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Needle procedures are among the most common causes of pain and distress for individuals seeking health care. While needle pain is especially problematic for children needle pain and associated fear also has significant impact on adults and can lead to avoidance of appropriate medical care. Currently there is not a standard definition of needle pain. A taxonomy, or classification system, for acute needle pain would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including needle pain. To accomplish this, a working group of experts in needle pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific needle pain. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of needle associated fear, are proposed to define the types of acute needle pain. PERSPECTIVE: This article presents a taxonomy for acute needle pain. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients undergoing needle procedures.

Although pain is the most common and disabling cancer symptom requiring management, the best index of cancer pain management adequacy is unknown. While the Pain Management Index is most commonly used, other indices have included relief, satisfaction, and pain intensity. We evaluated their correlations and agreement, compared their biopsychosocial correlates, and investigated whether they represented a single construct reflecting the adequacy of cancer pain management in 269 people with advanced cancer and pain. Despite moderate-to-severe average pain in 52.8% of participants, 85.1% had PMI scores suggesting adequate analgesia, pain relief was moderate and satisfaction was high. Correlations and agreement were low-to-moderate, suggesting low construct validity. Although the correlates of pain management adequacy were multidimensional, including lower pain interference, neuropathic and nociceptive pain, and catastrophizing, shorter cancer duration, and greater physical symptoms, no single index captured this multidimensionality. Principal component analysis demonstrated a single underlying construct, thus we constructed the Adequacy of Cancer Pain Management from factor loadings. It had somewhat better agreement, however correlates were limited to pain interference and neuropathic pain. This study demonstrates the psychometric shortcomings of commonly used indices. We provide suggestions for future research to improve measurement, a critical step in optimizing cancer pain management.PerspectiveThe Pain Management Index and other commonly used indices of cancer pain management adequacy have poor construct validity. This study provides suggestions to improve the measurement of the adequacy of cancer pain management.

PurposeIn the absence of treatments for chemotherapy-induced peripheral neuropathy (CIPN), dose reductions (DR) and premature discontinuation (PD) are primary management strategies. However, decision-making guidance is insufficient and knowledge of factors associated with DR/PD is limited. We examined biopsychosocial factors associated with CIPN-related DR/PD in women undergoing taxane-based chemotherapy for early-stage breast cancer.Patients and methodsAs part of a longitudinal study of CIPN measurement, women completed assessments before the first taxane infusion and at the final infusion or within the originally expected timeframe for the final infusion. Participants completed self-report measures of CIPN, pain, and physical and psychosocial wellbeing, and underwent physical testing of lower limb disability and Quantitative Sensory Testing for sensation and pain threshold to thermal, vibration, and touch stimuli in the feet and hands. Sociodemographic and clinical data were collected. Logistic regression was used to identify factors associated with neuropathy-related DR/PD.ResultsAmong 121 participants, 66 (54.5%) received taxane-as-prescribed, 46 (38.0%) had neuropathy-related DR/PD, and 9 (7.4%) had DR/PD for other reasons. Factors associated with neuropathy-related DR/PD were receipt of paclitaxel (Odds Ratio [OR]=75.05, 95% Confidence Interval [CI] 2.56-2197.96]), lower pre-treatment pain catastrophizing (OR=0.72, 95% CI: 0.54 – 0.95), and higher post-treatment neuropathic pain (OR=10.77, 95% CI: 1.99 – 58.15) and sensitivity to cold pain in the hand (OR=1.64, 95% CI: 1.05 – 2.56).ConclusionCIPN-related DR/PD is associated with paclitaxel treatment and post-treatment neuropathic pain and cold pain sensitivity in the hands. CIPN communication to healthcare providers may be influenced by pain catastrophizing, suggesting symptom appraisal may be an important factor in communication. Findings could contribute to clinical practice recommendations to facilitate treatment decision-making.Lay summaryWe studied pre- and post-treatment factors associated with reduced taxane dose or early cessation due to chemotherapy-induced peripheral neuropathy in women undergoing chemotherapy for early-stage breast cancer. Reduced taxane dose or early cessation is associated with paclitaxel treatment, and high post-treatment neuropathic pain and sensitivity to cold pain stimuli in the hands. Communication of these experiences to healthcare providers may be influenced by pre-treatment thoughts and feelings about symptoms.Precis for use in the Table of Contentstwo concise sentences that state the significant conclusion(s) or message of the manuscript; Chemotherapy-induced peripheral neuropathy-related reduced taxane dose or premature discontinuation is associated with paclitaxel treatment and high post-treatment neuropathic pain and cold pain sensitivity in the upper limbs. Reporting of these experiences may be influenced by pre-treatment symptom appraisal and communication style.

Pain-related stoicism and cautiousness are theorized to be more prevalent in older than younger patients and to lead to greater pain under-reporting and consequently inadequate pain management in older patients. The Pain Attitudes Questionnaire-Revised (PAQ-R), which measures 5 pain-related stoicism (fortitude, concealment, superiority) and cautiousness (self-doubt, reluctance) factors in chronic pain, can help test this hypothesis in advanced cancer but requires validation. We conducted a psychometric evaluation of the PAQ-R in 155 younger (younger than 60 years) and 114 older (aged 60 years and older) patients with advanced cancer. Participants showed disagreement with self-doubt items and floor effects with the subscale. Confirmatory factor analyses revealed good fit of the PAQ-R's 5 factors to younger and older groups' data but collinearity between fortitude and concealment. Multisample confirmatory factor analyses supported partial scalar invariance between age groups. Few hypothesized age-related differences were observed. Younger patients reported higher superiority scores than older patients. Whereas older patients showed greater fortitude and superiority with lower average pain intensity, younger patients showed greater concealment or fortitude with greater worst and average pain intensity. Furthermore, whereas older patients displayed greater superiority with lower interference in relations with others, younger patients displayed greater concealment and superiority with greater interference in walking ability and greater concealment and self-doubt with more interference in relations with others. Cross-validation of the PAQ-R's factor structure and identification of pathways to the factors and effect on pain-related outcomes using multivariate approaches are warranted. Perspective This article presents the psychometric properties of a measure of 2 particular pain-related attitudes. The measure can help clarify whether these attitudes adversely influence pain reporting in older patients with advanced cancer as hypothesized and, in turn, explain the inadequate pain management frequently reported with this clinical group.

