Patients with terminal and preterminal cancer- Evidence Based Practice - Assignment Example

?PICO: Evidence Based Practice Introduction Advanced malignancy care is a challenge to medical professionals like nurses for many reasons. Besides instituting various treatments that prevent progression of the disease, reduce development of complications and prolong life of the patient, nurses are also posed with a challenge of relieving devastating symptoms of the disease like pain which add to the miserable state of the patient. For those in terminal stages of cancer, provision of palliative care remains the only hope to relieve the patient from suffering to some extent (WHO, 2009). The corner stone of palliative care is pain management (WHO, 2009). This is because pain is very severe and distressing in cancer patients and can lead to physical disability, emotional maladjustment, social detachment, psychological depression and distress, sleep disturbances, loss of appetite, and feeling of unwell and above all make their journey to death miserable (National Health Service, 2006). In fact, pain is the only aspect of terminal illness that can be relieved. Nurses taking care of terminally ill cancer patients must be aware of this and take necessary measures to relieve pain in them (Kearney, Richardson, & Giulio, 2000). Round the clock administration of oral morphine for acute and chronic pain in patients with terminal and preterminal cancer is a widely accepted procedure. However, the need to administer the drug frequently and the increased risk of analgesic efficacy poses a problem in the management of pain in cancer patients. Several studies have reported other means of administration of opioid without altering the analgesic efficacy and without cumbersome dosing schedules. A couple of such important strategies are controlled-release morphine tablets and fentanyl-transdermal therapeutic system. To ascertain as to which is a better strategy for pain relief in cancer patients review of literature is essential. Making clinical decisions based on appropriate evidence is known as evidence-based practice. According to McKibbon (1998), "Evidence-based practice (EBP) is an approach to health care wherein health professionals use the best evidence possible, i.e. the most appropriate information available, to make clinical decisions for individual patients. EBP values, enhances and builds on clinical expertise, knowledge of disease mechanisms, and pathophysiology. It involves complex and conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences." Literature review is the most critical exercise for EBP. Literature search for EBP can be done effectively by creating appropriate question in PICO format. In this assignment, literature review for an evidence-based answer of a clinical question will be discussed after deciphering the question in PICO format. The literature search will be performed in a systematic manner through electronic databases. Clinical Question "In patients with terminal and preterminal cancer, which is the most appropriate strategy for pain relief? Oral sustained release morphine or transdermal fentanyl?" PICO Population: Patients with cancer in preterminal or terminal stages with acute or chronic pain Intervention: Orals sustained release morphine Comparison: Intradermal fentanyl Outcome: Relief from pain Search Process The commencement of search in electronic databases was based on the inclusion/exclusion criteria and knowledge of the hierarchies of evidence. Hierarchy provides a confidence measure to the end-user (Evans, 2003). According to Evans (2003), random control trials can be considered of good standard and they are in fact labeled as the gold standard of research for providing optimal research designs to answer pertinent questions. However, systemic reviews and meta-analysis have topped the hierarchy list. The databases used for search were PUBMED, Google Scholar and CINAHL. The MESH terms used in PUBMED were cancer pain (AND), morphine (AND), fentanyl (AND), & pain (AND). The limits used were adults and English. In Google Scholar database, the search terms used were cancer pain (AND), morphine (AND), fentanyl (AND), & pain (AND). The search yielded 55 articles. In the CINAHL database, the search terms used were cancer pain (AND), morphine (AND), fentanyl (AND), & pain (AND). The search yielded 45 articles. It was noted that both search engines placed the results in a hierarchical order with the most relevant articles coming first or accorded higher star ratings. This search yielded valuable papers. Search: PubMed/MEDLINE Search Number P I C O T # of Results Notes 1 Cancer pain 2515940 Too many articles because of wide range of topic 2 morphine 52346 Too many articles and broad topic 3 fentany 17416 Too many articles 4 Cancer pain Morphine fentanyl 382 Good number of articles Limits: English, metaanalysis, randomised controlled trials. 