Original Article American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(3) 335-340 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114520715 ajhpm.sagepub.com
Symptoms Other Than Pain in Palliative Care in Portugal Ferraz Gonc¸alves, MD, MSc, PhD1, Ana Almeida, MSc1, Catarina Antunes2, Maria Cardoso, MD3, Margarida Carvalho, MD4, Maria Claro, MD5, Francisca Coimbra6, Ineˆs Diniz2, Bruno Fonseca5, Emı´lia Fradique7, Edna Gonc¸alves, MD, MSc8, Florbela Gonc¸alves, MD9, Maria Gonc¸alves4, Ame´rico Magalha˜es, MD10, Paulo Pina, MD6, Conceic¸a˜o Pires, MD8, Paula Silva, MD, MSc1, Ricardo Silva3, Rui Silva, MD9, Filipa Tavares, MD7, and Laura Teixeira10
Abstract Objective: To study the burden of patients’ symptoms other than pain and their treatment by Portuguese palliative care teams. Methods: Of the 21 Portuguese palliative care teams identified, 10 accepted to participate. Data from all patients observed on the 18th week of 2011 were collected. Results: One hundred and sixty-four patients were included in this study. One hundred and fifty-one patients (92%) had cancer. The patients’ median age was 71 years (16-95) and 84 (51%) were females. The main symptoms were fatigue (116 [85%]) and depression/sadness (107 [65%]). Many different drugs were used for symptom control and other aims. Symptoms and drugs used here are similar to those practiced in other countries. Conclusion: The practice of palliative care in Portugal seems to be similar to those in other countries. Keywords palliative care, symptoms other than pain, symptom control, nonphysical problems, psychological problems, existential problems
Introduction Palliative care began in Portugal some years after other European countries started practicing. The first team started working in 1994 as an inpatient palliative care service belonging to the Portuguese Institute of Oncology—Porto.1 Since then, the number of teams increased slowly. In 2000, the European Association for Palliative Care carried out a cross-sectional survey of European centers, and at that time only 3 Portuguese centers had operational palliative care teams.2 Now there are around 25 teams working around the country, which is still insufficient to the needs of the more than 10,000,000 people living in Portugal now. There are plans for improvement, and the number of palliative care teams is expected to increase in the next few years. There is little evidence regarding the activity of the Portuguese palliative care teams, their professionals, the activities carried out, the patients treated, such as their demographic data, diagnosis, and symptoms/problems and how they are treated and by whom. In an attempt to collect these data, a crosssectional survey was carried out involving all teams that wished to participate. One of the most important aspects of the roles of palliative care teams is to detect, assess, and control
physical and nonphysical problems/symptoms as patients with advanced cancer and other chronic diseases monitored by
1
Department of Palliative Care, Instituto Portugueˆs de Oncologia, Porto, Portugal 2 Department of Palliative Care, Hospital do Mar, Lisboa, Portugal 3 Department of Palliative Care, Centro Hospitalar Lisboa Central, Lisboa, Portugal 4 Department of Palliative Care, Hospital do Litoral Alentejano, Santiago do Cace´m, Portugal 5 Department of Palliative Care, Unidade Local de Sau´de de Matosinhos, Matosinhos, Portugal 6 Department of Palliative Care, Instituto Portugueˆs de Oncologia, Lisboa, Lisboa, Portugal 7 Department of Palliative Care, Hospital de St. Maria, Lisboa, Portugal 8 Department of Palliative Care, Centro Hospitalar de S. Joa˜o, Porto, Portugal 9 Department of Palliative Care, Instituto Portugueˆs de Oncologia, Coimbra, Coimbra, Portugal 10 Department of Palliative Care, Centro Hospitalar de Tra´s-os-Montes e Alto Douro, Vila Real, Portugal Corresponding Author: Ferraz Gonc¸alves, PhD, Unidade de Cuidados Paliativos, Instituto Portugueˆs de Oncologia, 4200-072 Porto, Portugal. Email: [email protected]
336 palliative care teams often have multiple problems/symptoms.3 In the survey, a large amount of data were collected on the different aspects of the teams’ activity. This article focuses on this important aspect of care, the burden of patients’ symptoms other than pain, adding that information to the international palliative care community.
