Nurse Practitioner Intervention Affects Cancer Patient QOL
May 30, 2012 — A consultative visit with a nurse practitioner improves the quality of life of patients with metastatic cancer, according to a small study published online May 4 in the Journal of Palliative Medicine. Patients who received this intervention showed significant improvements in their emotional and mental wellbeing.
On the emotional domain of the Functional Assessment of Cancer Therapy-General (FACT-G) scale, an assessment tool that has been widely used and prospectively validated as a measure of quality-of-life end points, there was a statistically significant improvement in the intervention group, compared with the control group (P = .0106).
However, there were no statistically significant differences on the other FACT-G domains between the 2 study groups.
On the Linear Analogue Self Assessment scale (LASA), a 12-question survey designed to assess quality-of-life parameters on a scale of 1 to 10, changes from baseline mental quality of life were statistically better in the intervention group than in the control group (19 vs –10; P = .02).
Simple Measure Brings Improvement
"A relatively simple consultation visit, that took anywhere from 30 to 60 minutes, with the nurse practitioner resulted in an improvement in the patient's quality of life," said senior author Gerardo Colon-Otero, MD, an oncologist in the division of hematology/oncology at the Mayo Clinic in Jacksonville, Florida.
The purpose of the intervention was to bring palliative care to the patients, he explained in a Mayo Clinic video. Palliative treatments usually involve a large team of professionals, but community acceptance is frequently less than optimal. This is primarily because of the lack of access to these services and the fact that physicians do "not really have the time to address the patient's psychological and social needs," Dr. Colon-Otero explained.
He noted that this was the first attempt at an intervention in which the nurse practitioner spoke with the patients about hospice and end-of-life wishes and assessed their quality of life and needs. It "resulted in the patients' quality of life improving when it was measured a month later," said Dr. Colon-Otero.
"The findings should be extremely helpful to oncologists, in both community and academic medical practices, concerned about how to incorporate palliative care, including discussions about advanced directives in the outpatient management of their cancer patients," he explained in a statement.
In their study, Dr. Colon-Otero and colleagues point out that in many cases, patients overestimate their chances for survival; this can lead them to resist interventions focused on the palliation of symptoms. In addition, academic medical centers and private oncology practices often do not offer ongoing care and support after hospice enrollment. Patients and/or their families might therefore be reluctant to use hospice services because of a strong attachment to their current caregivers and a "perceived sense of abandonment."
Physicians might be reluctant to discuss hospice with patients, they note, because explaining that a treatment is futile or no longer effective is difficult. They might also feel that the patient will not be understanding of or receptive to the idea of palliative care or hospice. As a result, patients often end up enrolling in hospice care much too late and do not complete advanced directives in a timely fashion.
Study Details
In this randomized phase 2 trial, Dr. Colon-Otero and colleagues assigned 26 patients with metastatic cancer to intervention with a nurse practitioner or to the control group. The study was designed enroll 100 patients, but accrual was halted after the first 26 patients because other recently completed randomized studies showed the benefit of nurse-driven palliative interventions.
The control group completed questionnaires about hospice care and quality-of-life tools, including the FACT-G and LASA scales, at baseline and 1 month later (or at the time of hospice referral, if that occurred earlier). This group had access to palliative care consultations and hospice referrals, determined by their oncology team.
Those in the intervention group completed the questionnaires and had an initial and a 1-month follow-up consultation with an oncology nurse practitioner who informed them about hospice care, helped fill out the Five Wishes and living will forms, and assessed their psychological, physical, intellectual/cognitive, social, and spiritual needs.
The "success of this study brings a simple way to introduce advanced directives discussions and symptom assessment early in the clinical course of metastatic cancer patient care by a professional...who is part of the oncology team," the authors write.
Advanced care planning and informed discussions about end-of-life issues were well received by patients, despite it being early in their clinical course of metastatic cancer, they add.
"In the future, we plan to explore the use of this intervention in broader study populations, with special attention to underserved and minority subgroups, given the reports of underutilization and decreased awareness of palliative care and hospice services in this subpopulation," the authors conclude.
The authors have disclosed no relevant financial relationships.
J Palliat Care. Published online May 4, 2012. Abstract
Medscape Medical News © 2012 WebMD, LLC
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