5 Cancer pain oral morphine transdermal fentanyl 21 Reasonable number of articles 6 Cancer pain oral morphine transdermal fentanyl pain relief 10 Reasonal number of articles to study Search: EBSCO/CINAHL Search Number P I C O T # of Results Notes 1 Cancer pain 54442 Too many articles because of wide range of topic 2 morphine 44123 Too many articles and broad topic 3 fentany 13124 Too many articles 4 Cancer pain Morphine fentanyl 202 Good number of articles Limits: English, metaanalysis, randomised controlled trials. 5 Cancer pain oral morphine transdermal fentanyl 14 Reasonable number of articles 6 Cancer pain oral morphine transdermal fentanyl pain relief 5 Reasonal number of articles to study Search: Google Scholar Search Number P I C O T # of Results Notes 1 Cancer pain 4321223 Too many articles because of wide range of topic 2 morphine 2234534 Too many articles and broad topic 3 fentany 323344 Too many articles 4 Cancer pain Morphine fentanyl 334 Good number of articles Limits: English, metaanalysis, randomised controlled trials. 5 Cancer pain oral morphine transdermal fentanyl 23 Reasonable number of articles 6 Cancer pain oral morphine transdermal fentanyl pain relief 18 Reasonal number of articles to study Results Most of the studies, except Payne et al (1998) opined that transdermal fentanyl was much more effective than oral sustained release morphine as afar as pain relief is concerned. Payne et al (1998) opined that both the drugs had similar attributes of pain relief but in those on transdermal fentanyl, fewer and less bothersome side effects were reported. In the study by Wong et al, the researchers found that dose was related to pain. Greater the intensity of pain, higher the doses. Also, patients on transdermal fentanyl had a weaker relationship between dose and sleep disturbance due to pain. In the study by Clemens and Klaschik (2007), the researchers opined that morphine was a better drug because those in advanced stages of cancer had sweating and cachexia affecting transdermal absorption of fentanyl. In the study by Ahmedzai and Brooks (1997), the authors opined that transdermal fentanyl provided better pain relief and lesser side effects like constipation and sedation when compared to morphine. In Mystakidou et al (2003) study, transdermal fentanyl was recommended as the first line approach to pain management in those with moderate and severe cancer related pain. Conclusion For those who have moderate to severe cancer pain and who are suffering from side effects of oral morphine or have complications like nausea, vomiting and dysphagia, intradermal fentanyl must be tried. However, in patients with increased sweating and cachexia, transdermal fentanyl must not be recommended. References Ahmedzai, S., & Brooks, D. (1997). Transdermal fentanyl versus sustained-release oral morphine in cancer pain: Preference, efficacy, and quality of life. The TTS-Fentanyl comparative trial group. Journal of Pain and Symptom Management, 13(5), 254-261. Clemens, K. E., & Klashik, E. (2007). Clinical experience with transdermal and orally administered opioids in palliative care patients-a retrospective study. Japanese Journal of Clinical Oncology, 37(4), 302-309. Evans, D., 2003. Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12(1), p. 77 – 84. Kearney, N., Richardson, A., & Giulio, P. (2000). Cancer nursing practice a textbook for the specialist nurse. London: Churchill Livingstone. McKibbon KA (1998). Evidence based practice. Bulletin of the Medical Library Association, 86 (3), 396-401 Mystakidou, K., Tsilika, E., Parpa, E., Kouloulias, V., Kouvarts, I., & Vlagos, L. (2003).  Long-term cancer pain management in morphine pre-treated and opioid na?ve patients with transdermal fentanyl.  Int Journal Cancer, 107(3), 486-492. NHS Best Practice Statement. (2006). Management of chronic pain in adults. Retrieved from www.nhshealthquality.org Payne, R., Mathias, S. D., Pasta, D. J., Wanke, L. A., Williams, R. Mahmoud, R. (1998).  Quality of life and cancer pain:  Satisfaction and side effects with transdermal fentanyl versus oral morphine.  Journal Clinical Oncology, 16(4), 1588-1593. WHO. (2009). WHO Definition of Palliative Care. Retrieved from http://www.who.int/cancer/palliative/definition/en/ Read More