Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:394–398. Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.959235
LATIN AMERICAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
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Assessment of Pain and Other Symptoms in Mexican Patients With Advanced Illness ´ Alfredo Covarrubias-Gomez, Eva E. Hern´andez-Mart´ınez, S. Ruiz-Ram´ırez, ´ and Maria Lopez Collada-Estrada AB STRACT Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. During this stage, several symptoms appear and contribute to a decrement in the quality of life. We performed a retrospective study evaluating medical records of terminally ill patients who attended a specialized pain and palliative medicine service. The Edmonton Symptom Assessment Scale (ESAS) was used to document symptoms intensity. Data analysis was carried out at two times: the initial assessment and the last visit before death. We analyzed thirty-eight cases of which 58% were women (22 cases) and the mean age of the sample was 60.7 years (SD: 15.6). All cases had an oncologic disease classified as end-stage cancer and were considered as palliative patients. Symptom intensity was documented by the ESAS in two different moments: pain 3.7 (SD: 3.2) vs. 4.1 (SD: 3.4), nausea 1.4 (SD: 3.2) vs. 1.8 (SD: 3.3), depression 3.4 (SD: 3.4) vs. 4.3 (SD: 3.7), anxiety 3 (SD: 3.5) vs. 2.4 (SD: 3.6), weakness 4.8 (SD: 3.5) vs. 6.2 (SD: 3.6), dyspnea 1.1 (SD: 2.7) vs. 2.8 (SD: 3.4), anorexia 3.5 (SD: 3.7) vs. 4.7 (SD: 3.8), and somnolence 2.6 (SD: 3.5) vs. 4.9 (SD: 3.5). Statistical significance was found in weakness, dyspnea, and somnolence. We found the ESAS a useful tool for symptom assessment. In this study, we document the prevalence of symptoms at the end of life in a Spanish-speaking country. Physicians trained in pain and palliative medicine managed those symptoms, and we observed that symptoms maintained the same intensity. There is the possibility that the intervention made by those clinicians modified the symptomatic outcome in those patients. Evaluation of effective protocols for symptom management at the end of life is needed. KEYWORDS end-stage disease, pain, palliative, symptoms
ness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.1 Advanced incurable diseases have an impact in the patient’s autonomy and quality of life. Towards the end of life a wide variety of symptoms may be present.2 The clinical manifestations of a terminal disease could have an emotional impact. Some of those may produce the loss of autonomy.2,3 During the “natural evolution” of a terminal disease, these symptoms may increase in intensity especially during the last 48 hours (agony) when an intense physical deterioration, extreme weakness, and cognitive disorders are present.4
INTRODUCTION Palliative care, as described by the World Health Organization (WHO), is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening ill´ Alfredo Covarrubias-Gomez, MD, Eva E. Hern´andez-Mart´ınez, MD, ´ S. Ruiz-Ram´ırez, MD, and M. Lopez Collada-Estrada, MD, are with the Department of Pain and Palliative Medicine, Instituto Nacional de Cien´ Salvador Zubir´an (National Institute for Medical cias M´edicas y Nutricion Sciences and Nutrition “Salvador Zubiran”), Mexico City. Address correspondence to: Alfredo Covarrubias-G´omez, MD, Department of Pain and Palliative Medicine, Instituto Nacional de Ciencias M´edicas y Nutrici´on Salvador Zubir´an, Vasco de Quiroga #15, Colonia Secci´on XVI, Tlalpan, Mexico City 14000, Mexico (E-mail: [email protected]).