Methods Twenty-one Portuguese palliative care teams identified at the beginning of 2011 through the Portuguese Association for Palliative Care website and through the Portuguese Continuous Care Network website were invited to participate in the survey. A questionnaire was prepared based on the study carried out by the European Association for Palliative Care in 2000.2 The questionnaire was sent to 10 of the 21 palliative care teams that agreed to participate in the survey for evaluation. A new questionnaire was designed with the suggestions received, and this was circulated for a final revision and face validity. For the selection of the symptom, the same general method was used. Data were collected from all patients seen on the 18th week of 2011. Each team filled in the questionnaire with the data from all patients (in the first encounter or in follow-up) seen each day of that week. The assessment was assisted by the professionals to include all patients who accepted to participate. One day of that week was allocated for possible team activity (inpatient unit, intrahospital team, outpatient clinic, and home care). The activity for each day of the week was previously determined by the study coordinator and was the same for all teams. Data were collected by the researchers at each center from all patients seen on that day and who had agreed to participate. The data collected concerning symptoms were demographic data, main diagnosis, symptoms and other problems, drugs given, and other techniques for symptom control. Survival prediction was clinical, as it seems to be a reliable method.4 The intensity of symptoms in the previous 24 hours was rated using a 5-point verbal rating scale: none, mild, moderate, severe, and maximum; but for statistical analysis, we divided the intensity of the symptoms into 2 groups as none or mild and moderate to maximum in order to divide patients between clinically nonsignificant intensity and clinically significant intensity. Patients with cognitive failure were assessed by the researchers. Drugs used in less than 5 patients were classified as other. An initial analysis was performed for statistical purposes to identify coding errors, inconsistencies, and the presence of missing categories or small numbers, and corrections were made where needed. Missing data were omitted, an approach usually called listwise deletion or complete case analysis. The variables were analyzed by proportions and means. To evaluate the existence or not of associations between categorical variables, the chi-square test was used. When the numbers were small, the values were calculated using the Monte Carlo simulation.5 The level of significance was deemed to be 0.05. SPSS version 19.0 statistical software was used to analyze the data. The study was approved by the ethics committees and authorized by the board of directors at each center.
American Journal of Hospice & Palliative Medicine® 32(3) Table 1. Diagnoses. No.(%) Diagnosis Cancer Neurological Respiratory AIDS Renal Hepatic Postoperative complications Undefined
151 6 2 1 1 1 1 1
(92.1) (3.7) (1.2) (0.6) (0.6) (0.6) (0.6) (0.6)
Results One hundred and sixty-four patients were included in this study without any refusal. The median number of patients per team was 15.5 (4-32). One hundred and fifty-one (92%) had cancer (Table 1). The patients’ median age was 71 years (16-95), and 84 (51%) were females. Other demographic data were presented elsewhere.6,7 Symptoms were directly assessed in 136 (83%) of the patients, whereas 28 patients could not report their symptoms due to cognitive failure. The main symptoms in the patients who could be assessed directly was (the severe to maximum [SM] intensity percentage is calculated for each symptom) fatigue 116 (85%), SM 43 (37%); depression/sadness 107 (65%), SM 34 (31%); anxiety 84 (51%), SM 21 (25%); and anorexia 84 (51%), SM 19 (23%) (Table 2). Although pain was not the focus of this article, Table 2 includes pain for the comparison of pain prevalence with other symptoms. There were no significant differences in the frequency of moderate to maximum symptom intensity in relation to sex. Dividing patients by the median age (71 years), no significant differences in symptoms were reported in the 2 age-groups. Comparing inpatients with outpatients, significant differences were observed in the following symptoms: dyspnea, with only 1 (2%) of 42 outpatients versus 18 (19%) of 93 inpatients with at least moderate dyspnea (P ¼ .007); and nausea, with 1 (2%) of 42 outpatients versus 14 (15%) of 92 inpatients with at least moderate nausea (P ¼ .037). Patients with cognitive failure were observed for signs of discomfort by the researcher: 7 (25%) had no signs of discomfort; 11 (39%) had mild signs of discomfort; 8 (29%) moderate; 2 (7%) severe; and 0 maximum. Other physical problems were pressure sores—31 (19%); neoplastic wounds—25 (15%); ascites—23 (14%); pleural effusion—18 (11%); and lymphedema—13 (8%). Indwelling catheters were the most common devices used. Feeding tubes were also used, mainly in patients with head and neck diseases and also in patients with neurological diseases (Table 3). Other problems reported were lack of support—36 (26%); loneliness—28 (21%); nonacceptance of the disease—39 (29%); existential—40 (29%); and other—16 (12%). The differences in the frequency of these problems among teams were significant for lack of support (P ¼ .009) and existential problems (P < .001) and nonsignificant for loneliness and nonacceptance.
