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 261,466 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Inadequate physician knowledge, particularly in areas of pain assessment and use of analgesics, has been identified as a major factor contributing to poor pain management in cancer patients. In most medical schools, teaching in Palliative Care at both the undergraduate and postgraduate levels is limited or nonexistent. Baseline knowledge and changes in knowledge in areas relevant to Palliative Care were assessed by the use of 2 16-question examinations (Exams A and B) in 78 second-year Family Medicine Residents from the University of Alberta Family Medicine Residency Program. The residents participated in a two-week rotation on the Acute Palliative Care Unit at the Edmonton General Hospital or Grey Nuns Community Health Centre between September 1991 and February 1996. The residents were randomly assigned on their first day (Time 1) to complete either Exam A or B and were subsequently crossed over on their final day of the rotation to complete the alternate Exam (Time 2). Six domains were represented in the Exams as follows: pain assessment, opioid use, adjuvant medications, delirium, urinary catheterization, and hydration. Improvements were noted in the mean percentage results in Time 2 compared with Time 1 for Exams A, B, and A and B combined. Mean global percentage results were 53 +/- 15 versus 73 +/- 13 (p < 0.001) at Times 1 and 2, respectively. There were significant improvements for domains in Time 2 compared to Time 1 (p < or = 0.05) for combined A and B Exam except for urinary catheterization. Despite these documented improvements in scores, serious deficiencies were identified particularly in the areas of pain assessment and opioid use, namely opioid sude effects and issues involving dependence, addiction, and tolerance. Examinations, such as the two used in this study, can be a useful aid in assessing physician knowledge in addition to structuring teaching in Palliative Care. Examination content will require updating as knowledge in Palliative Care evolves.
J Pain Symptom Manage 1997 Nov
PMID:Assessment and knowledge in palliative care in second year family medicine residents. 939 19

A survey was developed to explore physician trainee competencies and concerns surrounding end-of-life care. Thirty-one medical students, interns, and residents from the Department of Internal Medicine completed the survey in August 1996. The survey instrument found differing levels of competence/concern among medical students, interns, and residents. Self-reported competence increased with level of training. All trainees indicated the least comfort around discussions of hydration and feeding withdrawal. Both residents and interns indicated concern about potential illegality, breach of ethics or potential malpractice when reviewing eight currently legal and ethical end-of-life scenarios involving pain management or treatment withdrawal. Pain management, ethical issues, and delirium were the top three topics for which residents indicated an interest in future educational sessions. Results from the survey will be used to guide the development of educational initiatives that address trainee concerns. The competence/concern survey adds an important dimension to understanding how best to incorporate end-of-life education into residency training programs.
J Pain Symptom Manage 1998 Feb
PMID:A survey of competencies and concerns in end-of-life care for physician trainees. 949 6

The authors prospectively assessed symptoms induced by the interruption of antidepressants in 16 patients (11 women and 5 men), aged from 33 to 85 years (mean = 52.4 +/- 16.4), treated with antidepressants since at least two weeks. All patients were free of alcohol abuse or dependence disorder and of other dependence to psychoactive substances. None of them presented medical illness. Diagnosis were made by separate evaluations by two authors and confirmed with a semistructered assessment instrument: the Schedule for Affective Disorders and Schizophrenia (Lifetime Version). All patients were submitted to a brutal discontinuation of their antidepressant agent. Patients were assessed twice, before the interruption of the antidepressant, and 72 hours later. Effects of antidepressant interruption were assessed by several means. Modification of anxiety and depression were evaluated using the Montgomery Asberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Scale. Symptoms of withdrawal were assessed with Cassano and al.'s scale SESSH including an evaluation of anxiety, agitation, irritability, anergy, difficulty on concentrating, depersonalization, sleep and appetite disorders, muscle pains, nausea, tremor, sweating, altered taste, hyperosmia, paresthesias, photophobia, motor incoordination, dizziness, hyperacousia pain, delirium. Fourteen of the 16 patients (87.5%) presented modifications of their somatic or psychic state 3 days after the interruption of the antidepressant treatment. Most frequent symptoms were: increase in anxiety (31%), increase in irritability (25%), sleep disorders (19%), decrease of anergia and fatigue (19%). Mean scores of anxiety and depression were not significantly modified by the withdrawal. Following TCAs interruption (7 patients) most frequent symptoms were sleep disorders; increase in anxiety, nausea. Among patients withdrawn from SSRIs (6 patients), most frequent symptoms were increase in anxiety, increase in irritability, headache. Patients also presented a decrease of nausea, and of anorexia.
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PMID:[Prospective evaluation of antidepressant discontinuation]. 969 14