Context: Health care professionals (HCPs) currently judge pain presence and intensity in patients with delirium despite the lack of a valid, standardized assessment protocol. However, little is known about how they make these judgments. This information is essential to develop a valid and reliable assessment tool. Objectives: To identify pain cues that HCPs report to judge pain in patients with delirium and to examine whether the pain cues differed based on patient cognitive status and delirium subtype. Methods: Mixed qualitative-quantitative design. Doctors and nurses were recruited. All participants provided written informed consent, and before the recorded interview, demographic information was collected; then participants were asked to describe their practices and beliefs regarding pain assessment and management with older patients who are cognitively intact and patients with delirium. Interviews were transcribed verbatim and coded for pain cues. Coded data were imported into SPSS software (IBM SPSS Statistics Version 24; IBM Corporation, Armonk, NY) to conduct bivariate analyses. Results: The pain cue self-report was stated more often for intact than for delirium patients (χ [1; N = 106] = 22.56; P < 0.001). HCPs stated yelling (χ [2; N = 159] = 11.14; P = 0.004), when describing pain in hyperactive than in hypoactive and mixed delirium patients; and significantly more HCPs stated grimace (χ [2; N = 159] = 6.88; P = 0.03), when describing pain in hypoactive than hyperactive and mixed patients. Conclusion: This study outlines how HCPs conduct pain assessment in patients who are delirious and, also, identifies pain behavior profiles for the subtypes of delirium.

Objective Acute leukemia (AL) is a life-threatening cancer associated with substantial morbidity and mortality, particularly in older adults. Given that there has been little research on the psychological impact of such malignancies with acute onset, we assessed the prevalence and correlates of depression and hopelessness in patients with AL. Methods Three hundred forty-one participants were recruited within 1 month of diagnosis or relapse and completed the Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), Memorial Symptom Assessment Scale, and other psychosocial measures. Multivariate regression analyses identified correlates of depression and hopelessness. Results 17.8% reported clinically significant depressive symptoms (BDI-II ≥ 15), 40.4% of which were in the moderate-severe range (BDI-II ≥ 20). 8.5% reported significant symptoms of hopelessness (BHS ≥ 8). Depression was associated with greater physical symptom burden (adjusted R2 = 48.4%), while hopelessness was associated with older age and lower self-esteem (adjusted R2 = 45.4%). Both were associated with poorer spiritual well-being. Conclusions Clinically significant depressive symptoms were common early in the course of AL and related to physical symptom burden. Hopelessness was less common and associated with older age and lower self-esteem. The results suggest that whereas depression in AL may be related to disease burden, the preservation of hope may be linked to individual resilience, life stage, and realistic prognosis. Copyright © 2015 John Wiley & Sons, Ltd.

Context Health care is increasingly focused on end-of-life care outcomes, but relatively little attention has been paid to how the dying experience is subjectively evaluated by those involved in the process. Objectives To assess the quality of death of patients with cancer and examine its relationship to receipt of specialized palliative care and place of death. Methods A total of 402 deaths of cancer patients treated at a university-affiliated hospital and home palliative care program in downtown Toronto, Ontario, Canada were evaluated by bereaved caregivers eight to 10 months after patient death with the Quality of Dying and Death (QODD) questionnaire. Caregivers also reported on bereavement distress, palliative care services received, and place of death. Results Overall quality of death was rated "good" to "almost perfect" by 39% and "neither good nor bad" by 61% of caregivers. The lowest QODD subscale scores assessed symptom control (rated "terrible" to "poor" by 15% of caregivers) and transcendence over death-related concerns (rated "terrible" to "poor" by 19% of caregivers). Multivariable analyses revealed that late or no specialized palliative care was associated with worse death preparation, and home deaths were associated with better symptom control, death preparation, and overall quality of death. Conclusion The overall quality of death was rated positively for the majority of these cancer patients. Ratings were highest for home deaths perhaps because they are associated with fewer complications and/or a more extensive support network. For a substantial minority, symptom control and death-related distress at the end of life were problematic, highlighting areas for intervention.

Age differences are not evident in pain-related stoicism and cautiousness in people with cancer pain. Little is known about the factors associated with these pain-related attitudes or age-related patterns in these associations. The present cross-sectional study investigated the biopsychosocial correlates of the attitudes in younger and older patients with advanced cancer. Pain-related stoicism (fortitude, concealment, superiority) and cautiousness (self-doubt, reluctance) were assessed using the Pain Attitudes Questionnaire-Revised (PAQ-R). Participants, 155 younger (younger than 60 years old) and 114 older (60 years old or older) patients with advanced cancer completed the PAQ-R and measures of sociodemographic and medical characteristics, pain intensity, cognitive-affective pain-related responses, physical functioning, psychological distress and well-being, and psychosocial functioning. Backwards regression analyses identified correlates for each PAQ-R factor separately for younger and older patients. Activity engagement was a frequent correlate, but its relationship with concealment was the only association common to both age groups. Younger and older patients exhibited different avoidance-related constructs suggesting relational challenges in the former group (avoidant attachment) and intrapersonal fear in the latter (cognitive avoidance). Medical correlates also showed age differences: younger patients showed symptom-focused correlates, whereas older patients showed aging-related correlates. Findings support a biopsychosocial framework of cancer-pain adaptation incorporating a lifespan-developmental perspective. Perspective To our knowledge, this article is the first to identify biopsychosocial correlates of stoic and cautious attitudes toward cancer pain in younger and older patients with advanced cancer. Findings highlight possible age-related motivations for greater pain-related stoicism or cautiousness and can potentially inform interventions addressing challenges in cancer-pain adaptation in advanced cancer.

Objective Age-related patterns in cancer pain remain equivocal. Most studies ignore heterogeneity across multiple domains of well-being, and the potential role of physical (PH) and mental health (MH) quality of life (QOL) in these age-related patterns is unknown. We investigated the relationships between age and cancer pain intensity, qualities, and interference, and physical and psychosocial adaptation and the interaction between age and PH and MH QOL on pain and adaptation to cancer pain. Design In this cross-sectional study, 244 patients with advanced cancer and pain completed measures of pain, QOL, physical function, and psychosocial well-being. Pearson's correlations and ANOVAs assessed relationships between age and demographic and clinical factors, pain, and physical and psychosocial measures. Regression models tested the role of age and its interaction with PH and MH QOL on pain and physical and psychosocial adaptation. Results Older age was associated with a lower likelihood of receiving an opioid prescription, greater likelihood of having comorbidities, and worse functional status. When we did not account for these factors, age was not associated with pain and most adaptation indices. When we did account for these factors and PH QOL, older age was associated with lower non-neuropathic and neuropathic pain and several indices of psychosocial adaptation. Most interestingly, older age was associated with lower non-neuropathic pain among those with high, but not low, MH QOL. Conclusions This study addresses knowledge gaps about factors underlying age-related patterns in cancer pain. Impaired MH QOL may be a proxy for age-related patterns in cancer pain. Summary This study investigated age-related patterns in the experience of cancer pain and the role of quality of life in resilience and vulnerability to pain and adaptation to pain. Older age is associated with lower non-neuropathic pain among those with high, but not low, mental health quality of life, suggesting that impaired mental health quality of life is an important indicator of vulnerability to multidimensional pain outcomes.