Gonc¸alves et al
337
Table 2. Main Symptom Prevalence. Symptom Fatigue Depression/sadness Anxiety Anorexia Pain Somnolence Constipation Dyspnea Insomnia Nausea Vomiting
Mild, no. (%)a 28 35 31 34 42 37 31 24 14 11 6
(24) (33) (37) (40) (55) (52) (55) (56) (35) (42) (50)
Moderate, no. (%)a 45 38 32 31 25 23 16 14 18 9 3
(39) (36) (38) (37) (32) (32) (29) (33) (45) (35) (25)
Severe, no (%)a
Maximum, no. (%)a
35 (30) 24 (22) 19 (23) 16 (19) 9 (12) 9 (13) 7 (13) 5 (12) 7 (18) 6 (23) 3 (25)
8 (7) 10 (9) 2 (2) 3 (4) 1 (1) 2 (3) 2 (4) 0 1 (3) 0 0
Total, no. (%) 116 107 84 84 77 71 56 43 40 26 12
(85) (78) (61) (61) (57) (52) (41) (31) (29) (19) (9)
a
Percentage for the symptom.
Table 3. Other Issues. No. (%) Pressure ulcers Indwelling catheter Neoplastic wounds Ascites Pleural effusion Lymphedema Nasogastric tube Gastrostomy Tracheostomy Colostomy Bowel obstruction Jejunostomy Nephrostomy
31 31 25 23 18 13 13 8 8 7 5 2 2
(19) (19) (15) (14) (11) (8) (8) (5) (5) (4) (3) (1) (1)
The prevalence of existential problems by team varied between 0% and 75%. Drugs used for treatment of symptoms excluding pain, which is described elsewhere,5 are very varied (Table 4). For digestive symptoms, metoclopramide was by far the most used antiemetic and lactulose the most common laxative. Proton pump inhibitors were used in most patients. For respiratory symptoms, bronchodilators and corticosteroids were the drugs prescribed most often. Oxygen was used in 27 (16%) patients. The psychotropic drugs were benzodiazepines, mainly lorazepam and midazolam, haloperidol, the neuroleptic most frequently administered, and a variety of antidepressants, mainly mirtazapine and trazodone. Many other drugs were used with various aims. Diuretics and antibiotics were the most commonly used.
Discussion This is the first survey carried out in Portugal concerning symptoms in palliative care patients, which included a significant number of teams and patients. Data from this study may be used as a baseline for comparison with future studies carried out in Portugal and even in other countries.
Most patients in palliative care have several physical and nonphysical problems/symptoms as a result of their underlying disease and/or of the treatments they are undergoing or they underwent in the past, including curative treatments such as surgery and radiotherapy. As in the 2000 survey, most patients had been diagnosed with cancer. Another comparison between the practice in Portugal at that time and the practice nowadays is not possible because the data from that study are not sufficiently individualized by country in order to make that comparison possible.8 Fatigue was the symptom with the highest prevalence. Of all the 136 who could report their symptoms, 85% had fatigue and 64% of them had at least moderate fatigue intensity. In other studies, fatigue is also one of the most, and often the most, frequent symptoms9-11 in patients with cancer.12,13 In other diseases, fatigue is very frequent as well.14-16 Fatigue has a major impact on patients’ quality of life and should be systematically assessed as many patients do not report it spontaneously as observed in one study.11 The authors of that study suggested as a possible explanation the perception that fatigue is an inevitable component of advanced disease and treatment is unavailable or ineffective. Fatigue is followed by psychological symptoms. Depression/sadness came second in prevalence. There are some studies that report only sadness10,17, while others report only depression.8,9,12 In this study, the item depression/sadness was used in a way similar to the Edmonton Symptom Assessment System, where depression means feeling sad.18 However, the distinction between sadness and depression is important because sadness may be a normal reaction in a patient dealing with an incurable and life threatening disease, whereas depression is a disease that can be treated pharmacologically.19 The diagnosis of depression is difficult in patients with advanced chronic diseases because the physical criteria of depression may result directly from the underlying disease not from depression. The studies that specifically address depression in advanced chronic diseases report a depression prevalence of about 25%,20,21 which is much lower than that reported in the studies of symptom prevalence referenced previously. Therefore, this study and the others already
American Journal of Hospice & Palliative Medicine® 32(3)