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Latin American Perspectives on Pain and Palliative Care
Decrement in basic physiological functions would cause a wide variety of symptoms at the end of life.5 It has been reported that 60% to 80% of cancer patients in advanced stages may experience pain before death.5 Other symptoms that are frequently observed in terminal diseases are (i) weakness, (ii) anorexia, (iii) nausea, (iv) fatigue, (v) dyspnea, and (vi) delirium.6 In addition, distress, depression, and anxiety may be present.7 It has been estimated that 30% of these patients experience an “adjustment disorder,” whereas 10% to 25% might develop a major depressive disorder (MDD).8 In order to establish a standardized system that would allow the documentation of the symptoms by health care providers, Bruera and colleagues developed the Edmonton Symptom Assessment Scale (ESAS).8 This is a useful tool in which the intensity of different symptoms that are commonly present in advanced cancer are documented. It also provides quantitative measurements that might help health care providers throughout the decision-making process during the evolution of a terminal disease.9–13 The ESAS has been used in ambulatory and hospitalized patients, it is easy to apply, and some studies had documented that the patients report on symptoms intensity can be done by telephone.14 The symptoms that are included in this instrument are (i) pain, (ii) weakness, (iii) nausea, (iv) depression, (v) anxiety, (vi) drowsiness, (vii) anorexia, (viii) well-being, (ix) dyspnea, and (x) constipation. The patient scores the intensity of any of these symptoms in a 0 to 10 scale.10–13 In Mexico, the inclusion of “palliative care” in the federal legislation occurred in 2009. Before that year, the country had a scarce number of these medical services. In addition, considering the “palliative care” settings, there was a practical inexistent number of specialized nurses, rehabilitators, pharmacists, and psychologists. Since clinical and epidemiological research about this subject is limited in Mexico, information about appropriate therapeutic strategies are in need. This report aims to assess the intensity of symptoms using the Edmonton Symptom Assessment Scale (ESAS) in Mexican terminally ill patients attending a pain and palliative medicine specialized service.
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pitalized patients who were attended in a specialized pain and palliative medicine department. Symptoms were documented from these ambulatory patients using the ESAS. Data extraction considered two different moments for analysis: (i) the initial assessment and (ii) the last visit before the patient’s death. Cases on which delirium was documented or with incomplete information were excluded from the study.
Selection Criteria Information from clinical records was registered. Inclusion criteria considered information from patients with terminal cancer, 18 years old or older, and either male or female. Exclusion criteria considered those records without ESAS evaluation, with incomplete information, and those with only one evaluation before the subject’s death.
Study Variables Pain intensity. The magnitude of an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It was measured using a visual analogue scale (VAS) from 0 to 10 (where 0 corresponds to “no pain” and 10 to “the worst pain imaginable”). Type of pain. This is a categorical variable that classifies pain according to its origin: somatic (originated from the musculoskeletal system), visceral (originated from solid or hollow viscera), and neuropathic (caused by injury or disease somatosensory system).15 Intensity of other symptoms associated with the disease. Intensity of other symptoms associated with the disease was assessed using the Edmonton Symptom Assessment Scale (ESAS). This tool uses a visual analogue scale (VAS) to evaluate the magnitude of a given symptom: (i) pain, (ii) weakness, (iii) nausea, (iv) depression, (v) anxiety, (vi) drowsiness, (vii) anorexia, (viii) well-being, (ix) dyspnea, and (x) constipation. The patient scores the intensity of any of these symptoms in a 0 to 10 scale). Characteristics of the study population. We documented the age, gender, type of malignancy (cancer type), and number of visits for medical attention.
Statistical Analysis
MATERIALS AND METHODS Design We performed a retrospective study on which we assessed the clinical records of terminally ill, nonhos C
2014 Informa Healthcare USA, Inc.
The results were reported using descriptive statistics and tendencies distributions. Whenever it was possible, a Student t test and/or Pearson correlations were performed for parametric variables and chi-square test and/or Spearman correlations were performed for nonparametric variables.
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JOURNAL OF PAIN & PALLIATIVE CARE PHARMACOTHERAPY
TABLE 1.
