Journal of Pain and Symptom Management

Severe acute pain caused by dressing changes for wounds extending into the dermis and deeper tissues of the body is a major patient care dilemma. Pain occurring with dressing changes represents a conglomerate of nociceptive, inflammatory, and neuropathic pain. The severe, acute, and transient nature of pain from wound dressing changes makes it especially difficult to manage effectively. The severity of this phenomenon warrants use of potent medications, such as opioid analgesics, which can yield undesirable side effects lasting for hours after completion of the dressing change. Inadequately controlled pain inflicts suffering on the patient and may deter the meticulous completion of procedures, such as dressing changes.

Persistent and delayed healing of fistulae and local infection in previously irradiated areas can increase the risk of systemic complications and complicated clinical management. Cancer patients have impaired immune systems secondary to the tumor or oncology treatments; this impairment decreases spontaneous healing. Surgical options are often associated with adverse side effects together with an increased risk of further delay in wound healing. Hyperbaric chambers have been used to treat delayed wound healing and several radiation-induced side effects. However, this technique is cumbersome and with limited accessibility. Additionally, treatment and assessment of radiation-induced subcutaneous fibrosis has had limited success. We describe a case of a persistent fistula in a previously irradiated area, which was refractory to treatment but which was successfully treated with local ozone applications. The potential role of spectroscopy analysis imaging for objective assessment of subcutaneous fibrosis was demonstrated.

Hiccups are defined as sudden, involuntary, spasmodic contractions of the diaphragm and external intercostal muscles that result in inspiration that ends abruptly with the closure of the glottis. The innervation of the hiccup reflex includes an afferent pathway via the vagus, phrenic, and sympathetic branches of T6–T12 and the efferent pathway via the phrenic nerve to the diaphragm, glottis, and external intercostal muscles. Hiccups can result from direct injury to the reflex arc or any underlying disease, including injury, irritation, or inflammation affecting one of the nerves involved in the reflex arc. The sudden closure of the glottis results in the “hic” sound, and the upward-jerking motion probably makes up the second part of the word.

Hyperacute allodynia, that is, pain elicited by nonpainful stimuli, after spinal cord injury, with secondary disappearance, is exceptional. Only a handful of cases are on record.

About three years ago, I published a review of all 32 Cochrane reviews of acupuncture available in 2007. Twenty-five of them failed to demonstrate the effectiveness of this treatment, five drew (tentatively) positive conclusions, and two were inconclusive. Here I present an update of this review.

Abstract: Context: Family members of people with advanced cancer can experience intensified distress and uncertainty during the final stages of their loved one’s illness. Enhanced comprehension about disease progression, symptom management, and options for care can help families adapt, cope, and plan for the future.Objectives: Guided by concepts from the Sense of Coherence Theory, which illuminates factors that contribute to adaptation in stressful situations, the objective of this study was to explore and describe family caregivers’ accounts of the nature and timing of communication they had with a loved one’s health care provider(s) during the advanced stages of cancer and before hospice enrollment.Methods: Retrospective in-depth interviews were conducted with caregivers of 46 people who died of cancer. Interviews were audiotaped, transcribed, and submitted to an iterative process of qualitative data analysis that included 1) systematic coding, 2) the use of data matrices to display summarized results and collapse the codes into themes, 3) and axial coding to characterize the nature of the themes.Results: Overall, communication with providers was found to be either 1) satisfactory or 2) unsatisfactory. Satisfactory communication was 1) compassionate, 2) responsive, and/or 3) dedicated. Unsatisfactory communication was described as 1) sparse, 2) conflicted, 3) contradictory, and/or 4) brink of death.Conclusion: Communication with health care providers is critical for helping family caregivers understand and manage the changes that accompany a life-limiting illness. Timely communication with information and meaningful discussion about disease progression can help families prepare for the advanced stages of an illness and approaching death.

Abstract: Conflict and chaos are prevalent in health care, and perhaps especially in palliative care. Typically, our point of entry into our patients' lives is often at the moment of conflict, discord, or intense suffering. Despite this, little in our formal training as clinicians teaches us how to be present for this suffering. Much has been written about the process of communication with regard to giving bad news, handling family meeting conflicts, and negotiating shifting goals of care, but little has been addressed about how to train the clinician to be present with the dissonance and suffering. In this paper, we explore how music, art, and literature teach us how to stay in moments of tension. In turn, lessons on how to learn to lean into the dissonance of many palliative care encounters are extrapolated.

Abstract: The relief of pain is widely considered to be a basic human right. Physicians are expected to make every attempt to relieve pain and suffering, especially in patients who do not have capacity. This article presents a case in which the family of a woman with severe somatic pain from metastatic breast cancer requests that pain medications be reduced and, at times, held. The ethical issues associated with surrogate decision making and the refusal of medical treatments are reviewed. The obligation to treat pain remains paramount despite family objections.

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Identify the opportunities and challenges inherent in integrating palliative care into the care of seriously ill older adults across a variety of venues.

Discuss the key elements of a standardized palliative care consult template.

Recognize and overcome barriers to care in patients with addiction, including interpreting and managing aberrant drug behaviors.

Discuss the key elements of young adult development and their clinical implications.

Discuss key literature, current nursing communication curriculum, and data summarizing nurses' communication needs.

Identify the research evidence for and key components of the Advanced Illness Coordinated Care Program (AICCP).

Discuss the current regulatory environment as it relates to hospice programs and what rules hospice practitioners need to know.

Distinguish between hope and hopelessness and false hope and false hopelessness; generate a list of attributes regarding domains of hope and hopelessness; and review the research on hope and how maintaining hope has important, positive clinical outcomes.

Identify steps in moving from ideas to a complete manuscript.

List the most commonly requested medications for “open access” admission to hospice care, and describe the evidence base supporting or refuting the use of these medications in patients with advanced illness.

Describe common patterns of grief.