338 Table 4. Drugs.
Table 4. (continued) No. (%)
Antiemetics Metoclopramide Domperidone Other antiemetic Laxatives Lactulose Senna Sodium picosulfate Sodium citrate Magnesium salts Bisacodyl Other laxatives Digestive protectors Proton pump inhibitors Ranitidine Other digestive drugs Butylscopolamine Loperamide Sucralfate Other Respiratory drugs Corticosteroids Ipratropium bromide Salbutamol Opioid Butylscopolamine Other Benzodiazepines Lorazepam Midazolam Diazepam Alprazolam Bromazepam Other Neuroleptics Haloperidol Levomepromazine Quetiapine Other Antidepressants Mirtazapine Trazodone Sertaline Escitalopram Other Other psychotropic drugs Other drugs Diuretics Antibiotics Antihypertensives Insulin Antiepileptic Iron salts Megestrol acetate Antifungals Low-molecular-weight heparin Paracetamol a-1 blocker
45 (27) 17 (10) 8 (5) 73 22 15 14 5 5 8
(45) (13) (9) (9) (3) (3) (5)
95 (58) 12 (7) 12 5 5 5
(7) (3) (3) (3)
20 23 17 12 8 14
(12) (14) (10) (7) (5) (9)
30 20 11 7 5 8
(18) (12) (7) (4) (3) (5)
27 5 5 9
(16) (3) (3) (5)
13 12 6 6 9 12
(8) (7) (4) (4) (5) (7)
44 43 19 14 11 10 9 8 7 7 7
(27) (26) (12) (9) (7) (6) (5) (5) (4) (4) (4)
(continued)
No. (%) Corticosteroids Digoxin Nitrate Oral antidiabetic agents Other
6 5 5 5 31
(4) (3) (3) (3) (19)
mentioned show the prevalence of sadness, with an indeterminate number of these patients being depressed, and this means that patients with sadness should be assessed further for depression. Anxiety was also a frequent occurrence. As with sadness, anxiety symptoms in some studies, referred to as feeling nervous, are natural in patients facing a severe disease. However anxiety as a psychiatric disease is not so frequent.22 Anorexia was the fourth most prevalent symptom in 61% of patients, and in 50% it was at least moderate. Other studies on symptoms report a high prevalence of anorexia although somewhat lower,8,10,14,23 but it can be even higher.24 Sleep disturbances often occur in patients with advanced diseases. In this study, somnolence is more frequent than insomnia. Not all studies reporting symptom prevalence mention somnolence and in those that do, the term used is usually feeling drowsy.10,14,23 Even in articles addressing sleep disturbances, more attention is given to insomnia than to somnolence.25,26 However, somnolence resulting from the disease and also from the medication may be very distressing for some patients, preventing the desired contact with significant people and other activities. On the other hand, some patients prefer to be drowsy. Therefore, the impact of somnolence on patients’ well-being must be clarified. Pain was addressed in a separate article.6 Other symptoms’ prevalence was less than 50%. The prevalence of constipation was 41%, which was very similar (43%) to that reported in the European survey carried out in 2000.8 The prevalence of dyspnea has been reported in a wide range of values,10,14,23 and the prevalence reported in this study is in the lower part of the range of 31%. Most patients included in this study had mild dyspnea, with only 5 of the 164 patients having severe dyspnea and none maximum dyspnea. Dyspnea, however, may be considered a very distressing symptom, explaining why most patients with at least moderate dyspnea are inpatients. The prevalence of nausea and vomiting are at the bottom of the list. The prevalence of nausea and vomiting is reported differently, but they are usually not the most prevalent ones.27 The prevalence of existential problems showed a huge varation between teams. This is a normal occurrence,28 but there are even studies of symptom/problem prevalence, which do not mention this type of problem.29,30 Those differences may be explained by the low level of attention to those problems or the confusion with psychosocial issues. The drugs most commonly used for symptom control are similar to those reported in the 2000 survey8 and are included
Gonc¸alves et al in the list of essential drugs for palliative care.31 After laxatives, proton pump inhibitors were one of the most commonly used therapeutic groups. It is well known that this class of drugs is one of the most commonly used in different settings, often inappropriately. However, they are deemed generally safe and their widespread use is recommended by some,32 although they are not free of side effects and interactions with other drugs.33 Antibiotics were used in 26% of all patients. The aim of using antibiotics in palliative care is essentially the same as other drugs, which is to improve the well-being of patients through symptom control. Some studies show that the appropriate use of antibiotics results in enhanced symptom control.34,35 This study has some weaknesses. Because only 10 of 21 teams participated, it is unclear whether these data may be generalized. However, we believe that they give an approximate idea of the activity of Portuguese palliative care teams. The methodology of this study can be questioned. However, it is similar to that used in a European survey carried out in 2000.
Conclusion Fatigue, psychological symptoms, and anorexia were the predominant symptoms other than pain, which is similar to the findings in other studies. Existential problems are also frequent, but their reported prevalence is heterogeneous among teams. The drugs most commonly used to control symptoms are those deemed essential. Therefore, the practice of palliative care in Portugal seems to be similar to that practiced elsewhere. Authors’ Note We declare that we have full control of all primary data and we agree to allow the journal to review the data if requested.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the North Section of the Portuguese League against Cancer.
