'I'm not that sick!' Overcoming the barriers to hospice discussions.

Hospice programs care for patients facing life-limiting illness. Although patients and family members report that they are satisfied once they are enrolled in a hospice service, many patients are referred late or not at all. Several barriers and misconceptions about hospice likely contribute to its underuse.

Early satiety in cancer patients: a common and important but underrecognized symptom.

Introduction: The severity of anorexia correlates with the presence of early satiety. The sense of fullness limits nutritional intake. The symptom is poorly understood because most assessment questionnaires do not include early satiety.

The clinical effects of music therapy in palliative medicine.

Goal: This study was to objectively assess the effect of music therapy on patients with advanced disease.

Patients And Methods: Two hundred patients with chronic and/or advanced illnesses were prospectively evaluated. The effects of music therapy on these patients are reported.

Managing nonmalignant chronic abdominal pain and malignant bowel obstruction.

Evaluation of abdominal pain requires an understanding of the possible causes(benign or malignant) and recognition of typical patterns and clinical presentation. Abdominal pain has multiple causes; associated signs and symptoms may aid in the diagnosis. Remember that some patients will not have a textbook presentation, and unusual causes for pain must be considered.

Symptom clustering in advanced cancer.

A major goal of palliative medicine is to control symptoms that interfere with quality of life. Identification of symptoms that occur together (cluster) may aid in symptom management, resulting in greater therapeutic benefit to the patient. An analysis of 25 symptoms from 922 patients with advanced cancer was undertaken to determine if symptom clusters could be identified.

Symptom evaluation in palliative medicine: patient report vs systematic assessment.

Purpose: This study examined symptoms reported by patients after open-ended questioning vs those systematically assessed using a 48-question survey.

Materials And Methods: Consecutive patients referred to the palliative medicine program at the Cleveland Clinic Foundation were screened. Open-ended questions were asked initially followed by a 48-item investigator-developed symptom checklist.

The financial benefits of acute inpatient palliative medicine: an inter-institutional comparative analysis by all patient refined-diagnosis related group and case mix index.

Financial comparisons of acute care hospital services are possible using the Centers for Medicare & Medicaid Services case mix index (CMI) and All Patient Refined-Diagnosis Related Group (APR-DRG) data. We compared The Cleveland Clinic's Inpatient Palliative Medicine (CCIPM) acute care unit's CMI and APR-DRG data with national and peer institution data. Total mean charges per admission to the CCIPM unit were 7,800 dollars lower than at other peer institutions despite an equivalent severity of illness and longer length of stay and higher mortality in the CCIPM unit.

Look before leaping: combined opioids may not be the rave.

The use of combinations of potent opioids is a common clinical practice. The addition of one potent opioid to another has been recommended to reduce opioid side effects, improve pain control, and limit dose escalation of the first opioid. The advantages of using combined opioids have been reported to be relative to differences in receptor activation versus endocytosis (RAVE).

Opioid rotation in cancer patients: pros and cons.

Opioid rotation involves changing from one opioid to another using correct equianalgesic conversion techniques to achieve better analgesia and/or fewer side effects. The strategy appears to work because of significant interindividual variations in response to both analgesic activity and toxicity. Although there are many retrospective studies, few prospective controlled trials of opioid rotation have been published.

Palliation of heart failure.

Heart failure is the major cause of morbidity and mortality in the United States. Stage D heart failure has a greater mortality rate than many cancers and has equivalent symptom burden and severity. There has been a paradigm shift in our understanding of the pathophysiology of heart failure.

Common symptoms in advanced cancer.

The key points of this article are anorexia and cachexia are: A major cause of cancer deaths. Several drugs are available to treat anorexia and cachexia. Dyspnea in cancer usually is caused by several factors.

Integration of palliative medicine into comprehensive cancer care.

Because of the advent of disease-modifying agents for patients with malignancies, cancer is now a chronic illness. However, most cancer patients will experience significant symptoms and complications during the course of their illness or its treatment. In addition to their physical symptoms, patient and families are burdened with psychological, social, and spiritual difficulties.

Advances in opioid therapy and formulations.

Newly developed opioid analgesics and drug delivery systems may provide pain relief for patients intolerant of morphine. Long-acting oral opioids supply satisfactory analgesia at more convenient dosing intervals. Implantable pumps can provide full analgesic doses of opioids both subcutaneously and intrathecally over extended time periods.

Communication in palliative medicine: a pilot study of a problem list to capture complex medical information.

We developed a one-page, structured problem list to facilitate communication of complex patient information in palliative medicine. The problem list was developed to provide a concise record of the complex problems presented by patients with advanced disease. It was also seen as a mechanism to facilitate interdisciplinary and multidisciplinary communication and continuity of care in the hospital and in the community.

Opioid dose titration for severe cancer pain: a systematic evidence-based review.

Dosing strategies to achieve rapid analgesia in patients with severe or crescendo cancer pain are important. A systematic review of research trials for treatment of severe or crescendo cancer pain was conducted; nine studies were identified. Eight trials were prospective; two were randomized between different dosing strategies.

The business of palliative medicine--part 4: Potential impact of an acute-care palliative medicine inpatient unit in a tertiary care cancer center.

In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes.

Epidemiology of cancer pain and factors influencing poor pain control.

Pain is one of the most commonly experienced and feared symptoms of advanced cancer. Most cancer patients experience pain, usually of moderate to severe intensity, and most also have a number of distinct pains. The most common type of pain is related to bone metastases.

Oral morphine and respiratory function amongst hospice inpatients with advanced cancer.

Background: Respiratory depression is the opioid adverse effect feared most by physicians. This may hinder adequate dosing in cancer pain. The study was conducted to examine the respiratory function of patients with advanced cancer receiving significant doses (>100 mg/24 h) of oral morphine.

Evaluation of nutritional status in advanced metastatic cancer.

Consecutive cancer referrals to a palliative medicine program were evaluated to assess nutritional status using a standard protocol. The study included 352 patients (180 men, 172 women; median age 61 years, range 22-94 years). The most common diagnosis was lung cancer.

A syllabus for fellowship education in palliative medicine.

Recent years have seen significant growth in palliative medicine training programs and positions. There are plans to pursue palliative medicine specialty status with the American Board of Medical Specialties and accreditation of fellowship programs with the American College of Graduate Medical Education. A work group of program directors, supported initially by the Cleveland Clinic and then by the American Board of Hospice and Palliative Medicine, has recently published standards for fellowship training.

Olanzapine as an antiemetic in refractory nausea and vomiting in advanced cancer.

Nausea and vomiting are difficult symptoms to manage in patients with advanced cancer. Several classes of antiemetics are available, including phenothiazines, butyrophenones, substituted benzamides and selective serotonin antagonists, as well as corticosteroids. Most patients will respond to either single agents or combinations that frequently include corticosteroids.

Established and potential therapeutic applications of cannabinoids in oncology.

Cannabis occurs naturally in the dried flowering or fruiting tops of the Cannabis sativa plant. Cannabis is most often consumed by smoking marihuana. Cannabinoids are the active compounds extracted from cannabis.