Open Access

Symptom severity of patients with advanced cancer in palliative care unit: longitudinal assessments of symptoms improvement

Contributed equally
BMC Palliative CareBMC series – open, inclusive and trusted201615:32

https://doi.org/10.1186/s12904-016-0105-8

Received: 28 April 2015

Accepted: 7 March 2016

Published: 11 March 2016

Abstract

Background

This study assessed the symptom severity of patients with advanced cancer in a palliative care unit and explored the factors associated with symptom improvement.

Methods

This study was conducted in a palliative care unit in Taiwan between October 2004 and December 2009. Symptom intensity was measured by the “Symptom Reporting Form”, and graded on a scale of 0 to 4 (0 = none, and 4 = extreme). These measures were assessed on the 1st, 3rd, 5th, and 7th Day in the palliative care unit. The study data comprised routine clinical records and patients’ demographic data. Generalized estimating equation (GEE) was used to assess the symptom improvement, and investigate the factors associated with the symptom reporting form scores.

Results

Among the 824 recruited patients with advanced cancer, pain (78.4 %), anorexia (64.4 %) and constipation (63.5 %)were the most common and severe symptom. After controlling for other factors in the multivariate GEE model, the day of palliative care administration was a significant factor associated with all of the scales, except Days 7 on the dyspnoea and oedema scales and Day 5 on the anxiety scale. In addition, patients aged ≥ 65 years exhibited significantly lower scores on the pain, sleep disturbance, depression, and anxiety scales than did those aged < 65 years. Moreover, female patients exhibited higher scores on the vomiting, anorexia, oedema, depression, and anxiety scales than did male patients. Furthermore, patients with gastrointestinal tract cancer exhibited higher scores on the constipation, vomiting, anorexia, oedema, depression, and anxiety scales and lower scores on the dyspnoea scale than did those with lung cancer. Patients with breast cancer exhibited higher scores on the oedema scale and lower scores on the anxiety scale. Patients with genitourinary cancer exhibited higher scores on the vomiting and oedema scales and lower scores on the dyspnoea scale. Patients with head, neck, and oral cancer exhibited lower scores on the oedema scale alone.

Conclusion

The symptom severity declined during the first week in the palliative care unit. In addition, differences in sex and primary cancer sites may contribute to varying degrees of symptom improvement.

Keywords

Advanced cancer Palliative care Symptom severity Generalised estimating equation

Background

Cancer is a leading cause of death worldwide and accounted for 8.2 million deaths in 2012 [1]. Since 1982, cancer has been the primary cause of death in Taiwan and accounts for over 30,000 deaths each year and this figure is increasing [2]. The Hospice Palliative Care, which originated in England, aims to provide symptom alleviation and holistic care through physical, emotional, and spiritual approaches to terminally ill patients towards the end of their lives. Until 2013, the hospice care programmes available in Taiwan included 44 hospital-based inpatient hospice care wards (hospice wards), 64 hospice home-care units (regular home visits by nurses and other interdisciplinary staff), and 58 hospitals with consultation or a combined care team [3].

Terminally ill patients with cancer suffer from several physical and psychological symptoms and multiple organ failures; therefore, one of their main needs is to be comfortable and symptom-free at the end stage of their lives [4]. Consequently, the initial and essential component of palliative cancer care is to provide advanced-cancer patients with symptom relief as soon as possible in lieu of disease treatment [5, 6]. The previous studies may tell us the symptom patterns [4, 710] and the good effect of the intervention (ex.: the case management model, the hospital- or day care- based palliative care team…etc.) in improving symptom control and even quality of life [1114] among advanced cancer patients. However, limited information is available regarding longitudinal assessments of symptom improvement after admission to a palliative care unit. Therefore, a clearer understanding of symptom improvement and factors associated with symptom improvement is required to provide optimal symptom relief for patients with advanced cancer. Thus, the Symptom Reporting Form was used in the present study to assess the symptom severity of patients with advanced cancer in a palliative care unit.