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American Journal of Hospice & Palliative Medicine® 32(3)
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Symptoms Other Than Pain in Palliative Care in Portugal Ferraz Gonc¸alves, MD, MSc, PhD1, Ana Almeida, MSc1, Catarina Antunes2, Maria Cardoso, MD3, Margarida Carvalho, MD4, Maria Claro, MD5, Francisca Coimbra6, Ineˆs Diniz2, Bruno Fonseca5, Emı´lia Fradique7, Edna Gonc¸alves, MD, MSc8, Florbela Gonc¸alves, MD9, Maria Gonc¸alves4, Ame´rico Magalha˜es, MD10, Paulo Pina, MD6, Conceic¸a˜o Pires, MD8, Paula Silva, MD, MSc1, Ricardo Silva3, Rui Silva, MD9, Filipa Tavares, MD7, and Laura Teixeira10
Abstract Objective: To study the burden of patients’ symptoms other than pain and their treatment by Portuguese palliative care teams. Methods: Of the 21 Portuguese palliative care teams identified, 10 accepted to participate. Data from all patients observed on the 18th week of 2011 were collected. Results: One hundred and sixty-four patients were included in this study. One hundred and fifty-one patients (92%) had cancer. The patients’ median age was 71 years (16-95) and 84 (51%) were females. The main symptoms were fatigue (116 [85%]) and depression/sadness (107 [65%]). Many different drugs were used for symptom control and other aims. Symptoms and drugs used here are similar to those practiced in other countries. Conclusion: The practice of palliative care in Portugal seems to be similar to those in other countries. Keywords palliative care, symptoms other than pain, symptom control, nonphysical problems, psychological problems, existential problems
Introduction Palliative care began in Portugal some years after other European countries started practicing. The first team started working in 1994 as an inpatient palliative care service belonging to the Portuguese Institute of Oncology—Porto.1 Since then, the number of teams increased slowly. In 2000, the European Association for Palliative Care carried out a cross-sectional survey of European centers, and at that time only 3 Portuguese centers had operational palliative care teams.2 Now there are around 25 teams working around the country, which is still insufficient to the needs of the more than 10,000,000 people living in Portugal now. There are plans for improvement, and the number of palliative care teams is expected to increase in the next few years. There is little evidence regarding the activity of the Portuguese palliative care teams, their professionals, the activities carried out, the patients treated, such as their demographic data, diagnosis, and symptoms/problems and how they are treated and by whom. In an attempt to collect these data, a crosssectional survey was carried out involving all teams that wished to participate. One of the most important aspects of the roles of palliative care teams is to detect, assess, and control
physical and nonphysical problems/symptoms as patients with advanced cancer and other chronic diseases monitored by
1
Department of Palliative Care, Instituto Portugueˆs de Oncologia, Porto, Portugal 2 Department of Palliative Care, Hospital do Mar, Lisboa, Portugal 3 Department of Palliative Care, Centro Hospitalar Lisboa Central, Lisboa, Portugal 4 Department of Palliative Care, Hospital do Litoral Alentejano, Santiago do Cace´m, Portugal 5 Department of Palliative Care, Unidade Local de Sau´de de Matosinhos, Matosinhos, Portugal 6 Department of Palliative Care, Instituto Portugueˆs de Oncologia, Lisboa, Lisboa, Portugal 7 Department of Palliative Care, Hospital de St. Maria, Lisboa, Portugal 8 Department of Palliative Care, Centro Hospitalar de S. Joa˜o, Porto, Portugal 9 Department of Palliative Care, Instituto Portugueˆs de Oncologia, Coimbra, Coimbra, Portugal 10 Department of Palliative Care, Centro Hospitalar de Tra´s-os-Montes e Alto Douro, Vila Real, Portugal Corresponding Author: Ferraz Gonc¸alves, PhD, Unidade de Cuidados Paliativos, Instituto Portugueˆs de Oncologia, 4200-072 Porto, Portugal. Email: [email protected]
336 palliative care teams often have multiple problems/symptoms.3 In the survey, a large amount of data were collected on the different aspects of the teams’ activity. This article focuses on this important aspect of care, the burden of patients’ symptoms other than pain, adding that information to the international palliative care community.