Summary Objective Clinical tools are needed to identify and target a neuropathic-like phenotype, which may be associated with central sensitization (CS), in osteoarthritis (OA). The modified painDETECT questionnaire (mPD-Q) has face and content validity for identifying neuropathic-like symptoms in knee OA. To further validate the mPD-Q, this study assessed the unknown relationship between mPD-Q scores and signs of CS on quantitative sensory testing (QST) in knee OA. Design 36 Individuals were recruited with chronic, symptomatic, knee OA without other pain/neurological conditions. Reference QST data were obtained from 18 controls/32 eligible knees, enabling identification of sensory abnormalities/CS among case knees. A standardized questionnaire assessed psychological factors (depressive symptoms and pain catastrophizing), and for individual knees, mPD-Q and pain intensity scores. A standardized/comprehensive QST protocol was conducted for each knee. QST signs of CS were defined as: mechanical hyperalgesia and/or enhanced temporal summation and/or allodynia. The relationship between the presence of CS (yes/no) and a pre-selected mPD-Q score (≤12 or >12), by knees, was assessed using generalized estimating equations. Results Among 57 eligible case knees, 45.6% had ≥1 sign of CS. Controlling for age, knees with higher mPD-Q scores (>12.0) had higher odds of having QST signs of CS (adjusted odds ratio (OR) = 5.6; 95% confidence interval (CI), 1.3–22.9). This relationship was unaffected by controlling for depression and pain intensity, but was attenuated by pain catastrophizing. Conclusions Among painful OA knees, higher mPD-Q scores were associated with greater odds of having signs of CS. Thus, the mPD-Q may aid the identification of CS in people with chronic knee OA.

Although an association between depression and physical burden has been demonstrated in advanced cancer, it remains unclear to what extent this is limited to specific physical symptoms, such as pain and fatigue, and is mediated by disease and treatment-related factors. We therefore investigated the relationship between depression and physical burden across a multitude of physical symptoms in this population, while controlling for cancer-related factors including disease severity and proximity to death.A secondary analysis was performed on cross-sectional data in 487 patients with advanced cancer. Measures included the Beck Depression Inventory II and the Memorial Symptom Assessment Scale, which measured physical burden across 24 common cancer symptoms. Disease severity was assessed by survival time and by functional status using the Karnofsky Performance Status scale.Depression severity significantly correlated with number of physical symptoms, symptom distress and symptom severity independent of cancer type, functional status, chemotherapy status and survival time (all p0.001). Depression was associated with increased incidence, severity and distress across multiple physical symptoms and was an independent predictor of physical burden on multiple regression analysis.These findings support the view that a synergistic relationship exists between depression and a broad array of physical symptoms in patients with advanced cancer.

Symptoms of traumatic stress are common in acute leukemia. The goal of the present qualitative study was to understand this traumatic stress, as perceived by patients. Participants were 43 patients with acute leukemia in Toronto, Canada. Participants were asked in serial interviews about their experience of diagnosis and treatment. A total of 65 interviews were analyzed utilizing the grounded theory method. Our findings provide insight into the traumatic experience of the diagnosis and treatment, as well as the initial psychological response to this trauma. Patients coped by surrendering control to the medical team, in whom they felt great trust. Patients also expressed a strong preference for limited information, with a preference to avoid discussions about overall prognosis. These results may inform interventions to relieve traumatic stress in this high risk population.

Pain is among the most common symptoms of cancer, with impacts on multiple domains of well-being. Biopsychosocial factors play an important role in adjustment to cancer pain. The Communal Coping Model (CCM), which may elucidate the social context of cancer pain, suggests that people catastrophize to convey distress and elicit support. Attachment style, one's ability to elicit and respond to available support, may be an important factor, but this has not been tested in people with cancer pain. This study examined pain catastrophizing, attachment style and relational context in relation to perceived solicitous, distracting, and punishing responses of significant others to pain in 191 patients with advanced cancer. Consistent with the CCM, higher pain catastrophizing was related to more frequent solicitous and distracting responses. Pain catastrophizing, attachment anxiety, and significant other type interacted in relation to punishing responses. Higher pain catastrophizing was related to less frequent punishing responses only in anxiously attached patients who identified their spouse/partner as their significant other. These results provide support for the CCM of cancer pain, and contribute to refinement of the model. Future research that includes patients and their caregivers is required to further explicate the social context of cancer pain. Perspective This article investigates the Communal Coping Model in people with cancer pain. In partial support of the model, we found that pain catastrophizing was related to more frequent solicitous and distracting responses but less frequent punishing responses only in anxiously attached patients who identified their spouse/partner as their significant other.

Delirium complicates pain assessment and management in advanced cancer. This retrospective cohort study compared health-care workers’ (HCWs) cancer pain judgments between older patients with advanced cancer with and without a diagnosis of delirium. We reviewed HCWs’ daily chart notations about pain presence and good pain control in 149 inpatients with advanced cancer, ≥65 years of age, admitted to a palliative care inpatient unit. Any day with 1 or more notations of pain presence was counted as 1 day with pain; days with notation(s) indicating good pain control were similarly counted. Proportions of days that HCWs judged inpatients to have pain and good pain control were calculated. Patients with and without a delirium diagnosis were compared on both pain outcomes. The moderating effect of highest analgesic class administered was examined. Although most patients received opioid analgesics, mean proportions of days with judged pain were high (39%-60%) and mean proportions of days with judged good pain control were low (

Developing educational interventions about pain may lead to improved pain management for older people. A public group educational session, entitled “Pain in the Older Person,” was presented in 7 cities across Canada (Vancouver, Calgary, London, Toronto, Ottawa, Montreal, and Halifax). The presentation lasted approximately 90 minutes and was followed by a question and answer period of at least 20 minutes. Prior to the educational session, participants provided demographic data and completed measures of pain intensity, frequency, interference, and treatment; of subjective health; and of knowledge about pain. Following the session, participants completed the same knowledge items again as well as items assessing satisfaction. Data were provided by 54 health care workers (HCW) and 54 older community members (66.3 ± 10.2 years old). Prior to the educational session, knowledge gaps were evident among the older community members, especially about analgesic use. Among the HCW, knowledge gaps were found about addiction and the relationship between pain and aging. Comparison of knowledge scores before and after the educational session revealed that both groups demonstrated significant knowledge gains. Satisfaction scores were very high, with no significant difference between HCW and older community members. This is the first study to show that a brief educational intervention is associated with gains in knowledge about pain and aging among both older community members and HCW. These results suggest that a brief public educational session is a promising method of pain education that may reduce barriers to pain management in older people. Perspective This article describes the results of a brief public educational session about pain and aging attended by older members of the community and health care workers. This intervention could potentially improve pain management for older people.