Methods

Study population

In this prospective study, participants were selected from amongst consecutive patients with advanced cancer who consented and were admitted between October 2004 and December 2009 to the palliative care unit of Kaohsiung Medical University Hospital, a medical centre in Southern Taiwan. The inclusion criteria included age older than 20 years, more than 1-week admission to the palliative care unit, and adequate level of consciousness to report symptoms in Mandarin or Taiwanese on admission and in the consecutive symptom assessments. The exclusion criteria included age younger than 20 years, passing away within one week after admission to the palliative care unit, and inadequate level of consciousness to report symptoms. The participants were receiving care from a multidisciplinary team comprising physicians, nurses, psychologists, social workers, clinical Buddhist chaplains, and volunteers. The study protocol was approved by the Kaohsiung Medical University Hospital Institutional Review Board (KMUH-IRB-20140333). Since all identifying personal information was not recorded, the review board waived the requirement for written informed consent from the patients involved.

Assessment instrument

The assessment tool was a symptom-reporting form designed by experienced specialists, which assessed the physical and psychosocial distress by using corresponding scales (see Additional file 1). The physical and psychosocial symptoms included pain, constipation, vomiting, dyspnoea, loss of appetite, sleep disturbance, oedema, uncomfortable, depression, and anxiety, graded on a scale of 0 to 4 (0 = none, 1 = mild, 2 = moderate, 3 = severe, and 4 = extreme). The internal consistency of questionnaire, Coefficients of Cronbach’s α value for the baseline measurement, was 0.715. Besides, 3 experts in the hospice filed were invited to judge and modify the content of the symptom reporting form and 7 experts to assess the content validity. The average content validity index (CVI) [15] was 0.91.

Symptom assessment and data collection

According to patient reports, the symptoms and their severities were recorded by the physicians on Days 1, 3, 5, and 7 in the palliative care unit and reviewed by the same staff members. Information regarding psychological distress, including depression and anxiety, were collected by medical staff and clinical psychologists. A consensus regarding the psychological distress rating was obtained after thorough discussion in team meetings which were held once per week. The data for this study comprised routine records, including patients’ demographic data (age, sex, primary site of cancer, and length of time in care) and the symptom reporting forms collected on Days 1, 3, 5, and 7 in the palliative care unit.

Training of the palliative care unit staff

According to the health insurance guidelines for palliative care, all the palliative team members, including physicians, nurses, psychologists, social workers, and clinical Buddhist chaplains, were required to finish 80 h of palliative care training which included basic, advanced, and internship courses. In addition, all members were required to undergo 20 h of palliative training every year to ensure the quality of care provided.

Statistical analysis

Descriptive statistical data were summarised as frequencies and percentages for categorical variables, medians and ranges for age and duration of palliative care received, and means (standard deviations, SD) and median (range) for symptom scores and other continuous variables. Patient age was categorised into 2 groups for easier comparisons (< 65 y and ≥ 65 y). To investigate the factors associated with the symptom reporting form scores, a generalised estimating equation (GEE) model was applied to accommodate the correlated data of repeated measurements (on Days 1, 3, 5, and 7) in the same patient. The symptom reporting score served as a continuous dependent variable, whereas age, sex, and type of cancer served as covariates. In addition, multivariate GEE models with identity links were used to calculate the adjusted mean differences and standard errors (SE) of the symptom scores and compare them with those of an appropriate reference group. A 2-tailed P value of < .05 indicated statistical significance. All statistical analyses were performed using the SAS software (Version 9.2; SAS Institute Inc., Cary, NC, USA).

Results

The study participants were 824 hospitalised patients with advanced cancer; 480 (58.3 %) of whom were men. The median age was 61 years (range: 21–97 y), and the median duration in care was 20 days (7–118 d). Regarding the primary cancer type, gastrointestinal cancer was the most common cancer type (32.4 %), followed by head, neck, and oral cancer (22.4 %) and lung cancer (18.2 %) (Table 1).
Table 1

The baseline demographic characteristics of all participants

 

Total (N = 824)

 

N

%

Age, year

  

Median (Range)

61 (21–97)

  < 65

461

56.0.

