualization, may help ease the psychological distress associated with cancer and its treatment.

Objectives were to

• Present evidence that will contribute to the improvement of palliative care at the end of life.
• Answer questions regarding critical elements.
• Identify patients who could benefit from palliative approaches.
• Identify treatment strategies that work for pain, dyspnea, and depression.
• Identify elements important in advance care planning, collaboration and consultation, and assessment and support aspects helpful to caregivers.

Included were patients with any disabling or symptomatic condition at the end of life.

The guideline was based on a systematic evidence review, done by others, in an Agency for Healthcare Research and Quality evidence report. The guideline does not address nutritional support, complementary and alternative therapies, or spiritual support because evidence related to these areas does not often appear in the literature. Specific procedures for grading the evidence and recommendations are not described.

The guideline was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Evidence and recommendations were graded using the clinical practice guidelines grading system (GRADE).

Databases searched were MEDLINE and the Database of Abstract Reviews of Effects (January 1990–November 2005); citations from the review by the National Consensus Project for Quality Palliative Care (2003) also were searched.

Search keywords were cancer, congestive heart failure, and dementia. The full description of search terms is published elsewhere.

The guideline outlines the strength of GRADE recommendations and includes a brief description of the supporting evidence for each recommendation.

Critical Elements for End-of-Life Care: Elements identified are preventing and treating pain and other symptoms; supporting families and caregivers; ensuring continuity of care; ensuring respect for patients as people and informed decision making; ensuring well-being, including consideration of existential and spiritual concerns; and supporting function and duration of survival.

Identifying Patients Who Could Benefit From Palliation: No evidence tools have been validated or effectively shown to predict optimal timing. Decisions should be based on each patient's symptoms and preferences.

Treatment Strategies:

• Pain
  • Evidence is strong in support of the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain, with bisphosphonates used for bone pain specifically.
  • Insufficient evidence exists to evaluate the usefulness of acupuncture or exercise for pain control.
  • Palliative care teams may be moderately beneficial in providing pain management.
• Dyspnea
  • Evidence shows a valuable effect of morphine.
  • Nebulized opioids show no additional benefit over oral opioids.
  • Evidence regarding the use of oxygen is equivocal.
  • Studies that evaluated facilitated communication or palliative care consultation showed no effect.
• Depression
  • Evidence suggests that long-term use of tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions are beneficial for patients with cancer who are depressed.
  • Evidence is mixed regarding the benefit of guided imagery and exercise in the defined patient population.
  • Evidence showed that care coordination had no effect.

Important Elements for Advance Care Planning: Evidence shows that extensive multicomponent interventions, goal-oriented interviews with palliative care providers, and proactive communication involving skilled discussants can reduce unnecessary services, without causing harm, and increase the use of advance directives.

Collaboration and Consultation: Use and patient-centered outcomes improve when multidisciplinary teams include nurses and social services providers, address care coordination, and use facilitated communication.

Supporting Caregivers: Evidence regarding the effects of palliative care teams for caregivers is mixed.

The following were graded as strong recommendations with moderate quality of evidence.

• Patients with serious illness at the end of life should be regularly assessed for pain, dyspnea, and depression.
• For patients with cancer, clinicians should use therapies with proven effectiveness to manage pain. These therapies include nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates.
• Clinicians should use therapies with proven effectiveness to manage dypsnea. These therapies include opioids (for unrelieved dyspnea) and oxygen (for the relief of short-term hypoxemia).
• Clinicians should use therapies with proven effectiveness to manage depression in patients with cancer. These therapies include tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions.
• Clinicians should ensure that advance care planning occurs for all patients with serious illness. Such planning includes the preparation of advance directives.

• Several authors had grants from the Agency for Healthcare Research and Quality or pharmaceutical companies.
• Financial support for this guideline was entirely from the American College of Physicians.

The guideline provides clear guidance in several areas of end-of-life care and symptom management and identifies the relevant evidence and strength of the evidence. The guideline may not apply to all patients and is not intended to override clinical judgment. In addition to recommending medication interventions for depression, the guideline recommends psychosocial interventions.