Recent comprehensive reviews have concluded that there is little evidence for the effectiveness of bereavement interventions. These reviews have not been limited to investigations of bereavement services for spouses of patients with cancer. This systematic review examined the evidence from 10 articles reporting on eight studies examining outcomes of bereavement interventions and adjustment to bereavement following specialized end-of-life patient care for spouses of patients with cancer. Patient end-of-life interventions may positively influence bereavement outcomes for spouses, but based on the available evidence, it is difficult to draw definitive conclusions about the effectiveness of bereavement group interventions for spouses of patients with cancer. Methodologically rigorous studies with larger sample sizes are required to determine the effectiveness of these interventions.

Context To increase the interpretability of quality of dying and death measures, research is needed to understand potential sources of response variation. Objectives The aim of this study was to understand how bereaved caregivers assess the quality of dying and death experience with the Quality of Dying and Death questionnaire (QODD) by exploring the cognitive processes that underlie their evaluations. Methods Bereaved caregivers of former metastatic cancer patients were asked to take part in a cognitive interview protocol after formulating the 31 quality ratings that contribute to the total QODD score. Qualitative content analysis was applied to transcribed interviews, with a specific focus on the information retrieved, the judgment strategies used, and any difficulties participants reported. Results Twenty-two bereaved caregivers were interviewed with the protocol. Information that formed the basis of quality ratings referred to the perspective of the patient, the caregiver, other family/friends, or a combination of perspectives. Quality rating judgment strategies were generally comparative, and the most common standards of comparison were to "a hoped for or ideal dying experience," "a state before the dying phase," "a state of distress/no distress," or "normalcy/humanness." All respondents relied on multiple perspectives and standards of comparison when answering the QODD. Conclusion These results suggest that the quality of dying and death is a complex construct based on multiple perspectives and standards of comparison. These findings have implications for clinical care, which, if it aspires to improve how dying and death are evaluated, must ensure that the family is the unit of care and aid in preparation for the dying and death experience.

Objective: The purpose of this study was to investigate the factor structure and psychometric properties of the Cardiac Rehabilitation Barriers Scale (CRBS). Design, setting, and participants: In total, 2636 cardiac inpatients from 11 hospitals completed a survey. One year later, participants completed a follow-up survey, which included the CRBS. A subsample of patients also completed a third survey which included the CRBS, the Cardiac Rehabilitation Enrolment Obstacles scale, and the Beliefs About Cardiac Rehabilitation scale three weeks later. The CRBS asked participants to rate 21 cardiac rehabilitation barriers on a five-point Likert scale regardless of cardiac rehabilitation referral or enrolment. Results: Maximum likelihood factor analysis with oblique rotation resulted in a four-factor solution: perceived need/healthcare factors (eigenvalue = 6.13, Cronbach’s α = .89), logistical factors (eigenvalue = 5.83, Cronbach’s α = .88), work/time conflicts (eigenvalue = 3.78, Cronbach’s α = .71), and comorbidities/functional status (eigenvalue = 4.85, Cronbach’s α = .83). Mean total perceived barriers were significantly greater among non-enrollees than cardiac rehabilitation enrollees ( P < .001). Convergent validity with the Beliefs About Cardiac Rehabilitation and Cardiac Rehabilitation Enrolment Obstacles scales was also demonstrated. Test-retest reliability of the CRBS was acceptable (intraclass correlation coefficient = .64). Conclusion: The CRBS consists of four subscales and has sound psychometric properties. The extent to which identified barriers can be addressed to facilitate greater cardiac rehabilitation utilization warrants future study.

Objective:Pain and delirium are commonly reported in older people with advanced cancer. However, assessing pain in this population is challenging, and there is currently no validated assessment tool for this task. The present retrospective cohort study was conducted to understand how healthcare workers (HCWs; nurses and physicians) determine that older cancer patients with delirium are in pain.Method:We reviewed the medical records of consecutive palliative care inpatients, 65 years of age and above (N= 113), in order to identify patient-based cues used by HCWs to make pain judgments and to examine how the cues differ by delirium subtype and outcome.Results:We found that HCWs routinely make judgments about pain in older patients with delirium using a repertoire of strategies that includes patient self-report and observations of spontaneous and evoked behavior. Using these strategies, HCWs judged pain to be highly prevalent in this inpatient palliative care setting.Significance of results:These novel findings will inform the development of valid and reliable tools to assess pain in older cancer patients with delirium.

Background: Although psychosocial care has been regarded as central to palliative and supportive care, there have been few empirically tested approaches to individual intervention. Aim: The subjective experience of advanced cancer patients receiving a new manualized brief individual psychotherapy, referred to as Managing Cancer and Living Meaningfully (CALM), was examined prior to the initiation of a randomized controlled trial testing the effectiveness of this intervention. Design: Semi-structured interviews were conducted with patients who had a diagnosis of advanced cancer, and who underwent the intervention. Setting/Participants: Patients were recruited from a large urban regional cancer center in Toronto, Canada. The 10 interviewees included seven women and three men. All had completed between three to six CALM sessions prior to the interview. Results: The CALM intervention was associated with profound and unique patient-identified benefits and no patient-identified risks or concerns. Five interrelated benefits of the intervention were identified: (1) a safe place to process the experience of advanced cancer; (2) permission to talk about death and dying; (3) assistance in managing the illness and navigating the healthcare system; (4) resolution of relational strain; and (5) an opportunity to ‘be seen as a whole person’ within the healthcare system. These benefits were regarded by participants as unique in their cancer journey. Conclusions: Findings from a qualitative study suggest that the CALM intervention provides substantial benefits for patients with advanced cancer prior to the end of life. Findings informed the development of a randomized controlled trial to evaluate the effectiveness of this intervention.