  ≥ 65

344

41.7

 missing

19

2.3

Gender

  

 Female

344

41.7

 Male

480

58.3

Primary diagnosis

  

 Lung cancer

150

18.2

 Gastrointestinal cancera

267

32.4

 Breast cancer

55

6.7

 Genitourinary cancerb

108

13.1

 Head, neck, and oral cancer

185

22.4

 Other cancersc

59

7.2

Length of time in care

  

 Median (Range)

20 (7–118)

  ≤ 14 days

231

28.0

 15–30 days

361

43.8

 31–60 days

180

21.8

  > 60 days

36

4.4

 Missing

16

 

aCancers of the gastrointestinal tract from esophagus to the rectum, pancreas, liver and gallbladder were combined to form this category

bCancers of the male and female genitals and the urinary tract were combined to form this category

cCancers that were not included above

Pain (78.4 %) was the most common symptom, followed by anorexia (64.4 %) and constipation (63.5 %). Regarding symptom severity, pain (mean ± SD: 1.63 ± 1.23) was the most severe symptom, followed by anorexia (1.24 ± 1.24), constipation (0.92 ± 1.05), dyspnoea (0.82 ± 1.07), and oedema (0.74 ± 1.10) (Table 2).
Table 2

Change in severity of symptoms among 1st,3rd,5th,and 7th day after admission (N = 824)

Variable of symptom

With symptoma

1st

3rd

5th

7th

Range of severity(0–4)

N

%

Mean (SD)

Median (range)

Mean (SD)

Median (range)

Mean (SD)

Median (range)

Mean (SD)

Median (range)

Pain

646

78.4

1.63 (1.23)

2 (0–4)

1.05 (0.99)

1 (0–4)

0.84 (0.90)

1 (0–4)

0.61 (0.81)

0 (0–4)

Constipation

463

63.5

0.92 (1.05)

1 (0–4)

0.81 (0.96)

1 (0–4)

0.75 (0.93)

1 (0–4)

0.72 (0.95)

0 (0–4)

Vomiting

313

38.0

0.62 (0.98)

0 (0–4)

0.43 (0.77)

0 (0–4)

0.34 (0.71)

0 (0–4)

0.26 (0.64)

0 (0–4)

Dyspnea

394

47.8

0.82 (1.07)

0 (0–4)

0.64 (0.92)

0 (0–4)

0.62 (0.90)

0 (0–4)

0.78 (1.12)

0 (0–4)

Anorexia

531

64.4

1.24 (1.24)

1 (0–4)

1.04 (1.14)

1 (0–4)

1.00 (1.14)

1 (0–4)

1.03 (1.28)

1 (0–4)

Sleep disturbance

356

43.2

0.67 (0.95)

0 (0–4)

0.50 (0.81)

0 (0–4)

0.46 (0.78)

0 (0–4)

0.35 (0.71)

0 (0–4)

Edema

340

41.3

0.74 (1.10)

0 (0–4)

0.67 (1.01)

0 (0–4)

0.66 (1.02)

0 (0–4)

0.71 (1.08)

0 (0–4)

Uncomfortable

364

44.2

0.67 (1.15)

0 (0–4)

0.60 (1.02)

0 (0–4)

0.57 (0.98)

0 (0–4)

0.55 (1.01)

0 (0–4)

Depression

333

40.4

0.58 (0.87)

0 (0–4)

0.47 (0.77)

0 (0–4)

0.43 (0.71)

0 (0–4)

0.31 (0.60)

0 (0–4)

Anxiety

280

34.0

0.45 (0.76)

0 (0–4)

0.38 (0.68)

0 (0–4)

0.36 (0.62)

0 (0–4)

0.25 (0.53)

