An exploration of family carers' experience of respite services in one specialist palliative care unit

BACKGROUND

Changing patterns of care for terminally ill people mean that 90% of patients in the UK now spend the majority of their last year of life at home. It is now widely accepted that supporting individuals to die at home relies heavily on the availability of family carers to provide the majority of the care needed. However, one of the most common reasons for unplanned admissions near the end of life is carers' inability to provide continuing care. One strategy to overcome these challenges has been to offer planned respite care. Despite recent studies, in reality little is known about respite services for patients with life limiting illness, in particular how respite is experienced by the caregivers or to what extent respite services address their needs.

METHODS

This prospective study, comprising mixed methods of data collection, explored the experiences of 25 family carers whose relative had been admitted to the local hospice for inpatient respite care. Semi-structured interviews were conducted at two time points: pre- and post-respite. The Relative Stress Scale Inventory was administered at both interviews.

RESULTS

Just over half of the sample were caring for a relative with a diagnosis of cancer (n=13); the majority of the others had a number of neurological conditions (n = 12). The data demonstrate that managing care for relatives with a life limiting illness was perceived to be hard work, both physically and mentally. Inpatient respite care was considered important as it enabled family carers to have a break from the ongoing care-giving responsibilities, as well as being an opportunity to experience 'normal life' independently. The majority of family carers felt that their expectations of respite for themselves had been achieved. The respite service was well evaluated in relation to: standard of nursing care; alternative facilities on offer, atmosphere; and other care homes.

DISCUSSION

Currently, inpatient respite services are provided to two patient groups--those in the last year of life and those with a chronic life limiting illness. However, on closer analysis, the current model of service delivery, a two-week inpatient stay, may not be best suited to those caring for a relative in the last year of life. Similarly, it might be questioned whether an inpatient hospice is the most suitable setting for those patients needing supportive care, rather than specialist palliative care. The study has raised many issues that need to be considered in the support of carers caring for relatives with a life limiting illness with uncertain trajectories.

Systematic review of the problems and issues of accessing specialist palliative care by patients, carers and health and social care professionals

OBJECTIVES

To determine the problems and issues of accessing specialist palliative care by patients, informal carers and health and social care professionals involved in their care in primary and secondary care settings.

DATA SOURCES

Eleven electronic databases (medical, health-related and social science) were searched from the beginning of 1997 to October 2003. Palliative Medicine (January 1997-October 2003) was also hand-searched.

STUDY SELECTION

Systematic search for studies, reports and policy papers written in English.

DATA EXTRACTION

Included papers were data-extracted and the quality of each included study was assessed using 10 questions on a 40-point scale.

RESULTS

The search resulted in 9921 hits. Two hundred and seven papers were directly concerned with symptoms or issues of access, referral or barriers and obstacles to receiving palliative care. Only 40 (19%) papers met the inclusion criteria. Several barriers to access and referral to palliative care were identified including lack of knowledge and education amongst health and social care professionals, and a lack of standardized referral criteria. Some groups of people failed to receive timely referrals e.g., those from minority ethnic communities, older people and patients with nonmalignant conditions as well as people that are socially excluded e.g., homeless people.

CONCLUSIONS

There is a need to improve education and knowledge about specialist palliative care and hospice care amongst health and social care professionals, patients and carers. Standardized referral criteria need to be developed. Further work is also needed to assess the needs of those not currently accessing palliative care services.

Access and referral to specialist palliative care: patients’ and professionals’ experiences

The aim of this study was to explore the reasons why patients and families are referred to specialist palliative care. Semi-structured interviews were undertaken with patients and professionals from primary care and specialist palliative care services in the north of England. A content analysis of the transcripts was undertaken, key issues were identified and common themes grouped. Twelve professionals working in specialist palliative care, three GPs, six community nurses and thirteen patients were interviewed (n = 34). Five key themes are reported: reasons why patients are referred to specialist palliative care; reasons why patients are not referred to specialist palliative care; timeliness of referrals; continuity of care; and use of referral criteria. It was found that the professionals in primary care would like more training and education about how to refer patients to specialist palliative care and how to deal with issues of death and dying. The patients were generally satisfied with the service but wanted to be able to be supported at home in their final days. Further training and education may improve the knowledge of professionals who refer patients to specialist palliative care. There are currently no standardized criteria in the UK to determine when a referral should be triggered. The development of a set of standardized referral criteria may be useful in aiding a referral decision.

Nonlinear optical properties of LaCa(4)O(BO(3))(3)

We have grown LaCa(4)O (BO(3))(3) (LaCOB), an isostructural member of GdCa(4)O(BO(3))(3) (GdCOB) family and characterized its nonlinear optical properties. At 1064nm, d(eff) of 0.52+/-0.05 pm /V and an angular sensitivity of 1224+/-184(cm rad)(-1) for type I frequency doubling in LaCOB were determined relative to those of KTiOPO(4) , beta-BaB(2)O(4) , KD(2)PO(4) , LiB(3)O(5) , YCa(4)O(BO(3))(3) (YCOB), and GdCOB. The d(alphabetabeta) and d(gammabetabeta) coefficients of the nonlinear optical tensor for LaCOB, GdCOB, and YCOB were determined to be equivalent within the experimental uncertainty and have values of ?0.26+/-0.04?pm/V and ?1.69+/-0.17?pm /V , respectively. From phase-matching angle measurements at 1064 and 1047nm, we predict that LaCOB is noncritically phase matched at 1042+/-1.5 nm .