Methods Twenty-one Portuguese palliative care teams identified at the beginning of 2011 through the Portuguese Association for Palliative Care website and through the Portuguese Continuous Care Network website were invited to participate in the survey. A questionnaire was prepared based on the study carried out by the European Association for Palliative Care in 2000.2 The questionnaire was sent to 10 of the 21 palliative care teams that agreed to participate in the survey for evaluation. A new questionnaire was designed with the suggestions received, and this was circulated for a final revision and face validity. For the selection of the symptom, the same general method was used. Data were collected from all patients seen on the 18th week of 2011. Each team filled in the questionnaire with the data from all patients (in the first encounter or in follow-up) seen each day of that week. The assessment was assisted by the professionals to include all patients who accepted to participate. One day of that week was allocated for possible team activity (inpatient unit, intrahospital team, outpatient clinic, and home care). The activity for each day of the week was previously determined by the study coordinator and was the same for all teams. Data were collected by the researchers at each center from all patients seen on that day and who had agreed to participate. The data collected concerning symptoms were demographic data, main diagnosis, symptoms and other problems, drugs given, and other techniques for symptom control. Survival prediction was clinical, as it seems to be a reliable method.4 The intensity of symptoms in the previous 24 hours was rated using a 5-point verbal rating scale: none, mild, moderate, severe, and maximum; but for statistical analysis, we divided the intensity of the symptoms into 2 groups as none or mild and moderate to maximum in order to divide patients between clinically nonsignificant intensity and clinically significant intensity. Patients with cognitive failure were assessed by the researchers. Drugs used in less than 5 patients were classified as other. An initial analysis was performed for statistical purposes to identify coding errors, inconsistencies, and the presence of missing categories or small numbers, and corrections were made where needed. Missing data were omitted, an approach usually called listwise deletion or complete case analysis. The variables were analyzed by proportions and means. To evaluate the existence or not of associations between categorical variables, the chi-square test was used. When the numbers were small, the values were calculated using the Monte Carlo simulation.5 The level of significance was deemed to be 0.05. SPSS version 19.0 statistical software was used to analyze the data. The study was approved by the ethics committees and authorized by the board of directors at each center.
American Journal of Hospice & Palliative Medicine® 32(3) Table 1. Diagnoses. No.(%) Diagnosis Cancer Neurological Respiratory AIDS Renal Hepatic Postoperative complications Undefined
151 6 2 1 1 1 1 1
(92.1) (3.7) (1.2) (0.6) (0.6) (0.6) (0.6) (0.6)
Results One hundred and sixty-four patients were included in this study without any refusal. The median number of patients per team was 15.5 (4-32). One hundred and fifty-one (92%) had cancer (Table 1). The patients’ median age was 71 years (16-95), and 84 (51%) were females. Other demographic data were presented elsewhere.6,7 Symptoms were directly assessed in 136 (83%) of the patients, whereas 28 patients could not report their symptoms due to cognitive failure. The main symptoms in the patients who could be assessed directly was (the severe to maximum [SM] intensity percentage is calculated for each symptom) fatigue 116 (85%), SM 43 (37%); depression/sadness 107 (65%), SM 34 (31%); anxiety 84 (51%), SM 21 (25%); and anorexia 84 (51%), SM 19 (23%) (Table 2). Although pain was not the focus of this article, Table 2 includes pain for the comparison of pain prevalence with other symptoms. There were no significant differences in the frequency of moderate to maximum symptom intensity in relation to sex. Dividing patients by the median age (71 years), no significant differences in symptoms were reported in the 2 age-groups. Comparing inpatients with outpatients, significant differences were observed in the following symptoms: dyspnea, with only 1 (2%) of 42 outpatients versus 18 (19%) of 93 inpatients with at least moderate dyspnea (P ¼ .007); and nausea, with 1 (2%) of 42 outpatients versus 14 (15%) of 92 inpatients with at least moderate nausea (P ¼ .037). Patients with cognitive failure were observed for signs of discomfort by the researcher: 7 (25%) had no signs of discomfort; 11 (39%) had mild signs of discomfort; 8 (29%) moderate; 2 (7%) severe; and 0 maximum. Other physical problems were pressure sores—31 (19%); neoplastic wounds—25 (15%); ascites—23 (14%); pleural effusion—18 (11%); and lymphedema—13 (8%). Indwelling catheters were the most common devices used. Feeding tubes were also used, mainly in patients with head and neck diseases and also in patients with neurological diseases (Table 3). Other problems reported were lack of support—36 (26%); loneliness—28 (21%); nonacceptance of the disease—39 (29%); existential—40 (29%); and other—16 (12%). The differences in the frequency of these problems among teams were significant for lack of support (P ¼ .009) and existential problems (P < .001) and nonsignificant for loneliness and nonacceptance.