0 (0–4)

aThe score at the 1st day of admission in this scale was equal to or more than 1

As mentioned previously, to investigate factors associated with the symptom reporting scores, a GEE model was applied to accommodate the correlated data of repeated measurements (on Days 1, 3, 5, and 7) in the same patient. After controlling for other factors in the multivariate GEE model, the day of palliative care administration proved a significant factor associated with all scales (all P ≤ 0.05), except Day 7 on the dyspnoea (P = .658) and oedema scales (P = .135) and Day 5 on the anxiety scale (P = .452) (Tables 3 and 4). In addition, after controlling for other factors in the multivariate GEE model, patients aged ≥ 65 years exhibited significantly lower scores on the pain, sleep disturbance, depression, and anxiety scales than did those aged < 65 years (all P ≤ .001). Moreover, after controlling for other factors in the multivariate GEE model, the female patients exhibited significantly higher scores on the vomiting (estimate [SD]: 0.32 [0.16] points), anorexia (0.23 [0.06] points), oedema (0.15 [0.16] points), depression (0.35 [0.11] points), and anxiety (0.77 [0.28] points) scales than did the male patients (all P ≤ .05) (Tables 3 and 4). Patients with gastrointestinal tract cancer exhibited higher scores on the constipation (0.21 [0.11] points), vomiting (0.90 [0.16] points), anorexia (0.59 [0.09] points), oedema (0.59 [0.16] points), depression (0.39 [0.15] points), and anxiety (0.35 [0.14] points) scales and lower scores on the dyspnoea (−0.36 [0.12] points) scale than did those with lung cancer. Patients with breast cancer exhibited higher scores on the oedema (1.43 [0.64] points) scale and lower scores on the anxiety (−0.61 [0.20] points) scale than did those with lung cancer. Furthermore, patients with genitourinary cancer exhibited higher scores on the vomiting (0.79 [0.19] points) and oedema (0.82 [0.21] points) scales and lower scores on the dyspnoea (−0.45 [0.15] points) scale than did those with lung cancer. Patients with head, neck, and oral cancer exhibited lower scores on the oedema (−1.02 [0.23] points) scale alone than did those with lung cancer. In addition, patients with other cancers exhibited higher scores on the anorexia (0.48 [0.13] points), sleep disturbance (0.58 [0.21] points), oedema (3.89 [0.54] points), uncomfortable (139.87 [0.19] points), and anxiety (3.08 [0.20] points) scales than did those with lung cancer (Tables 3 and 4).
Table 3

Estimates from GEEb modles of indicators of pain, constipation, vomiting, dyspnea, and anorexia

 

Pain

Constipation

Vomiting

Dyspnea

Anorexia

 

N

β(SE)a

P-value

β(SE)a

P-value

β(SE)a

P-value

β(SE)a

P-value

β(SE)a

P-value

Age, year

           

  < 65

 

Reference

-

Reference

-

Reference

-

Reference

-

Reference

-

  ≥ 65

 

−0.23 (0.06)

< 0.001

−0.19 (0.08)

0.087

−0.06 (0.12)

0.614

0.07 (0.09)

0.428

0.04 (0.06)

0.475

Gender

           

 Male

480

Reference

-

Reference

-

Reference

-

Reference

-

Reference

-

 Female

344

0.01 (0.06)

0.828

0.18 (0.12)

0.129

0.32 (0.16)

0.046

−0.06 (0.09)

0.548

0.23 (0.06)

< 0.001

Cancer

           

 Lung cancer

150

Reference

-

Reference

-

Reference

-

Reference

-

Reference

-

 Gastrointestinal cancer

267

0.12 (0.08)

0.146

0.21(0.11)

0.044

0.90 (0.16)

< 0.001

−0.36 (0.12)

0.002

0.59 (0.09)

< 0.001

 Breast cancer

55

0.02 (0.13)

0.875

−0.20 (0.19)

0.287

0.41 (0.23)

0.075

0.12 (0.18)

0.507

−0.07 (0.15)

0.638

 Genitourinary cancer

108

0.03 (0.10)

0.777

0.10 (0.14)