SummaryObjectiveA neuropathic pain (NP) questionnaire may facilitate the identification of a neuropathic component to osteoarthritis (OA) pain. An existing questionnaire, the painDETECT, was modified for use in knee OA and administered to measure the prevalence and correlates of NP symptoms among adults with this condition.MethodSensibility of the modified painDETECT (mPD-Q) was assessed in 20 OA subjects followed by mail administration in an established knee OA cohort. NP symptoms were defined using a previously established, painDETECT cut-point. Correlates of NP symptoms, including OA severity (Western Ontario and McMaster Universities Osteoarthritis Index, Von Korff Chronic Pain Grade pain subscale score), psychological factors (Centre for Epidemiological Studies Depression Scale, Pain Catastrophizing Scale), and concomitant medical conditions, were evaluated using logistic regression. Construct validity of the mPD-Q was evaluated through co-administration with another NP questionnaire (S-LANSS).ResultsThe mPD-Q had face and content validity. Of 259 eligible cohort members, 171 (66%) completed the questionnaire; 28% had NP symptoms on the mPD-Q (19% among those without neurological conditions). Independent correlates of NP symptoms were: pain intensity (adjusted odds ratio [OR]=2.1 per 10 unit increase, P

Higher rates of depression in women compared to men have been attributed to intrinsic biological or psychological vulnerabilities, to their disproportionate exposure to stressful events and circumstances, or to the combined contributions of these factors. This study aimed to determine if there is a gender disparity in depression rates in patients with advanced cancer, a circumstance associated with multiple stressors and a high prevalence of depression. Data were collected from 569 patients, assessing demographic characteristics, depressive symptoms, physical symptoms, and social support. Clinically significant symptoms of depression (BDI-II scores ≥16) were reported by more than 20% of the sample, with no significant gender differences in depression. There were no significant gender differences in potentially confounding factors such as social support or physical symptom burden. The results indicated that men and women may be equally likely to develop depression when faced with a highly stressful circumstance.

Objective: Although the Beck Hopelessness Scale is often used with the seriously ill, its factor structure has been given relatively little consideration in this context. Methods: The factor structure of this scale was examined in a sample of 406 ambulatory patients with advanced lung or gastrointestinal cancer, using a sequential exploratory-confirmatory factor analysis procedure. Results: A two-factor model was consistent with the data: The first factor reflected a negative outlook and was labeled ‘negative expectations’; the second factor identified a sense of resignation and was labeled ‘loss of motivation.’ Conclusions: Implications regarding scoring of the scale in this population are discussed, as are implications of the two-factor structure for our understanding of hopelessness in individuals with advanced cancer. Copyright © 2009 John Wiley & Sons, Ltd.

Psychological distress in cancer patients is inversely related to age, although the reasons are unclear. The adult development literature suggests that ageing may be associated with the development of adaptive capacities, specifically greater attachment security (the sense that others will be available and supportive when needed) and spirituality (the capacity to view one's life as having meaning, purpose and value), that enable older people to cope better with disease. We examined whether age-related patterns in attachment security and spiritual wellbeing account for the protective effect of age against distress. Measures of depression, attachment security, spiritual wellbeing and disease burden were collected from 342 patients aged from 21 to 88 years with advanced, metastatic cancer. Attachment security and spiritual wellbeing were tested as mediators of the effect of age on depression, controlling for disease burden. It was found that age was associated inversely with depression and positively with spiritual wellbeing and attachment security. Depression was inversely related to attachment security and spiritual wellbeing, and the effect of age on depression was fully mediated by attachment security and spiritual wellbeing. The relative protection from psychological distress among older cancer patients may be the result of age-related developmental accomplishments and/or differences in the response to adverse life-events.

Research is needed on the desire for hastened death (DHD) in the context of advanced cancer in order to address the clinical, ethical, and legal questions that it raises. The goal of the present qualitative study was to understand the experience of the DHD as expressed by individuals with advanced cancer, and to understand how it evolves over time. Participants were 27 ambulatory patients aged 45-82 years with advanced lung or gastrointestinal cancer. Participants were recruited through theoretical sampling from outpatient clinics at a large cancer center in Toronto Canada, and were asked about the DHD in serial, open-ended interviews until the point of death. A total of 54 interviews were analyzed based on the grounded theory method. The experience of the DHD in the context of advanced cancer was found to be subsumed under three distinct categories: i) DHD as a hypothetical exit plan; ii) DHD as an expression of despair; and iii) DHD as a manifestation of letting go. Each category had unique temporal and qualitative characteristics. The identification of these categories may be important to inform future research on the DHD, the criteria for clinical intervention in individuals who express this desire, and the public debate about physician-assisted suicide and euthanasia for individuals with advanced disease.

Objective: Attachment security has been identified as an important buffer of distress in patients with cancer and other medical illnesses but current measures have not been adapted for this population who may be older, in long-term stable relationships, and suffering from considerable disease burden. This study reports on (1) the psychometric properties of a modified 36-item Experiences in Close Relationships scale (ECR), adapted for this population; and (2) the validity of a brief 16-item version of our modified scale. Methods: A modified ECR (ECR-M36) was constructed by rephrasing relevant items to refer more generally to people with whom one feels close, instead of specifically in relation to one's romantic partner(s). Patients with metastatic gastrointestinal (GI) and lung cancer completed the ECR-M36 and other scales tapping self-esteem, social support, and depressive symptoms on two occasions within a period of 4–6 months. Based on factor analyses of the ECR-M36, 16 items were selected to form a brief measure (ECR-M16). Results: Factor analyses of both ECR forms revealed a higher-order factor structure in which four first-order factors (Worrying about Relationships, Frustration about Unavailability, Discomfort with Closeness, Turning Away from Others) loaded onto two second-order factors tapping Attachment Anxiety and Avoidance. Both ECR forms were reliable and valid. Conclusion: The ECR-M36 and ECR-M16 are good measures of attachment orientations for use with medically ill, older populations. Copyright © 2008 John Wiley & Sons, Ltd.

The pain and aging subfield has grown dramatically, including a 6-fold increase in publications over the last 2 decades. This subfield is based on the assumption that pain in older and younger adults differs in clinically and theoretically significant ways. If this were not the case, data from younger groups could be generalized to older persons, and the subfield would not be needed. This article considers the evidence for this assumption. Possible interpretations of the discrepant findings of age-related increases, decreases and stability in pain, including methodological limitations, challenges of gerontological research, and the possibility of nonuniform age-related variation, are discussed. Evidence is presented for several unique characteristics of geriatric pain: difficulty using Visual Analog Scales, increased vulnerability to neuropathic pain, decreased vulnerability to acute pain related to visceral pathology, prolonged recovery from tissue and nerve injury, including prolonged hyperalgesia, and differences in the relationships among psychosocial factors important in adjustment to chronic pain. However, without a theoretical framework, it is difficult to integrate these results in a heuristic manner. Further research is needed to elucidate the characteristics of geriatric pain, to examine the mechanisms for age-related patterns, and to develop and test the efficacy of age-tailored interventions. Perspective This article reviews the emerging subfield of pain and aging, discusses the interpretation of age-related patterns in pain, and presents several avenues for future research and subfield development. This could contribute to the continued growth of this subfield.