Gonc¸alves et al
337
Table 2. Main Symptom Prevalence. Symptom Fatigue Depression/sadness Anxiety Anorexia Pain Somnolence Constipation Dyspnea Insomnia Nausea Vomiting
Mild, no. (%)a 28 35 31 34 42 37 31 24 14 11 6
(24) (33) (37) (40) (55) (52) (55) (56) (35) (42) (50)
Moderate, no. (%)a 45 38 32 31 25 23 16 14 18 9 3
(39) (36) (38) (37) (32) (32) (29) (33) (45) (35) (25)
Severe, no (%)a
Maximum, no. (%)a
35 (30) 24 (22) 19 (23) 16 (19) 9 (12) 9 (13) 7 (13) 5 (12) 7 (18) 6 (23) 3 (25)
8 (7) 10 (9) 2 (2) 3 (4) 1 (1) 2 (3) 2 (4) 0 1 (3) 0 0
Total, no. (%) 116 107 84 84 77 71 56 43 40 26 12
(85) (78) (61) (61) (57) (52) (41) (31) (29) (19) (9)
a
Percentage for the symptom.
Table 3. Other Issues. No. (%) Pressure ulcers Indwelling catheter Neoplastic wounds Ascites Pleural effusion Lymphedema Nasogastric tube Gastrostomy Tracheostomy Colostomy Bowel obstruction Jejunostomy Nephrostomy
31 31 25 23 18 13 13 8 8 7 5 2 2
(19) (19) (15) (14) (11) (8) (8) (5) (5) (4) (3) (1) (1)
The prevalence of existential problems by team varied between 0% and 75%. Drugs used for treatment of symptoms excluding pain, which is described elsewhere,5 are very varied (Table 4). For digestive symptoms, metoclopramide was by far the most used antiemetic and lactulose the most common laxative. Proton pump inhibitors were used in most patients. For respiratory symptoms, bronchodilators and corticosteroids were the drugs prescribed most often. Oxygen was used in 27 (16%) patients. The psychotropic drugs were benzodiazepines, mainly lorazepam and midazolam, haloperidol, the neuroleptic most frequently administered, and a variety of antidepressants, mainly mirtazapine and trazodone. Many other drugs were used with various aims. Diuretics and antibiotics were the most commonly used.
Discussion This is the first survey carried out in Portugal concerning symptoms in palliative care patients, which included a significant number of teams and patients. Data from this study may be used as a baseline for comparison with future studies carried out in Portugal and even in other countries.
Most patients in palliative care have several physical and nonphysical problems/symptoms as a result of their underlying disease and/or of the treatments they are undergoing or they underwent in the past, including curative treatments such as surgery and radiotherapy. As in the 2000 survey, most patients had been diagnosed with cancer. Another comparison between the practice in Portugal at that time and the practice nowadays is not possible because the data from that study are not sufficiently individualized by country in order to make that comparison possible.8 Fatigue was the symptom with the highest prevalence. Of all the 136 who could report their symptoms, 85% had fatigue and 64% of them had at least moderate fatigue intensity. In other studies, fatigue is also one of the most, and often the most, frequent symptoms9-11 in patients with cancer.12,13 In other diseases, fatigue is very frequent as well.14-16 Fatigue has a major impact on patients’ quality of life and should be systematically assessed as many patients do not report it spontaneously as observed in one study.11 The authors of that study suggested as a possible explanation the perception that fatigue is an inevitable component of advanced disease and treatment is unavailable or ineffective. Fatigue is followed by psychological symptoms. Depression/sadness came second in prevalence. There are some studies that report only sadness10,17, while others report only depression.8,9,12 In this study, the item depression/sadness was used in a way similar to the Edmonton Symptom Assessment System, where depression means feeling sad.18 However, the distinction between sadness and depression is important because sadness may be a normal reaction in a patient dealing with an incurable and life threatening disease, whereas depression is a disease that can be treated pharmacologically.19 The diagnosis of depression is difficult in patients with advanced chronic diseases because the physical criteria of depression may result directly from the underlying disease not from depression. The studies that specifically address depression in advanced chronic diseases report a depression prevalence of about 25%,20,21 which is much lower than that reported in the studies of symptom prevalence referenced previously. Therefore, this study and the others already
American Journal of Hospice & Palliative Medicine® 32(3)