0.469

0.79 (0.19)

< 0.001

−0.45 (0.15)

0.002

0.19 (0.12)

0.102

 Head, neck, and oral cancer

185

0.15 (0.09)

0.108

0.10(0.13)

0.452

−0.25 (0.22)

0.245

−0.22 (0.13)

0.089

−0.15 (0.13)

0.242

 Other cancers

59

−0.02 (0.12)

0.836

0.09 (0.21)

0.684

−0.10 (0.34)

0.773

−0.22(0.15)

0.140

0.48 (0.13)

< 0.001

Day of palliative care

           

 1st day

822

Reference

-

Reference

-

Reference

-

Reference

-

Reference

-

 3rd day

824

−0.45 (0.02)

< 0.001

−0.20 (0.08)

0.013

−0.35 (0.05)

< 0.001

−0.22 (0.03)

< 0.001

−0.18 (0.02)

< 0.001

 5th day

823

−0.67 (0.03)

< 0.001

−0.22 (0.04)

< 0.001

−0.47 (0.08)

< 0.001

−0.25 (0.04)

< 0.001

−0.23 (0.03)

< 0.001

 7th day

822

−0.98 (0.04)

< 0.001

−0.21 (0.06)

< 0.001

−1.04 (0.09)

< 0.001

−0.02 (0.05)

0.658

−0.18 (0.04)

< 0.001

a Adjusted mean difference compared to referent group. bGEE:generalized estimating equation

Table 4

Estimates from GEEb modles of indicators of sleep disturbance, edema, uncomfortable, depression and anxiety

 

Sleep disturbance

Edema

Uncomfortable

Depression

Anxiety

 

N

β(SE)a

P-value

β(SE)a

P-value

β(SE)a

P-value

β(SE)a

P-value

β(SE)a

P-value

Age, year

           

  < 65

 

Reference

-

Reference

-

Reference

-

Reference

-

Reference

-

  ≥ 65

 

−0.39 (0.11)

< 0.001

−0.26 (0.15)

0.093

−0.08(0.11)

0.510

−0.52 (0.10)

< 0.001

−0.80 (0.12)

< 0.001

Gender

           

 Male

480

Reference

-

Reference

-

Reference

-

Reference

-

Reference

-

 Female

344

(0.07)

0.664

0.15 (0.16)

0.046

−0.06 (0.09)

0.548

0.35 (0.11)

< 0.001

0.77 (0.28)

0.005

Cancer

           

 Lung cancer

150

Reference

-

Reference

-

Reference

-

Reference

-

Reference

-

 Gastrointestinal cancer

267

0.37 (0.14)

0.008

0.59 (0.16)

< 0.001

0.24 (0.16)

0.126

0.39 (0.15)

0.010

0.35(0.14)

0.012

 Breast cancer

55

0.36 (0.37)

0.337

1.43 (0.64)

0.026

0.19 (0.28)

0.502

−0.13 (0.20)

0.527

−0.61 (0.20)

0.002

 Genitourinary cancer

108

0.12 (0.19)

0.518

0.82 (0.21)

< 0.001

0.16 (0.20)

0.419

0.22 (0.19)

0.252

0.04(0.17)

0.836

 Head, neck, and oral cancer

185

−0.03 (0.20)

0.881

−1.02 (0.23)

< 0.001

0.07 (0.19)

0.695

0.20(0.16)

0.215

0.34 (0.21)

0.105

 Other cancers

59

0.58 (0.21)

0.006

3.89 (0.54)

< 0.001

139.87(0.19)

<0.001

0.26 (0.19)

0.166

3.08 (0.20)

<0.001

Day of palliative care

           

 1

822

Reference

-

Reference

-

Reference

-

Reference

-

Reference

-

 3

824

−0.30 (0.04)

< 0.001

−0.11 (0.02)

< 0.001

−0.12 (0.04)

0.003

−0.20 (0.03)

< 0.001

−0.10 (0.02)

< 0.001

 5

823

−0.41(0.05)