Characteristics of the Studied Patients (N = 38)
Pain Intensity
Variable
n
%
Women Men
22 16 Average
57.9 42.1 SD
61 4
15.6 2.6
Age (years) Number of consultations
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RESULTS General Characteristics of the Study Sample Seventy-one possible cases of ambulatory patients for analysis were identified. Thirty-one of those cases (44%) were excluded because they sought medical attention in only one occasion. Two more cases (3%) were excluded because a cognitive impairment was documented during the first visit. This study reports the information obtained from 38 cases. Of the 38 selected cases, 22 were female (58%), the mean age was 60.7 years (minimum 30 years and maximum 90 years, SD: 15.6), and the mean number of visits was 4 (minimum 2 and maximum 10, SD: 2.6) (Table 1). The type of neoplasm was categorized in two variables: (i) hematologic neoplasm (3 cases, 8%) and (ii) solid tumors (35 cases, 92%). All the cases of hematologic neoplasm were leukemia (100%). Of solid tumors, the frequencies were as follows: (i) 63% gastrointestinal tumors (24 cases), 11% renal tumors (4 cases), 5% prostate tumors (2 cases), and 21% other types of tumors (8 cases).
TABLE 2.
When patients were asked about the presence of pain, we found out that 71% reported this symptom during their first visit to the pain and palliative medicine department (27 cases); on the other hand, 79% manifested its presence in their last visit (30 cases). No statistical differences were observed. Most (89%) of the subjects with pain required an opioid analgesic drug in their last visit (27 of 30 cases). Morphine was prescribed in 18 patients (60% of the patients with pain during the last visit). In those with pain, the main morphine daily dose prescribed during the last visit was 17 mg (SD: 41.5). The severity of pain measured with the VAS reported a main value of 3.7 (SD: 3.2) in the first visit and 4.1 (SD: 3.4) during the last visit. No statistical differences were observed (Table 2). The type of pain was grouped as follows: 63% had visceral pain (24 cases), 16% somatic (6 cases), and neuropathic 8% (3 cases).
Intensity of Other Symptoms We used the ESAS to document the presence and intensity of other symptoms both on the first and last medical visitations. With that instrument the following results were documented: nausea 1.4 (SD: 3.2) vs. 1.8 (SD: 3.3), depression 3.4 (SD: 3.4) vs. 4.3 (SD: 3.7), anxiety 3 (SD: 3.5) vs. 2.4 (SD: 3.6), weakness 4.8 (SD: 3.5) vs. 6.2 (SD: 3.6), dyspnea 1.1 (SD: 2.7) vs. 2.8 (SD: 3.4), anorexia 3.5 (SD: 3.7) vs. 4.7 (SD: 3.8), dry mouth 1.3 (SD: 2.5) vs. 2.5 (SD: 3.5), and somnolence 2.6 (SD: 3.5) vs. 4.9 (SD:
Symptom Assessment Using the ESAS (N = 38) Visual analogue scale (VAS) First visit
Symptom Pain Nausea Depression Anxiety Weakness Dyspnea Anorexia Dry mouth Somnolence
Last Visit
Main value
SD
Main value
SD
P value (Student t)
3.7 1.4 3.4 3 4.8 1.1 3.5 1.3 2.6
3.2 3.2 3.4 3.5 3.5 2.7 3.7 2.5 3.5
4.1 1.8 4.3 2.4 6.2 2.8 4.7 2.5 4.9
3.4 3.3 3.7 3.6 3.6 3.4 3.8 3.5 3.5
NS NS NS NS .043∗ .011∗ NS NS .002∗
The table shows the score that was provided by the patients during their visit to an specialized pain and palliative medicine department using the ESAS (Edmonton Symptom Assessment Scale). Scores are expressed as mean value and standard deviation (SD) during the first visit and the visit before death. ∗ Statistical significance were found for dyspnea (Student t, df = 37, P = .011), somnolence (Student t, df = 37, P = .002), and weakness (Student t, df = 37, P = .037). NS = nonsignificance.
Journal of Pain & Palliative Care Pharmacotherapy
Latin American Perspectives on Pain and Palliative Care
3.5). Eight cases reported constipation (21%). Dyspnea, somnolence, and weakness presented significant statistical differences (dyspnea: Student t, df = 37, P = .011; sleepiness: Student t, df = 37, P = .002; and weakness: Student t, df = 37, P = .037) (Table 2).