Purpose This study examines the rate and prediction of referral for specialized psychosocial oncology care in 326 patients with metastatic GI or lung cancer. Patients and Methods Referral information was abstracted from medical records and hospital databases. Patients completed measures of psychosocial and physical distress and functioning. Results Routine referral occurred in 33% of patients, and in 42% and 44%, respectively, of those scoring high on measures of depression (Beck Depression Inventory [BDI]-II ≥ 15) and hopelessness (Beck Hopelessness Scale ≥ 8). Univariate analyses indicated that referral was associated with younger age, unmarried status, living alone, presence of more depressive symptoms, hopelessness, and attachment anxiety, and with less social support, self-esteem, and spiritual well-being (all P < .05). Among the significantly depressed (BDI-II ≥ 15), 100% of those less than 40 years of age, but only 22% of those age 70 years or older were referred. Multivariate analyses indicated that referral was associated with younger age, unmarried status, and presence of more depressive symptoms. Moreover, increasing age was associated with a progressively lower likelihood of referral independent of the level of distress. Conclusion Routine referral of patients with metastatic cancer for psychosocial oncology care was predicted by presence of more severe depressive symptoms, younger age, and unmarried status. The rate of referral progressively declined with each decade of age, even among those with significant distress. These findings are consistent with some aspects of Andersen's model of health care utilization. The extent to which referred patients represent those who are most likely to benefit deserves further investigation.

A substantial minority of patients in palliative care settings report a high desire for hastened death (DHD), in association with physical and emotional distress, low social support, and impaired spiritual well being. To clarify to what extent DHD emerges in association with suffering prior to the end of life, we determined its prevalence and correlates in ambulatory patients with metastatic cancer, the majority of whom had an expected survival of6 months. We hypothesized that DHD in this sample would be directly linked to physical and psychological distress, and inversely related to perceived social support, self-esteem, and spiritual well being. Three hundred twenty-six outpatients completed the Schedule of Attitudes Toward Hastened Death (SAHD), Brief Pain Inventory, Memorial Symptom Assessment Scale, Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), Medical Outcomes Study Social Support Survey, FACIT-Spiritual Well-Being Scale, Rosenberg Self-Esteem Scale, and Karnofsky Performance Status. Over 50% of participants reported pain,20% reported elevated levels of depression (BDI-IIor =15) and hopelessness (BHSor =8), but2% had a high DHD (SAHDor =10). DHD was correlated positively with hopelessness, depression, and physical distress, and negatively with physical functioning, spiritual well being, social support, and self-esteem; it was not associated with treatment status or proximity to death. Over 34% of the variance in predicting SAHD scores was accounted for by hopelessness, depression, and functional status. The relative absence of a strong DHD in this sample suggests that the will to live tends to be preserved in cancer patients prior to the end of life, in spite of significant emotional and physical suffering.

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

Acute leukemia (AL) is a life-threatening cancer associated with substantial morbidity and mortality, particularly in older adults. Given that there has been little research on the psychological impact of such malignancies with acute onset, we assessed the prevalence and correlates of depression and hopelessness in patients with AL.Three hundred forty-one participants were recruited within 1 month of diagnosis or relapse and completed the Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), Memorial Symptom Assessment Scale, and other psychosocial measures. Multivariate regression analyses identified correlates of depression and hopelessness.17.8% reported clinically significant depressive symptoms (BDI-II ≥ 15), 40.4% of which were in the moderate-severe range (BDI-II ≥ 20). 8.5% reported significant symptoms of hopelessness (BHS ≥ 8). Depression was associated with greater physical symptom burden (adjusted R(2) = 48.4%), while hopelessness was associated with older age and lower self-esteem (adjusted R(2) = 45.4%). Both were associated with poorer spiritual well-being.Clinically significant depressive symptoms were common early in the course of AL and related to physical symptom burden. Hopelessness was less common and associated with older age and lower self-esteem. The results suggest that whereas depression in AL may be related to disease burden, the preservation of hope may be linked to individual resilience, life stage, and realistic prognosis.Copyright © 2015 John WileySons, Ltd.

Age differences in the experience of chronic pain remain unclear. A serious barrier to progress in the field of pain and aging arises from the lack of data regarding the psychometric properties of pain scales for use with the elderly. The present study was designed to assess age differences in pain intensity and quality and to compare the psychometric properties of the McGill Pain Questionnaire (MPQ) in young and elderly chronic pain patients. Young (n=139, mean age=42.93+/-9.41 years) and elderly (n=139, mean age=70.12+/-7.51 years) pain center patients, matched on primary diagnosis or pain location, duration, and sex, completed the MPQ, numeric ratings (0-10) of pain intensity, a Pain Map, and the Hospital Anxiety and Depression Scale (HADS). A Pain Management Index (PMI) score was calculated for each patient. Age differences on the measure of pain qualities were found. The elderly group had significantly lower MPQ total and sensory scores and chose fewer words than the young group. However, there were no significant differences between the groups on numeric ratings of highest, usual, and lowest pain intensity. Similarly, there were no age differences on PMI, Pain Map, or the HADS Depression or Anxiety Subscales. Finally, the latent structure, internal consistency, and pattern of subscale correlations of the MPQ were very similar in the young and elderly groups. Possible explanations for the discrepancy in the pattern of age differences on measures of pain intensity and quality are explored. The implications of this pattern of age differences for basic pain mechanisms and pain management should be given serious empirical attention.

As the population ages, research into the assessment of postoperative pain in older patients is urgently needed. The reliability and validity of most pain scales for the assessment of acute postoperative pain in the elderly remain to be demonstrated. The present study reports the analysis of age-related patterns on three pain scales (McGill Pain Questionnaire, MPQ; Present Pain Intensity, PPI; and Visual Analog Scale, VAS) completed by younger (n=95, mean age=56.4+/-5.8 years) and older (n=105; mean age=66.8+/-2.7 years) men following radical prostatectomy. All patients received intravenous morphine via patient-controlled analgesia (PCA) throughout the study. On the first 2 postoperative days (POD), patients completed the pain scales and PCA opioid intake was recorded. An interaction was found between amount of opioid self-administered and POD. In both groups, less opioid was administered on POD 2 than POD 1, but the decrease over time was greater in younger than older men. On both PODs, older men self-administered less opioid than younger men. Age differences in pain were dependent on the pain scale used. Older men had significantly lower scores than younger men on the MPQ and PPI but there were no differences on the VAS. Several age differences in the psychometric properties of the scales were evident. On both PODs, the correlation between VAS and MPQ scores was significantly lower in the older than younger group. POD effect sizes did not differ between the scales or age groups suggesting that all three scales have comparable sensitivity within an age group. However, the different results between the scales for the effect of age suggests that the VAS is not sufficiently sensitive to detect age differences. Therefore, age differences in postoperative pain are better captured by verbal descriptions of pain qualities than non-verbal measures of intensity.