< 0.001

−0.10 (0.02)

< 0.001

−0.17 (0.05)

< 0.001

−0.28 (0.04)

< 0.001

−0.02 (0.03)

0.452

 7

822

−0.66 (0.07)

< 0.001

0.10 (0.07)

0.135

−0.20 (0.06)

0.001

−0.63 (0.06)

< 0.001

−1.24 (0.05)

< 0.001

a Adjusted mean difference compared to referent group. b GEE generalized estimating equation

Discussion

This study demonstrated that the most severe symptoms of patients hospitalised for palliative care are pain, anorexia and constipation. In addition, the integration of hospital palliative care demonstrated favourable improvement in symptom severity. Moreover, differences in sex and primary cancer sites may contribute to varying degrees of improvement in symptom severity.

Terminally ill patients with cancer suffer from several physical and psychological symptoms and multiple organ failures; therefore, one of their main needs is to be comfortable and symptom-free at the end stage of their lives [16]. Thus, palliative cancer care essentially aims to provide such patients with symptom relief and higher quality of life [5, 17]. The findings of the present study confirmed the efficacy of palliative care based on the symptom improvement observed during the first week of the palliative unit inpatient care, except on Day 7 of dyspnoea and oedema assessment and Day 5 of anxiety assessment. Most previous studies have focused on the symptoms or symptom cluster screening in patients with advanced cancer receiving palliative care [7, 9, 18, 19]. Certain studies have conducted a longitudinal follow-up to observe the quality of life, symptom severity, and mood amongst outpatients with advanced cancer [14, 18]. The present study recruited 824 participants who were all admitted to the palliative care unit of a medical centre.

In addition, previous studies have focused on the roles of age and sex differences in symptoms improvement amongst patients with advanced cancer [9, 2023]. Consistent with the findings of a previous systematic review of symptom prevalence [9], we observed a significant association between pain improvement and older age. Moreover, similar associations were observed with sleep disturbance, depression, and anxiety. These findings suggest that younger patients require particular attention and active monitoring during symptom management. In addition considerable sex differences were observed regarding certain symptoms: female patients reported less improvement of vomiting, anorexia, sleep disturbance, depression, and anxiety after adjustment for age, primary cancer site, and day of palliative care administration. These results are consistent with those of a large-scale study of patients who did not receive anticancer treatments, which revealed marked sex differences in the prevalence of nausea [9, 23] but is inconsistent with the results of another similar study [18]. These differences may be attributable to the different measurement methods (symptom severity vs frequency), the different treatment settings (in outpatients vs in a palliative unit care), and varying analysis methods (adjustment of other factors or repeated measurements). Therefore, additional pooled data is required from such settings to determine the effects of age and sex on symptom improvement in such a patient population.

Moreover, our results helped identify the crucial aspects of symptom improvement for different primary cancer sites. Regarding pain, no significant differences were observed between the different types of cancer during the first week of admission. Gastrointestinal symptoms, including constipation, vomiting, and anorexia, were the most common and severe problems in patients with advanced cancer, particularly those with advanced gastrointestinal cancer; these symptoms may be attributable to refractory ascites or intra-abdominal masses or may be the side effects of opioid drugs administered to such patients. Dyspnoea is a concerning symptom and is more challenging to relieve in patients with advanced lung cancer. It may result from the destruction of lung tissue because of the growth and spreading of cancer cells. In addition, improvement of sleep disturbance was significantly lower amongst patients with advanced gastrointestinal cancer than amongst those with advanced lung cancer. Compared with patients with advanced lung cancer, management of lymphoedema was more challenging amongst those with advanced gastrointestinal, breast, and genitourinary cancer but easier amongst those with head, neck, and oral cancer. However, the varying sites of lymphoedema amongst patients with different types of cancer required further investigation to facilitate efficient management. Improvement of mood states, including depression and anxiety, was more challenging amongst patients with advanced gastrointestinal cancer than amongst those with advanced lung cancer ones. Patients with advanced breast cancer exhibited greater control of anxiety than did those with lung cancer; the reasons for this difference may be complicated because of other underlying physical symptoms (eg, dyspnoea).