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DISCUSSION In this study, we analyzed a total of 38 cases. Since reports of patients during the last days of life present methodological difficulties, the generation of research lines is in need. Our study considered a sample of patients in the terminal stage of an oncologic disease in a Latin American country. The studied sample was conformed predominantly by women (58% of the sample). This could be related to (i) institutional biases,16 (ii) the distribution of oncologic pathologies according to gender,17,18 or (iii) that the distribution of Latin American women that receive medical attention is superior to men. Most of our patients were 60 years or older. We considered for that finding an inversion of the population pyramid that had been documented in most countries (including Mexico and some Latin American countries)19 or institutional biases. We observed a high prevalence of solid gastrointestinal tumors; this finding is related to the characteristics of the population that is attended in the medical setting where the study was carried out. This is also an important finding because its presence might lead to serious complications at the end of life (i.e., bowel obstruction). Seven out of 10 patients showed pain during their first visit, and 8 out of 10 did so in their last visit. Cancer pain at the end of life is a common feature. The progression of the disease promotes an increase in its intensity. Most of these patients reach out for a palliative care service at an advanced stage of their disease. Those elements strongly suggest the need to establish protocols for early medical attention for this group of patients. The severity of pain presented no statistical differences in this report. This called our attention because 9 out of 10 patients received opiod analgesic therapy during their last visit and because the mean intensity did not exceeded a value of 4 points, which could be considered as mild pain intensity. One of our weaknesses in this study is that we couldn’t find in the clinical records if the pain was considered as “controlled” or “bearable.” We need more studies focus on different pain variables in a prospective way. The fact that most of the symptoms evaluated using the ESAS hadn’t presented statistical differences
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between the first and the last visit in an outpatient setting reflects the possible usefulness of a specialized palliative care service. The intervention of palliative clinicians may promote that symptoms might be bearable or controlled with low intensities. Weakness, somnolence, and dyspnea were symptoms with statistical differences, and this finding reflects the necessity of more intensive protocols that promote a more effective palliation. Further studies are needed in order to provide sufficient evidence about the prevalence of symptoms in this population. Knowledge about the prevalence of symptoms and their intensities will help Latin American clinicians to elaborate effective guidelines for an optimal management of patients at the end of life.19 Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES [1] Hui D, De La Cruz M, Mori M, et al. Concepts and definitions for “supportive care,” “best supportive care,” “palliative care,” and “hospice care” in the published literature, dictionaries, and textbooks. Support Care Cancer. 2013;21:659–85. [2] Twycross RG. Palliative care: an international necessity. J Pain Palliat Care Pharmacother. 2002;16:61–79. [3] Twycross R. Symptom management algorithms in palliative care. Am J Hosp Palliat Care. 1999;16:701–704. [4] Englert M, Ronson A, Lossignol D, Body JJ. Terminal medical interventions: psychosocial, medical, ethical and legal aspects]. Rev Med Brux. 2001;22:93–99. [5] WHO Expert Committee. Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee. Technical Report Series 804. Geneva: World Health Organization; 1990. [6] Brandt HE, Ooms ME, Deliens L, van der Wal G, Ribbe MW. The last two days of life of nursing home patients—a nationwide study on causes of death and burdensome symptoms in The Netherlands. Palliat Med. 2006;20:533–540. [7] Carvajal A, Duarte E. The Spanish Version of the Edmonton Symptom Assessment System—Revised (ESAS-r): first psychometric analysis involving patients with advanced cancer. J Pain Symptom Manage. 2013;45:129–136. [8] Bruera E, MacDonald S. Audit methods: the Edmonton Symptom Assessment System. In: Higginson I, ed. Clinical Audit in Palliative Care. Oxford, UK: Radcliffe Medical Press; 1993:61–77. [9] Carvajal-Valc´arcela A, Mart´ınez-Garc´ıa M, Centeno-Cort´es ´ espanola ˜ C. Version del Edmonton Symptom Assessment Sytem (ESAS): un instrumento de referencia para la valo´ sintom´atica del paciente con c´ancer avanzado. Med Paliat. racion 2013;20:143–149. [10] Bruera E, Kuehn N, Miller M, Selmser P, MacMillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 1991;7:6–9. [11] Carvajal A. Centeno C, Bruera E. A comprehensive study of psychometric properties of the Edmonton Symptom