The need to sedate terminally ill patients for uncontrolled symptoms has been previously documented in a few reports. A retrospective consecutive chart review was undertaken at a hospice in Cape Town, South Africa, to develop an understanding of the local experience and assess the potential for improved patient management. Twenty-three of seventy-six (30%) patients received sedating therapies: twenty patients for delirium, two patients for delirium and dyspnea, and one patient for dyspnea alone. Fourteen patients were sedated with a continuous subcutaneous infusion of midazolam, seven patients with intermittent doses of benzodiazepines, and two patients with chlorpromazine and lorazepam. The mean midazolam dose was 29 mg per day (median 30 mg; range 15-60 mg per day). Patients were sedated on average 2.5 days before death (median 1 day; range 4 hours-12 days). The mean equivalent daily dose of parenteral morphine in the last week of life showed a significantly higher mean for the sedated group, as compared to the nonsedated group. There was minimal investigation of reversible causes for delirium, none of the patients underwent an opioid rotation, and the opioid dose was seldom decreased. None of the patients received parenteral hydration. The prevalence for the use of sedating treatment is consistent with the range of other literature reports. Nevertheless, the wide disparity in the reported prevalence of these problems, and the ethical concerns raised by the relative frequency of this sedative approach, cannot be ignored.
J Pain Symptom Manage 1998 Sep
PMID:Sedation for uncontrolled symptoms in a South African hospice. 1038 52

Delirium is common among cancer patients, especially those with advanced disease. Typical treatment involves addressing the underlying cause if possible; eliminating nonessential and/or other drugs that can worsen confusion, manipulating the environment; and administering antipsychotic drugs to control symptoms and agitated behavior, and attempt to clear the patient's sensorium. The newer atypical antipsychotics may have potential in the treatment of delirium and also have the added benefit of causing less akithisia and other extrapyramidal side effects. This is illustrated by the case of a 59-year-old woman with leukemia and pain of unclear etiology who developed a delirium and a moderate to severe extrapyramidal syndrome (EPS) in the setting of escalation of her pain medications and concomitant escalation of prochlorperazine. The patient presented with confusion and moderate to severe cogwheeling rigidity, masked facies, bradykinesia, and tremor. Additionally, the patient had a relatively recent history of subdural hematoma and one seizure. Conservative management including eliminating multiple nonessential medications (including the prochlorperazine); changing her opioid analgesic; providing a 24-hour companion: and administering low doses of haloperidol (0.5 mg-2.0 mg) were not effective in treating the patient's delirium. The patient's EPS was dramatically worse following haloperidol doses. After approximately I week without improvement, the patient was started on olanzapine 5 mg daily with initial improvement but with residual confusion in the evenings and overnight. The dose was titrated up to 10 mg nightly with 2.5 mg as needed during the day. After 3 days on this regimen, the patient's mental status exam was normal and she was discharged home. We discuss the potential utility of this atypical antipsychotic in the palliative care setting.
J Pain Symptom Manage 1999 Mar
PMID:Complicated delirium in a cancer patient successfully treated with olanzapine. 1009 65