The conditions of patients with advanced cancer may rapidly deteriorate during their terminal phase, and symptoms often worsen rapidly, suddenly, and unexpectedly. Thus, rapid and effective management of these symptoms is essential to ensure adequate improvement and a high ‘quality of death’. Therefore, the symptom severity assessment of patients with advanced cancer in palliative care units may provide additional valuable information regarding this crucial aspect of quality of care.

This was an observational study which evaluated clinical experiences and thus had considerable limitations. First, the symptom assessment checklist was a relatively short instrument which assessed only 10 symptoms. Second, assessment of the symptom scale scores every 2 days may be too close. However, this study aimed to explore the levels of symptom improvement after admission to the palliative care unit, where the palliative care team could resolve the symptoms as soon as possible. In addition, because the cancer progression in such patients may alter unexpectedly, we used a simple instrument to closely assess the improvement in symptom severity. Third, there was no information of the individual co-morbidity, which may be associated with distressing symptoms among advanced cancer patients. Fourth, this study recruited only advanced cancer patients with adequate level of consciousness to report symptoms and was conducted in one palliative care unit of a medical center, which may limit the generalization for all terminal patients and all palliative care units. A consistent symptom assessment tool for the routine quality indicators of the palliative care units is needed in the future.

Conclusion

This study confirmed considerable symptom improvement during the first week of palliative unit inpatient care, except on Day 7 of dyspnoea and oedema assessment and Day 5 of anxiety assessment. Improvement of pain, sleep disturbance, depression, and anxiety were significantly associated with older age. In addition, female patients with advanced cancer reported lower symptom improvement of vomiting, anorexia, sleep disturbance, depression, and anxiety than did the corresponding male patients. In addition, patients with different types of advanced cancer exhibited varying degrees of symptom improvement.

Abbreviations

GEE model: 

a generalised estimating equation model

Estimate [SD]: 

estimate [standard deviation]

Declarations

Acknowledgments

We appreciate the participation of all the advanced cancer patients in this palliative care unit during the study period and the cooperation of the staff. Besides, this study was supported by Kaohsiung Medical University Hospital (KMUH101-1R44 and KMUH103-3R68), Kaohsiung Municipal Hsiao-Kang Hospital (Kmhk-103-032) and the Ministry of Science and Technology (MOST103-2314-B-037-004-MY3). None of which had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Authors’ Affiliations

(1)
Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University
(2)
Department of Family Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University
(3)
Department of Family Medicine, Kaohsiung Medical University Hospital
(4)
Department of Family Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University
(5)
Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University
(6)
Department of Otorhinolaryngology, School of Medicine, College of Medicine, Kaohsiung Medical University
(7)
Departments of Otorhinolaryngology, Kaohsiung Medical University Hospital
(8)
Department of Otolaryngology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University