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[12]
[13]
[14]
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JOURNAL OF PAIN & PALLIATIVE CARE PHARMACOTHERAPY Assessment System (ESAS) in Spanish advanced cancer patients. Eur J Cancer. 2011;47:1863–1872. Nekolaichuk C. The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991–2006). Palliat Med. 2008;22:111–122. Tassinari D, Montanari L, Maltoni M, et al. The palliative prognostic score and survival in patients with advanced solid tumors receiving chemotherapy. Support Care Cancer. 2008;16:359–370. Juli˜ao M, Barbosa A, Oliveira F, Nunes B. Prevalence and factors associated with desire for death in patients with advanced disease: results from a Portuguese cross-sectional study. Psychosomatics. 2013;54:451–457. Carli Buttenschoen D, Stephan J, Watanabe S, Nekolaichuk C. Health care providers’ use and knowledge of the Edmonton Symptom Assessment System (ESAS): is there a need
[16]
[17]
[18]
[19]
to improve information and training? Support Care Cancer. 2014;22:201–208. Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain. 1979;6:249. ´ ´ Covarrubias-Gomez A, Guevara-Lopez U, Lara-Solares A, Tamayo-Valenzuela AC, Salinas-Cruz J, Torres-Gonz´alez R. Clinical pattern of patients cared for at pain clinic by first time. Rev Med Inst Mex Seguro Soc. 2008;46:467–472. Vogelzang N, Benowitz S, Adamas S. Clinical Cancer Advances 2011: Annual Report on Progress Against Cancer From the American Society of Clinical Oncology. J Clin Oncol. 2012;30:88–109. Goss PE, Lee BL, Badovinac-Crnjevic T, et al. Planning cancer control in Latin America and the Caribbean. Lancet Oncol. 2013;14:391–436.
Journal of Pain & Palliative Care Pharmacotherapy
LATIN AMERICAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
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Assessment of Pain and Other Symptoms in Mexican Patients With Advanced Illness ´ Alfredo Covarrubias-Gomez, Eva E. Hern´andez-Mart´ınez, S. Ruiz-Ram´ırez, ´ and Maria Lopez Collada-Estrada AB STRACT Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. During this stage, several symptoms appear and contribute to a decrement in the quality of life. We performed a retrospective study evaluating medical records of terminally ill patients who attended a specialized pain and palliative medicine service. The Edmonton Symptom Assessment Scale (ESAS) was used to document symptoms intensity. Data analysis was carried out at two times: the initial assessment and the last visit before death. We analyzed thirty-eight cases of which 58% were women (22 cases) and the mean age of the sample was 60.7 years (SD: 15.6). All cases had an oncologic disease classified as end-stage cancer and were considered as palliative patients. Symptom intensity was documented by the ESAS in two different moments: pain 3.7 (SD: 3.2) vs. 4.1 (SD: 3.4), nausea 1.4 (SD: 3.2) vs. 1.8 (SD: 3.3), depression 3.4 (SD: 3.4) vs. 4.3 (SD: 3.7), anxiety 3 (SD: 3.5) vs. 2.4 (SD: 3.6), weakness 4.8 (SD: 3.5) vs. 6.2 (SD: 3.6), dyspnea 1.1 (SD: 2.7) vs. 2.8 (SD: 3.4), anorexia 3.5 (SD: 3.7) vs. 4.7 (SD: 3.8), and somnolence 2.6 (SD: 3.5) vs. 4.9 (SD: 3.5). Statistical significance was found in weakness, dyspnea, and somnolence. We found the ESAS a useful tool for symptom assessment. In this study, we document the prevalence of symptoms at the end of life in a Spanish-speaking country. Physicians trained in pain and palliative medicine managed those symptoms, and we observed that symptoms maintained the same intensity. There is the possibility that the intervention made by those clinicians modified the symptomatic outcome in those patients. Evaluation of effective protocols for symptom management at the end of life is needed. KEYWORDS end-stage disease, pain, palliative, symptoms