Objective To test a conceptual model of sources of spiritual well-being in patients facing life-limiting disease. Design Cross-sectional survey. Setting Princess Margaret Hospital, Toronto, Canada. Participants 747 patients with stage IV gastrointestinal, breast, genitourinary or gynaecological cancer, or stage IIIA, IIIB or IV lung cancer, recruited from 2002 to 2008. Main outcome measure Spiritual well-being as assessed by the FACIT-Sp-12. Results Using structural equation modelling, spiritual well-being was specified as being predicted by religiosity, self-esteem, social relatedness and the physical burden of disease. The model had a good fit, Comparative Fit Index=0.96, Non-normed Fit Index=0.94, Root Mean Square Error of Approximation=0.057. Standardised path coefficients relating each factor to spiritual well-being were as follows: religiosity 0.50, social relatedness 0.28, self-esteem 0.26 and physical burden −0.11. Conclusions The authors confirmed our theoretical model in which spiritual well-being is positively associated with religiosity, self-esteem and social relatedness, and is negatively associated with physical suffering. Our findings support a multidimensional approach to spiritual well-being that addresses not only religious issues, but also pain and symptom control, and the potentially damaging effects of advanced disease on self-worth and close relationships. The spiritually informed clinical encounter may be one in which sufficient time and opportunity for reflection are afforded to consider illness trajectories and treatment decisions in the context of religious beliefs and personal values, self-worth, support systems and concerns about dependency.

Treatment of adult acute myeloid leukemia (AML) is intensive, with induction treatment initiated in an inpatient setting and subsequent consolidation therapy often conducted in an outpatient setting. The purpose of the present qualitative paper is to provide insight into the experience of patients in the transition from inpatient to ambulatory care.Participants were 35 AML patients who were interviewed about their experience of the illness and treatment. Utilizing the grounded theory method, we describe the adjustment of participants to the transition to ambulatory care.As outpatients, participants described adjusting to the intensity of ambulatory treatment and to the need to assume greater responsibility for their care. They also expressed a growing desire to understand their long-term care plan, compared to their preference to focus on the present prior to discharge, and they were struggling to construct a new sense of identity.AML patients are now leaving acute care settings sicker and earlier. Considering their perceptions can inform interventions to facilitate adjustment during the transition to outpatient care.

We report the results of a study designed to assess age differences in the response to the formalin test, a model of tissue injury and inflammation, while controlling for differences in weight and motoric abilities in three groups of adult male Long-Evans rats: young (3 months old), middle-aged (18 months old), and old (24 months old). The first part of the study assessed initial differences in responsivity and found that the middle-aged group showed the greatest response, whereas the young and old groups did not differ from each other. In the second part of the study, the young and middle-aged animals were followed for a 4-month period. The formalin test was repeated at 2-month intervals. These results indicate that there may be an age-associated change in the sensitivity to tonic pain and that this sensitivity may peak at mid-life.

During presentations about aging and clinical pain, almost invariably, someone will ask, “Does pain threshold change with age? Wouldn't that explain your results?” These are complicated questions, and there is rarely time in the few minutes usually allotted for “Q and A” to give an adequate response. Instead, more than once I've replied, “What would age differences in pain threshold tell you about clinical pain?” This is not intended to challenge the audience member but rather to reflect the pain research community's long struggle to understand the relevance of data from experimental pain models to clinical pain. Most experimental, or laboratory, pain models involve the application of carefully controlled stimulation. Experimental participants are asked to indicate when they first feel the sensation (detection threshold), when it first becomes painful (pain threshold), and if stimulation is continued or its intensity increased, when they would like it to be terminated (pain tolerance) [1]. In these studies, participants are informed that they will suffer no permanent damage from the stimulation and may terminate it whenever they choose. Critics have suggested that the experimental situation cannot adequately mirror the clinical situation, especially in regard to the affective and evaluative dimensions of pain [2]. For instance, while a healthy older person may experience some transient anxiety about an upcoming shock which they have been assured will cause no permanent damage and can be easily terminated, this is far from the anxiety an older person with cancer might experience in the face of an exacerbation of pain. This person may fear disease progression, uncontrollable pain, physical disability that may necessitate institutionalization, and the impact of the pain on their quality of life and death. Proponents of experimental pain models do not deny this limitation. Instead, they point out that there are important …

BACKGROUND: Recent studies of the relationship between age and the intensity of chronic pain report increases, decreases or no change in pain intensity as a function of age. These inconsistencies may be due in part to the pain assessment tools employed and their appropriateness with different age groups.OBJECTIVES: To assess age differences in chronic pain by using several measures of pain intensity and a multidimensional measure of pain qualities in the same sample; to assess the consistency of pain intensity estimates obtained from different scales within age groups; to determine whether the failure rates for appropriately completing the scale (such as choosing more than one descriptor or making more than one mark on the Visual Analog Scale [VAS]) differ among age groups.SUBJECTS: Seventy-nine adults aged 27 to 79 years with chronic arthritis pain.MEASUREMENTS: The unidimensional pain intensity scales used were the VAS, the Verbal Descriptor Scale and the Behavioural Rating Scale. The multidimensional pain scale used was the short form McGill Pain Questionnaire (SF-MPQ). The Beck Depression Inventory was also administered.RESULTS: Age-related decreases were found in the sensory and affective dimensions of chronic pain as measured with the SF-MPQ. No age differences in pain intensity were measured with any of the unidimensional scales. These results were maintained after controlling for the effects of concurrent depressive symptomatology. Pain intensity estimates differed within groups, with verbal descriptors yielding the most consistent estimates in the elderly group. The elderly were significantly more likely to fail on the VAS than younger subjects. There were no age differences on any other measure.CONCLUSIONS: There may be age-related changes in the quality but not in the intensity of chronic arthritis pain. Implications for clinical pain assessment in the elderly are discussed.

Pain is among the most common symptoms of cancer. Because cancer can occur at any age, it is imperative that pain assessment tools are valid for use across the adult lifespan. The Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2) is a valid and reliable tool for the assessment of the multidimensional qualities of pain in people with chronic nonmalignant pain, but its psychometric properties in people with cancer pain and in older versus younger people require investigation. This study evaluated age differences in the validity, reliability, and use of the SF-MPQ-2 in 244 people with advanced cancer and pain. We confirmed the previously reported 4-factor solution in older (≥ 60 years) and younger (60 years) patients. Internal consistency reliability and convergent validity were similar across age groups, although the SF-MPQ-2 sensory subscales were correlated with mental health quality of life in older, but not younger, patients. Older and younger patients selected the same words with the same intensity to describe their pain. The most commonly selected words in both age groups were aching, tiring-exhausting, sharp, and dull. These results demonstrate that the SF-MPQ-2 is appropriate for use across the adult lifespan in people with cancer pain.This study demonstrated that the SF-MPQ-2 is valid for use in older and younger people with advanced cancer and pain. This measure could improve cancer pain assessment across the adult lifespan, which may lead to improved pain management.