This study compares subcutaneous (s.c.) morphine and fentanyl with respect to pain control and side effects using a 6-day randomized, double-blind, cross-over design. Results were obtained from 23 patients (12 males and 11 females: mean age of 70.5 years) who could tolerate morphine. Thirteen patients were randomized to receive morphine for the first 3 days followed by fentanyl; 10 received fentanyl first followed by morphine. There were no significant differences in the scores for pain between the two drugs, suggesting that fentanyl is equally efficacious and the conversion ratio of morphine 10 mg: fentanyl 150 micrograms is appropriate. Patients had more frequent bowel movements during days 4-6 while on the fentanyl arm [t-test, df (22), P = 0.015]. Other measures for nausea, delirium, and cognitive function showed no differences between the two drugs. This study highlights the need to further assess the role of various opioids in hospice patients, and emphasizes the requirement for sensitive and simple cognitive tests in this population.
J Pain Symptom Manage 1999 Aug
PMID:A comparison of subcutaneous morphine and fentanyl in hospice cancer patients. 1048 58

This article reviews the literature about the extent of posttraumatic stress disorder (PTSD) in patients with burns. PTSD is a relatively new diagnostic label, although the emotional effects of severe trauma have long been recognized. A burn injury-one of the most traumatic of all injuries--can be accompanied by serious psychological sequelae, including PTSD. Psychiatric symptoms may not be immediately apparent in patients with burns because the patients often develop PTSD many months after the injury. The reported prevalence rate of PTSD in patients with burns varies from 8% to 45%. The factors increasing these patients' risks include preburn affective disorder, delirium or severe pain during acute treatment, and less perceived social support. Psychosocial issues must be considered in the recovery or rehabilitation phase. Pharmacotherapy, psychodynamic psychotherapy, cognitive-behavioral therapy, and eye-movement desensitization and reprocessing may be helpful to the PTSD patient. Early detection and treatment of PTSD cannot only diminish the effects of this disabling disorder but can also help the rehabilitation of patients with this condition.
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PMID:Posttraumatic stress disorder in patients with burn injuries. 1050 32

The majority of cancer patients develop pain before death. This pain has been shown to be underdiagnosed and undertreated. Opioid use has increased in the past 20 years in both developing and developed countries. The changing pattern in opioid use has resulted in the emergence of neurotoxicity as a major side effect of the treatment of cancer pain. The syndrome of opioid-induced neurotoxicity (OIN) encompasses delirium, hallucinosis, myoclonus/seizures and hyperalgesia. Increased vigilance can lead to the timely diagnosis of OIN, and strategies for its treatment can be implemented with encouraging results. Identification and modification of risk factors for the development of OIN can help in its prevention and improve the quality of life in advanced cancer patients.
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PMID:Opioid use in cancer pain. Is a more liberal approach enhancing toxicity? 1052 40

Because cancer is a life-threatening illness, its impact on the patient's emotional well-being, such as suicidal thoughts, has become a significant problem in public health as well as in clinical oncology. Factors such as the pain and hopelessness are suggested as making cancer patients more vulnerable to suicide. On the other hand, euthanasia and physician-assisted suicide are now important medical and social issues all over the world. However, little is known about the relationship between the characteristics of cancer patients and suicidal thoughts. The present study investigated the characteristics of patients who were referred to the Psychiatry Division, National Cancer Center Hospital East, due to risk of suicide or suicide attempts. Fourteen patients were referred, representing 3.9% of all consultations. Most of these patients suffered from advanced cancer and poor physical functioning. The most frequent psychiatric diagnosis was mood disorder (57%), and the next was delirium (29%). In patients with mood disorders (8 cases), suicidal thoughts disappeared after psychiatric treatment in 5 cases, but not in 3 cases. Those three patients survived a significantly shorter time than the others after psychiatric consultation. These empirical data might indicate that most suicidal thoughts experienced by cancer patients are not rational, and a careful evaluation, including psychiatric assessment, should be conducted in such patients.
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PMID:Suicidal thoughts in cancer patients: clinical experience in psycho-oncology. 1059 81

In 2 patients, a woman aged 38 years and a man aged 48 years, in the terminal phase of life due to metastasized+ malignancy, palliative care failed. They suffered seriously from pain, delirium, restlessness, nausea, and fear. Deep sedation was given to induce almost continuous sleep without the intention of causing death. After one and five quiet days respectively the patients died. Deep sedation is an option when palliative care fails to diminish serious suffering. Midazolam, given by continuous subcutaneous infusion is the drug of choice.
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PMID:[Sedation in the terminal phase of life]. 1063 3


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