ness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.1 Advanced incurable diseases have an impact in the patient’s autonomy and quality of life. Towards the end of life a wide variety of symptoms may be present.2 The clinical manifestations of a terminal disease could have an emotional impact. Some of those may produce the loss of autonomy.2,3 During the “natural evolution” of a terminal disease, these symptoms may increase in intensity especially during the last 48 hours (agony) when an intense physical deterioration, extreme weakness, and cognitive disorders are present.4
INTRODUCTION Palliative care, as described by the World Health Organization (WHO), is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening ill´ Alfredo Covarrubias-Gomez, MD, Eva E. Hern´andez-Mart´ınez, MD, ´ S. Ruiz-Ram´ırez, MD, and M. Lopez Collada-Estrada, MD, are with the Department of Pain and Palliative Medicine, Instituto Nacional de Cien´ Salvador Zubir´an (National Institute for Medical cias M´edicas y Nutricion Sciences and Nutrition “Salvador Zubiran”), Mexico City. Address correspondence to: Alfredo Covarrubias-G´omez, MD, Department of Pain and Palliative Medicine, Instituto Nacional de Ciencias M´edicas y Nutrici´on Salvador Zubir´an, Vasco de Quiroga #15, Colonia Secci´on XVI, Tlalpan, Mexico City 14000, Mexico (E-mail: [email protected]).
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Latin American Perspectives on Pain and Palliative Care
Decrement in basic physiological functions would cause a wide variety of symptoms at the end of life.5 It has been reported that 60% to 80% of cancer patients in advanced stages may experience pain before death.5 Other symptoms that are frequently observed in terminal diseases are (i) weakness, (ii) anorexia, (iii) nausea, (iv) fatigue, (v) dyspnea, and (vi) delirium.6 In addition, distress, depression, and anxiety may be present.7 It has been estimated that 30% of these patients experience an “adjustment disorder,” whereas 10% to 25% might develop a major depressive disorder (MDD).8 In order to establish a standardized system that would allow the documentation of the symptoms by health care providers, Bruera and colleagues developed the Edmonton Symptom Assessment Scale (ESAS).8 This is a useful tool in which the intensity of different symptoms that are commonly present in advanced cancer are documented. It also provides quantitative measurements that might help health care providers throughout the decision-making process during the evolution of a terminal disease.9–13 The ESAS has been used in ambulatory and hospitalized patients, it is easy to apply, and some studies had documented that the patients report on symptoms intensity can be done by telephone.14 The symptoms that are included in this instrument are (i) pain, (ii) weakness, (iii) nausea, (iv) depression, (v) anxiety, (vi) drowsiness, (vii) anorexia, (viii) well-being, (ix) dyspnea, and (x) constipation. The patient scores the intensity of any of these symptoms in a 0 to 10 scale.10–13 In Mexico, the inclusion of “palliative care” in the federal legislation occurred in 2009. Before that year, the country had a scarce number of these medical services. In addition, considering the “palliative care” settings, there was a practical inexistent number of specialized nurses, rehabilitators, pharmacists, and psychologists. Since clinical and epidemiological research about this subject is limited in Mexico, information about appropriate therapeutic strategies are in need. This report aims to assess the intensity of symptoms using the Edmonton Symptom Assessment Scale (ESAS) in Mexican terminally ill patients attending a pain and palliative medicine specialized service.
395
pitalized patients who were attended in a specialized pain and palliative medicine department. Symptoms were documented from these ambulatory patients using the ESAS. Data extraction considered two different moments for analysis: (i) the initial assessment and (ii) the last visit before the patient’s death. Cases on which delirium was documented or with incomplete information were excluded from the study.
Selection Criteria Information from clinical records was registered. Inclusion criteria considered information from patients with terminal cancer, 18 years old or older, and either male or female. Exclusion criteria considered those records without ESAS evaluation, with incomplete information, and those with only one evaluation before the subject’s death.