References

  1. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA: A Cancer Journal for Clinicians 2015;65:87-108.Google Scholar
  2. Ministry of Health and Welfare. 2014; http://www.mohw.gov.tw/EN/Ministry/Statistic.aspx?f_list_no=474&fod_list_no=3443.
  3. Hospice Foundation of Taiwan. 2014; http://www.hospice.org.tw/2009/english/index.php.
  4. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS,heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006;31:58-69.View ArticlePubMedGoogle Scholar
  5. Grunberg S. New directions in supportive care. Support Care Cancer. 2005;13:135–7.View ArticlePubMedGoogle Scholar
  6. Hoekstra J, de Vos R, van Duijn NP, Schade E, Bindels PJ. Using the symptom monitor in a randomized controlled trial: the effect on symptom prevalence and severity. J Pain Symptom Manage 2006;31:22-30.Google Scholar
  7. Tsai JS, Wu CH, Chiu TY, Hu WY, Chen CY. Symptom patterns of advanced cancer patients in a palliative care unit. Palliat Med. 2006;20:617–22.View ArticlePubMedGoogle Scholar
  8. Murtagh FEM, Addington-Hall J, Higginson IJ. The prevalence of symptoms in end-stage renal disease: a systematic review. Adv Chronic Kidney Dis. 2007;14:82–99.View ArticlePubMedGoogle Scholar
  9. Teunissen SC, Wesker W, Kruitwagen C, de Haes HC, Voest EE, de Graeff A. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage. 2007;34:94–104.View ArticlePubMedGoogle Scholar
  10. Dhingra L, Lam K, Homel P, Chen J, Chang VT, Zhou J, Chan S, Lam WL, Portenoy R. Pain in underserved community-dwelling Chinese American cancer patients: demographic and medical correlates. Oncologist. 2011;16:523–33.View ArticlePubMedPubMed CentralGoogle Scholar
  11. Ozcelik H, Fadiloglu C, Karabulut B, Uyar M. Examining the effect of the case management model on patient results in the palliative care of patients with cancer. Am J Hosp Palliat Med. 2013.Google Scholar
  12. Kao C-Y, Hu W-Y, Chiu T-Y, Chen C-Y. Effects of the hospital-based palliative care team on the care for cancer patients: an evaluation study. Int J Nurs Stud. 2013.Google Scholar
  13. Goodwin DM, Higginson IJ, Myers K, Douglas HR, Normand CE. Effectiveness of palliative day care in improving pain, symptom control, and quality of life. J Pain Symptom Manage. 2003;25:202–12.View ArticlePubMedGoogle Scholar
  14. Bakitas M, Lyons K, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the project enable ii randomized controlled trial. JAMA. 2009;302:741–9.View ArticlePubMedPubMed CentralGoogle Scholar
  15. LYNN MR. Determination and quantification of content validity. Nurs Res. 1986;35:382–6.View ArticlePubMedGoogle Scholar
  16. Klinkenberg M, Willems DL, van der Wal G, Deeg DJ. Symptom burden in the last week of life. J Pain Symptom Manage. 2004;27:5–13.View ArticlePubMedGoogle Scholar
  17. Hoekstra J, Bindels PJ, van Duijn NP, Schade E. The symptom monitor. A diary for monitoring physical symptoms for cancer patients in palliative care: feasibility, reliability and compliance. J Pain Symptom Manage. 2004;27:24–35.View ArticlePubMedGoogle Scholar
  18. Yamagishi A, Morita T, Miyashita M, Kimura F. Symptom prevalence and longitudinal follow-up in cancer outpatients receiving chemotherapy. J Pain Symptom Manage. 2009;37:823–30.View ArticlePubMedGoogle Scholar
  19. Tsai JS, Wu CH, Chiu TY, Chen CY. Significance of symptom clustering in palliative care of advanced cancer patients. J Pain Symptom Manage. 2010;39:655–62.View ArticlePubMedGoogle Scholar
  20. Grond S, Zech D, Diefenbach C, Bischoff A. Prevalence and pattern of symptoms in patients with cancer pain: a prospective evaluation of 1635 cancer patients referred to a pain clinic. J Pain Symptom Manage. 1994;9:372–82.View ArticlePubMedGoogle Scholar
  21. Lidstone V, Butters E, Seed PT, Sinnott C, Beynon T, Richards M. Symptoms and concerns amongst cancer outpatients: identifying the need for specialist palliative care. Palliat Med. 2003;17:588–95.View ArticlePubMedGoogle Scholar
  22. Lo RS, Ding A, Chung TK, Woo J. Prospective study of symptom control in 133 cases of palliative care inpatients in Shatin Hospital. Palliat Med. 1999;13:335–40.View ArticlePubMedGoogle Scholar
  23. Walsh D, Donnelly S, Rybicki L. The symptoms of advanced cancer: relationship to age, gender, and performance status in 1,000 patients. Support Care Cancer. 2000;8:175–9.View ArticlePubMedGoogle Scholar

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© Tai et al. 2016

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