338 Table 4. Drugs.
Table 4. (continued) No. (%)
Antiemetics Metoclopramide Domperidone Other antiemetic Laxatives Lactulose Senna Sodium picosulfate Sodium citrate Magnesium salts Bisacodyl Other laxatives Digestive protectors Proton pump inhibitors Ranitidine Other digestive drugs Butylscopolamine Loperamide Sucralfate Other Respiratory drugs Corticosteroids Ipratropium bromide Salbutamol Opioid Butylscopolamine Other Benzodiazepines Lorazepam Midazolam Diazepam Alprazolam Bromazepam Other Neuroleptics Haloperidol Levomepromazine Quetiapine Other Antidepressants Mirtazapine Trazodone Sertaline Escitalopram Other Other psychotropic drugs Other drugs Diuretics Antibiotics Antihypertensives Insulin Antiepileptic Iron salts Megestrol acetate Antifungals Low-molecular-weight heparin Paracetamol a-1 blocker
45 (27) 17 (10) 8 (5) 73 22 15 14 5 5 8
(45) (13) (9) (9) (3) (3) (5)
95 (58) 12 (7) 12 5 5 5
(7) (3) (3) (3)
20 23 17 12 8 14
(12) (14) (10) (7) (5) (9)
30 20 11 7 5 8
(18) (12) (7) (4) (3) (5)
27 5 5 9
(16) (3) (3) (5)
13 12 6 6 9 12
(8) (7) (4) (4) (5) (7)
44 43 19 14 11 10 9 8 7 7 7
(27) (26) (12) (9) (7) (6) (5) (5) (4) (4) (4)
(continued)
No. (%) Corticosteroids Digoxin Nitrate Oral antidiabetic agents Other
6 5 5 5 31
(4) (3) (3) (3) (19)
mentioned show the prevalence of sadness, with an indeterminate number of these patients being depressed, and this means that patients with sadness should be assessed further for depression. Anxiety was also a frequent occurrence. As with sadness, anxiety symptoms in some studies, referred to as feeling nervous, are natural in patients facing a severe disease. However anxiety as a psychiatric disease is not so frequent.22 Anorexia was the fourth most prevalent symptom in 61% of patients, and in 50% it was at least moderate. Other studies on symptoms report a high prevalence of anorexia although somewhat lower,8,10,14,23 but it can be even higher.24 Sleep disturbances often occur in patients with advanced diseases. In this study, somnolence is more frequent than insomnia. Not all studies reporting symptom prevalence mention somnolence and in those that do, the term used is usually feeling drowsy.10,14,23 Even in articles addressing sleep disturbances, more attention is given to insomnia than to somnolence.25,26 However, somnolence resulting from the disease and also from the medication may be very distressing for some patients, preventing the desired contact with significant people and other activities. On the other hand, some patients prefer to be drowsy. Therefore, the impact of somnolence on patients’ well-being must be clarified. Pain was addressed in a separate article.6 Other symptoms’ prevalence was less than 50%. The prevalence of constipation was 41%, which was very similar (43%) to that reported in the European survey carried out in 2000.8 The prevalence of dyspnea has been reported in a wide range of values,10,14,23 and the prevalence reported in this study is in the lower part of the range of 31%. Most patients included in this study had mild dyspnea, with only 5 of the 164 patients having severe dyspnea and none maximum dyspnea. Dyspnea, however, may be considered a very distressing symptom, explaining why most patients with at least moderate dyspnea are inpatients. The prevalence of nausea and vomiting are at the bottom of the list. The prevalence of nausea and vomiting is reported differently, but they are usually not the most prevalent ones.27 The prevalence of existential problems showed a huge varation between teams. This is a normal occurrence,28 but there are even studies of symptom/problem prevalence, which do not mention this type of problem.29,30 Those differences may be explained by the low level of attention to those problems or the confusion with psychosocial issues. The drugs most commonly used for symptom control are similar to those reported in the 2000 survey8 and are included
Gonc¸alves et al in the list of essential drugs for palliative care.31 After laxatives, proton pump inhibitors were one of the most commonly used therapeutic groups. It is well known that this class of drugs is one of the most commonly used in different settings, often inappropriately. However, they are deemed generally safe and their widespread use is recommended by some,32 although they are not free of side effects and interactions with other drugs.33 Antibiotics were used in 26% of all patients. The aim of using antibiotics in palliative care is essentially the same as other drugs, which is to improve the well-being of patients through symptom control. Some studies show that the appropriate use of antibiotics results in enhanced symptom control.34,35 This study has some weaknesses. Because only 10 of 21 teams participated, it is unclear whether these data may be generalized. However, we believe that they give an approximate idea of the activity of Portuguese palliative care teams. The methodology of this study can be questioned. However, it is similar to that used in a European survey carried out in 2000.
Conclusion Fatigue, psychological symptoms, and anorexia were the predominant symptoms other than pain, which is similar to the findings in other studies. Existential problems are also frequent, but their reported prevalence is heterogeneous among teams. The drugs most commonly used to control symptoms are those deemed essential. Therefore, the practice of palliative care in Portugal seems to be similar to that practiced elsewhere. Authors’ Note We declare that we have full control of all primary data and we agree to allow the journal to review the data if requested.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the North Section of the Portuguese League against Cancer.
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