Study Variables Pain intensity. The magnitude of an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It was measured using a visual analogue scale (VAS) from 0 to 10 (where 0 corresponds to “no pain” and 10 to “the worst pain imaginable”). Type of pain. This is a categorical variable that classifies pain according to its origin: somatic (originated from the musculoskeletal system), visceral (originated from solid or hollow viscera), and neuropathic (caused by injury or disease somatosensory system).15 Intensity of other symptoms associated with the disease. Intensity of other symptoms associated with the disease was assessed using the Edmonton Symptom Assessment Scale (ESAS). This tool uses a visual analogue scale (VAS) to evaluate the magnitude of a given symptom: (i) pain, (ii) weakness, (iii) nausea, (iv) depression, (v) anxiety, (vi) drowsiness, (vii) anorexia, (viii) well-being, (ix) dyspnea, and (x) constipation. The patient scores the intensity of any of these symptoms in a 0 to 10 scale). Characteristics of the study population. We documented the age, gender, type of malignancy (cancer type), and number of visits for medical attention.
Statistical Analysis
MATERIALS AND METHODS Design We performed a retrospective study on which we assessed the clinical records of terminally ill, nonhos C
2014 Informa Healthcare USA, Inc.
The results were reported using descriptive statistics and tendencies distributions. Whenever it was possible, a Student t test and/or Pearson correlations were performed for parametric variables and chi-square test and/or Spearman correlations were performed for nonparametric variables.
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TABLE 1.
Characteristics of the Studied Patients (N = 38)
Pain Intensity
Variable
n
%
Women Men
22 16 Average
57.9 42.1 SD
61 4
15.6 2.6
Age (years) Number of consultations
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RESULTS General Characteristics of the Study Sample Seventy-one possible cases of ambulatory patients for analysis were identified. Thirty-one of those cases (44%) were excluded because they sought medical attention in only one occasion. Two more cases (3%) were excluded because a cognitive impairment was documented during the first visit. This study reports the information obtained from 38 cases. Of the 38 selected cases, 22 were female (58%), the mean age was 60.7 years (minimum 30 years and maximum 90 years, SD: 15.6), and the mean number of visits was 4 (minimum 2 and maximum 10, SD: 2.6) (Table 1). The type of neoplasm was categorized in two variables: (i) hematologic neoplasm (3 cases, 8%) and (ii) solid tumors (35 cases, 92%). All the cases of hematologic neoplasm were leukemia (100%). Of solid tumors, the frequencies were as follows: (i) 63% gastrointestinal tumors (24 cases), 11% renal tumors (4 cases), 5% prostate tumors (2 cases), and 21% other types of tumors (8 cases).
TABLE 2.
When patients were asked about the presence of pain, we found out that 71% reported this symptom during their first visit to the pain and palliative medicine department (27 cases); on the other hand, 79% manifested its presence in their last visit (30 cases). No statistical differences were observed. Most (89%) of the subjects with pain required an opioid analgesic drug in their last visit (27 of 30 cases). Morphine was prescribed in 18 patients (60% of the patients with pain during the last visit). In those with pain, the main morphine daily dose prescribed during the last visit was 17 mg (SD: 41.5). The severity of pain measured with the VAS reported a main value of 3.7 (SD: 3.2) in the first visit and 4.1 (SD: 3.4) during the last visit. No statistical differences were observed (Table 2). The type of pain was grouped as follows: 63% had visceral pain (24 cases), 16% somatic (6 cases), and neuropathic 8% (3 cases).