We examined the symptoms and referral rates to specialized palliative care and psychosocial oncology services of patients with acute leukemia. The Memorial Symptom Assessment Scale (MSAS) was completed by 249 adult patients with acute leukemia. Patients reported a median of 9 physical and 2 psychological symptoms, and those with intense lack of energy, difficulty sleeping and pain were more likely to report intense worrying/sadness (P < 0.001). No patients with moderate-severe pain were referred for specialized symptom control and only 13% of those with severe worrying/sadness were referred to psychiatry/psychology within one month of the assessment. Patients in this population have a substantial symptom burden; further research is needed to determine the benefit of early referral to specialized supportive care services.

Objective Acute leukemia is a condition with an acute onset that is associated with considerable morbidity and mortality. However, the psychological impact of this life-threatening condition and its intensive treatment has not been systematically examined. In the present study, we investigate the prevalence and correlates of post-traumatic stress symptoms in this population. Methods Patients with acute myeloid, lymphocytic, and promyelocytic leukemia who were newly diagnosed, recently relapsed, or treatment failures were recruited at a comprehensive cancer center in Toronto, Canada. Participants completed the Stanford Acute Stress Reaction Questionnaire, Memorial Symptom Assessment Scale, CARES Medical Interaction Subscale, and other psychosocial measures. A multivariate regression analysis was used to assess independent predictors of post-traumatic stress symptoms. Results Of the 205 participants, 58% were male, mean age was 50.1 ± 15.4 years, 86% were recently diagnosed, and 94% were receiving active treatment. The mean Stanford Acute Stress Reaction Questionnaire score was 30.2 ± 22.5, with 27 of 200 (14%) patients meeting criteria for acute stress disorder and 36 (18%) for subsyndromal acute stress disorder. Post-traumatic stress symptoms were associated with more physical symptoms, physical symptom distress, attachment anxiety, and perceived difficulty communicating with health-care providers, and poorer spiritual well-being (all p

The alleviation of distress associated with death and dying is a central goal of palliative care, despite the lack of routine measurement of this outcome. In this study, we introduce the Death and Dying Distress Scale (DADDS), a new, brief measure we have developed to assess death-related anxiety in advanced cancer and other palliative populations. We describe its preliminary psychometrics based on a sample of 33 patients with advanced or metastatic cancer. The DADDS broadly captures distress about the loss of time and opportunity, the process of death and dying, and its impact on others. The initial version of the scale has a one-factor structure and good internal reliability. Dying and death-related distress was positively associated with depression and negatively associated with spiritual, emotional, physical, and functional well-being, providing early evidence of construct validity. This distress was relatively common, with 45% of the sample scoring in the upper reaches of the scale, suggesting that the DADDS may be a relevant outcome for palliative intervention. We conclude by presenting a revised 15-item version of the scale for further study in advanced cancer and other palliative populations.

Acute leukemia is a condition with an acute onset that is associated with considerable morbidity and mortality. However, the psychological impact of this life-threatening condition and its intensive treatment has not been systematically examined. In the present study, we investigate the prevalence and correlates of post-traumatic stress symptoms in this population.Patients with acute myeloid, lymphocytic, and promyelocytic leukemia who were newly diagnosed, recently relapsed, or treatment failures were recruited at a comprehensive cancer center in Toronto, Canada. Participants completed the Stanford Acute Stress Reaction Questionnaire, Memorial Symptom Assessment Scale, CARES Medical Interaction Subscale, and other psychosocial measures. A multivariate regression analysis was used to assess independent predictors of post-traumatic stress symptoms.Of the 205 participants, 58% were male, mean age was 50.1 ± 15.4 years, 86% were recently diagnosed, and 94% were receiving active treatment. The mean Stanford Acute Stress Reaction Questionnaire score was 30.2 ± 22.5, with 27 of 200 (14%) patients meeting criteria for acute stress disorder and 36 (18%) for subsyndromal acute stress disorder. Post-traumatic stress symptoms were associated with more physical symptoms, physical symptom distress, attachment anxiety, and perceived difficulty communicating with health-care providers, and poorer spiritual well-being (all p0.05).The present study demonstrates that clinically significant symptoms of traumatic stress are common in acute leukemia and are linked to the degree of physical suffering, to satisfaction with relationships with health-care providers, and with individual psychological characteristics. Longitudinal study is needed to determine the natural history, but these findings suggest that intervention may be indicated to alleviate or prevent traumatic stress in this population.

The will to live is a natural instinct experienced by all human beings. It tends to persist in humans, despite marked adversity such as that associated with advanced cancer. The will to live may be measured directly, or indirectly, by assessing the desire for hastened death. Factors that may affect it include age, life stage, and physical and psychological distress. In particular, states of depression and hopelessness may precede the loss of the will to live. Other psychosocial variables that may affect the will to live include physical suffering, attachment security, self-esteem, and spiritual well-being. A number of screening tools are available to identify risk factors for the loss of the will to live. Awareness of these factors can guide interventions to preserve morale and maintain hope in patients faced with a terminal illness. Critical among these are the alleviation of physical and psychosocial distress and the establishment of a therapeutic alliance that is sensitive to the specific support needs of individual patients. Comfort and facility with such supportive interventions in oncology will require greater attention to the development of communication and relationship skills at both undergraduate and postgraduate levels of training.

Objective: Improving quality of life is the main goal of palliative cancer care. However, there is a lack of measures validated specifically for advanced cancer. The purpose of this study was to validate the Quality of Life at the End of Life (QUAL-E) measure in a sample of patients with advanced cancer. Methods: Data were analysed for 464 patients with advanced cancer who were participating in a randomised controlled trial of early palliative care intervention versus routine care. Patients completed the 26-item QUAL-E, the Functional Assessment of Cancer Therapy (FACT-G) quality of life measure and measures of spiritual well-being, performance status, symptom burden, satisfaction with care and communication with health care providers. We conducted a confirmatory factor analysis on the QUAL-E to test for the hypothesised four-factor structure and examined construct validity by calculating correlations with relevant scales. Results: A 17-item reduced version of the QUAL-E, the QUAL-E-Cancer (QUAL-EC) achieved an acceptable fit to a four-factor model. Both the full and reduced versions of the QUAL-E were internally reliable and showed good construct validity. Symptom Control was correlated with other measures of physical functioning; Relationship with Healthcare Provider was correlated with satisfaction with care and better physician and nurse communication; Preparation for End of Life was strongly associated with emotional well-being; and Life Completion was strongly associated with social and spiritual well-being. Conclusions: Due to its good factor structure and sound psychometrics, we recommend the reduced QUAL-EC scale to assess quality of life in patients with advanced cancer.