¶ … nursing research findings into clinical practice. Nociceptive Pain at the end of life

Conduct a Medline/PubMed & CINAHL search to identify 2 (two) PRIMARY SOURCE research articles that were published within the last 5 years that are not cited in the text Oxford Textbook of Palliative Nursing by Ferrell & Coyles chapter 6.

McMillan and Small (2007) conducted research in order to test whether the COPE intervention would help caregivers better manage symptoms and pain that is experienced by patients with incurable cancer. Since the caregiver acts as mediator between the critically ill patient and the hospital staff, the hospital staff, usually, relies on the caregiver for description of the patient's pain and symptoms. Caregivers, however, are frequently unable to adequately describe and recognize the intensity of symptoms as well as the emotional quality of life (QOL) of patient (all of which contributes to the pain). The researchers wondered whether the COPE intervention could be used in order to help caregivers better their skills in recognizing and reporting symptoms of their patients.

The researchers used a repeated measure three-group comparative design on 329 hospice homecare patients with cancer and their caregivers. The control group (n=109) received standard care; a second group (n=109) received standard care and friendly visits, and a third group (n=11) received standard care and the COPE intervention.

The sample was drawn from a large nonprofit hospice where most patients receive home care. Caregivers and patients were carefully matched in order to eliminate interfering factors. Caregivers received experimental training in the COPE intervention over the course of nine days in order to recognize and assist with symptom management of patient. The pain characteristics of the patients that were measured included intensity of pain, dyspnea, constipation, overall symptom distress, and QOL (emotional). Each of these variables was rated on numeric rating or self-report scales. Data was collected within 24-48 hours after hospice admission and collected again on days 16 and 30 of hospice admission when patients were once again asked to report symptom intensity and to complete the Memorial Symptom Assessment Scale (a self-report scale used to measure the distress caused by the symptoms) and the Hospice QOL Index (a 28-item self-report tool that assesses overall functional, social and psychophysiological well-being). The study's rigidity was substantiated by a colleague who conducted a random survey of 10% of all of the cases each month.

The quality of the data of this study is reliable and authoritative. Thorough steps were taken (as described) to ensure that cofounding elements were excluded. The only limitation that I notice is disparity of the groups. The control groups consisted of 109 members each, while the COPE group consisted of only 11 members. However, the fact that each individual received the same treatment (it was a repeated study with rotation of groups) may have eliminated the problem of this factor.

Rosedale and Fu (2010) investigated the impact that treatments have on breast cancer. Part of the intense pain that lingers as result, they theorized, may be due to the interventions as well as to the ways that the women perceive and respond to their symptoms.

Rosedale and Fu (2010)'s study differed from that of McMillan and Small (2007) in that their study was qualitative rather than experimental. They used a phenomenological research approach that zoned in on attempting to isolate the features of the treatment that women receive and to assess their possible negative impact.

They recruited thirteen women (mean age 33-74 years) from a volunteer list at Reach for Recovery where each had completed treatment for breast cancer 1-18 years prior to the study. This was the second time that Rosedale was conducting the study. She read the transcripts of her earlier study several times in order to gain a broad understanding of the text. Rosedale and a team of researchers identified key themes. They then reviewed these themes, discussed them with the thirteen participants for feedback, and checked the themes to see whether they matched other studies on the same subject.

The symptoms that were analyzed included intense pain, loss of energy, impaired limb movement, cognitive disturbance, changed sexual experience, and lymphedema. The main research variables were breast cancer symptom distress, ongoing symptoms, and unexpected experience.

Although this study is less reliable (as qualitative studies generally are) than that of McMillan and Small (2007), exhaustive steps too were taken to ensure that bias was excluded. The themes were reiteratively explored by a team of objective researchers to see whether all concurred on their commonality; they were 'fed back' on the original...

Evaluate the quality of the data and how this compares to the data presented in the Ferrell & Coyles chapter.
The difference between these articles and that of the two quoted studies is several-fold. Firstly, both McMillan and Small (2007) and Rosedale and Fu (2010) feature a certain disease - cancer -- and described reduction of pain in connection with that. Ferrell and Coyles (2010), on the other hand, was more general, drawing up lists of drugs that are allegedly helpful in reducing pain, describing these drugs, and using their research studies to advice patients on all matters related to these drugs including their limitations. Tables, too, generously sprinkle their commentary and categorize the information in clear form. Ferrell and Coyles (2010), therefore, provided their readers with a descriptive meta-analytic study that was intended for the informative intent of caregivers (and patients). Readers are accorded the information of the various drugs available to them for relieving their pain (or the pain of patients). All necessary details are also provided so that readers can know when to best apply them.

The studies of McMillan and Small (2007) and Rosedale and Fu (2010), on the other hand, are exploratory rather than descriptive. The one is experimental, the other is qualitative. They are -- as stated -- on a specific illness rather than general, and one at least was designed primarily for hospice caregivers than for patients. Both, too, were largely emotional rather than physiological understanding that pain can eventuate as much from psychological sources as it can from physical origins. By curing one, the researchers hoped to reduce the effects of the other. Doing so, would reduce the need to rely on the army of drugs that is described by Ferrell and Coyles (2010). Being experimental, the articles, too, differ from that of Ferrell and Coyles (2010) in major ways. Tables that exist are only included to substantiate and clarify statistical results. The study follows the required outline of "Introduction," "Methodology," "Results," "Discussion," and "Conclusion" with its focus on the experiment. That of Ferrell and Coyles (2010) is, however, involved with explaining the characteristics of the drugs available to critically ill people and, therefore, confines itself to discussion of the subject of the essay. Both are academic and discuss the same theme -- pain reduction. The one, however, is informative, descriptive, and general, focused on the drugs. The other is experimental and focused on pain as an emotional component. These are the key differences.

Develop a case study in palliative end-of-life care that features the symptom you have chosen as your topic.

This case study is adapted and modified from the following true case study of a fifty-three-year-old African-American man, who had been diagnosed with a rare and aggressive type of cancer that the patient was told was incurable (Rutecki, 2011). Nonetheless, the man recovered. He was admitted to the hospital 25 years later for severe hypoglycemia where it was discovered that the man had a large metastatic tumor in the liver, as well as extensive metastatic disease in the lungs, kidneys, and pancreas as well as his subcutaneous tissue. The patient quickly regressed, and from intense chronic pain, rapidly declined into first belligerent and then a non-communicative situation. Being that the patient was uncommunicative the Visual Analog Scale scoring system was used to measure the patient's pain and rated 10 out of 10.

The oncologist first prescribed methadone that was administered via a fentanyl transdermal patch with each patch delivering 215 mcg over 72 hours. This did little to alleviate the pain. The team then worked towards localizing the pain and prescribed 30 mg of orally administered methadone, instead. This was administered in pill form since the patient was not vomiting and could still swallow. The team also performed image-guided blockade injections of certain veins and joints using a combination of bupivicaine and methylprednisolone acetate. This was not very successful in reducing the pain, although the methadone helped.

There was one tumor, too, on the upper right arm that, whilst not causing the patient pain, the family wanted removed in order to enable the patient to at least use this arm to aid him in his concerns. The physicians, however, considered this operation invasive and futile. Instead, relying on the patient's wishes, the family and hospice team met together and decided to provide palliative care without a resuscitate order. The patent endured increased pain over the next few weeks. He accumulated a lot of abdominal fluid and had trouble breathing.…