Intensity of Other Symptoms We used the ESAS to document the presence and intensity of other symptoms both on the first and last medical visitations. With that instrument the following results were documented: nausea 1.4 (SD: 3.2) vs. 1.8 (SD: 3.3), depression 3.4 (SD: 3.4) vs. 4.3 (SD: 3.7), anxiety 3 (SD: 3.5) vs. 2.4 (SD: 3.6), weakness 4.8 (SD: 3.5) vs. 6.2 (SD: 3.6), dyspnea 1.1 (SD: 2.7) vs. 2.8 (SD: 3.4), anorexia 3.5 (SD: 3.7) vs. 4.7 (SD: 3.8), dry mouth 1.3 (SD: 2.5) vs. 2.5 (SD: 3.5), and somnolence 2.6 (SD: 3.5) vs. 4.9 (SD:
Symptom Assessment Using the ESAS (N = 38) Visual analogue scale (VAS) First visit
Symptom Pain Nausea Depression Anxiety Weakness Dyspnea Anorexia Dry mouth Somnolence
Last Visit
Main value
SD
Main value
SD
P value (Student t)
3.7 1.4 3.4 3 4.8 1.1 3.5 1.3 2.6
3.2 3.2 3.4 3.5 3.5 2.7 3.7 2.5 3.5
4.1 1.8 4.3 2.4 6.2 2.8 4.7 2.5 4.9
3.4 3.3 3.7 3.6 3.6 3.4 3.8 3.5 3.5
NS NS NS NS .043∗ .011∗ NS NS .002∗
The table shows the score that was provided by the patients during their visit to an specialized pain and palliative medicine department using the ESAS (Edmonton Symptom Assessment Scale). Scores are expressed as mean value and standard deviation (SD) during the first visit and the visit before death. ∗ Statistical significance were found for dyspnea (Student t, df = 37, P = .011), somnolence (Student t, df = 37, P = .002), and weakness (Student t, df = 37, P = .037). NS = nonsignificance.
Journal of Pain & Palliative Care Pharmacotherapy
Latin American Perspectives on Pain and Palliative Care
3.5). Eight cases reported constipation (21%). Dyspnea, somnolence, and weakness presented significant statistical differences (dyspnea: Student t, df = 37, P = .011; sleepiness: Student t, df = 37, P = .002; and weakness: Student t, df = 37, P = .037) (Table 2).
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DISCUSSION In this study, we analyzed a total of 38 cases. Since reports of patients during the last days of life present methodological difficulties, the generation of research lines is in need. Our study considered a sample of patients in the terminal stage of an oncologic disease in a Latin American country. The studied sample was conformed predominantly by women (58% of the sample). This could be related to (i) institutional biases,16 (ii) the distribution of oncologic pathologies according to gender,17,18 or (iii) that the distribution of Latin American women that receive medical attention is superior to men. Most of our patients were 60 years or older. We considered for that finding an inversion of the population pyramid that had been documented in most countries (including Mexico and some Latin American countries)19 or institutional biases. We observed a high prevalence of solid gastrointestinal tumors; this finding is related to the characteristics of the population that is attended in the medical setting where the study was carried out. This is also an important finding because its presence might lead to serious complications at the end of life (i.e., bowel obstruction). Seven out of 10 patients showed pain during their first visit, and 8 out of 10 did so in their last visit. Cancer pain at the end of life is a common feature. The progression of the disease promotes an increase in its intensity. Most of these patients reach out for a palliative care service at an advanced stage of their disease. Those elements strongly suggest the need to establish protocols for early medical attention for this group of patients. The severity of pain presented no statistical differences in this report. This called our attention because 9 out of 10 patients received opiod analgesic therapy during their last visit and because the mean intensity did not exceeded a value of 4 points, which could be considered as mild pain intensity. One of our weaknesses in this study is that we couldn’t find in the clinical records if the pain was considered as “controlled” or “bearable.” We need more studies focus on different pain variables in a prospective way. The fact that most of the symptoms evaluated using the ESAS hadn’t presented statistical differences
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between the first and the last visit in an outpatient setting reflects the possible usefulness of a specialized palliative care service. The intervention of palliative clinicians may promote that symptoms might be bearable or controlled with low intensities. Weakness, somnolence, and dyspnea were symptoms with statistical differences, and this finding reflects the necessity of more intensive protocols that promote a more effective palliation. Further studies are needed in order to provide sufficient evidence about the prevalence of symptoms in this population. Knowledge about the prevalence of symptoms and their intensities will help Latin American clinicians to elaborate effective guidelines for an optimal management of patients at the end of life.19 Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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