Consideration of Stimulated Raman Scattering in Yb:Sr(5)(PO(4))(3)F Laser Amplifiers

The stimulated Raman-scattering (SRS) gain coefficient has been measured quantitatively for the first time to our knowledge in Yb:Sr(5)(PO(4))(3)F to be 1.23 ? 0.12 cm/GW at 1053 nm. These data, along with surface and bulk losses, feedback that is due to surface reflections, gain saturation, and bandwidth, have been applied to a quantitative model that predicts the effects of SRS within a laser amplifier system where the laser gain media show SRS gain. Limitations and impact to the laser amplifier performance are discussed, along with possible techniques to reduce SRS loss.

High-power dual-rod Yb:YAG laser

We describe a diode-pumped Yb:YAG laser that produces 1080 W of power cw with 27.5% optical optical efficiency and 532 W Q-switched with M(2)=2.2 and 17% optical-optical efficiency. The laser uses two composite Yb:YAG rods separated by a 90 degrees quartz rotator for bifocusing compensation. A microlensed diode array end pumps each rod, using a hollow lens duct for pump delivery. By changing resonator parameters we can adjust the fundamental mode size and the output beam quality. Using a flattened Gaussian intensity profile to calculate the mode-fill efficiency and clipping losses, we compare experimental data with modeled output power versus beam quality.

Three-level Q-switched laser operation of ytterbium-doped Sr(5)(PO(4))(3)F at 985 nm

Ytterbium-doped Sr(5)(PO(4))(3)F was successfully lased at 985 nm in quasi-cw mode with a slope efficiency of 74% and an absorbed threshold energy of 18 mJ. Q-switched slope efficiencies of 21% were obtained with a maximum energy of 9.4 mJ in 8.8-ns pulses.

Gain saturation measurements of ytterbium-doped Sr5(PO4)3 F

We report on the experimental measurement of the saturated gain of Yb(3+):Sr(5)(PO(4))(3)F at the 1047-nm laser line as a function of pump fluence and probe energy. The emission line was accurately modeled as a single homogeneous extraction, yielding values of 6.2 x 10(-20) cm(2) for the emission cross section and 3.3 J/cm(2) for the saturation fluence.

Creating and maintaining 'optimism' in cancer care communication

This study investigates nurse-patient communication in the cancer care context. Interviews with nurses and patients about their communication experiences and audio-recorded nurse-patient conversations were collected and analysed. A theme of 'optimism' largely manifesting as 'constructive realism' was one of four features identified by the qualitative analysis. The health professional has traditionally been viewed as the party with the power and control over conversation progression and topics. In particular, the superficial, positive and chatty nature of nurse-patient interaction has often been attributed to a lack of nurses' communication skills training. This research indicates that both patient and nurse are active in its construction and argues that the optimistic cheerful nature of nurse-patient interaction may be better viewed as a jointly produced institutional feature of cancer care. This paper illustrates and examines some of the ways this outcome was created and maintained by participants and discusses the implications of this.

4.0-4.5-mum lasing of Fe:ZnSe below 180 K, a new mid-infrared laser material

Lasing of Fe:ZnSe is demonstrated, for the first time to the authors' knowledge, for temperatures ranging from 15 to 180 K. The output wavelength of the Fe:ZnSe laser was observed to tune with temperature from 3.98mum at 15 K to 4.54mum at 180 K. With an Er:YAG laser operating at 2.698mum as the pump source, a maximum energy per pulse of 12muJ at 130 K was produced. Laser slope efficiencies of 3.2% at 19 K and 8.2% at 150 K were determined for an output coupling of 0.6%. A laser emission linewidth of 0.007mum at 3.98mum was measured at 15 K. Absorption and emission spectra and emission lifetimes for Fe:ZnSe are also discussed.

Room-temperature laser action at 4.34.4 mum in CaGa(2)S(4):Dy(3+)

We report room-temperature mid-IR laser operation in a new low-phonon-frequency nonhygroscopic host crystal, calcium thiogallate (CaGa(2)S(4)) . Laser action at 4.314.38 mum on the Dy(3+)H(11/2)(6)?H(13/2)(6) transition occurred with a maximum slope efficiency of 1.6%.

Terminally ill patients' and lay-carers' perceptions and experiences of community-based services

This paper reports on terminally ill patients' and their lay-carers' perceptions and experiences of community-based services. It forms part of a larger investigation which examined the extent of service provision and any perceived gaps and problems from the perspectives of both clients and providers of community-based assistance for the terminally ill. The participants were nine terminally ill patients and 12 lay-carers receiving community nursing care. Fifteen face-to-face, semi-structured interviews were conducted to elicit their experiences and perceptions of the care being provided. Qualitative, thematic analysis was carried out on the audio-taped interviews. On the whole, respondents reported a high level of satisfaction and appreciation for the help provided. Several areas appeared more problematic, however, and warrant further consideration. These include perceptions of health professionals, particularly their role domains, power and expertise, and some of the practical disadvantages and problems faced by some patients and their families. These are illustrated and the implications for dying patients, their lay-carers and community-based health professionals are discussed.

A comparative study of death anxiety in hospice and emergency nurses

This paper describes a preliminary cross-sectional study which aimed to compare levels of death anxiety and coping responses in palliative care and accident and emergency (A & E) nurses. Forty-three nurses (23 from palliative care and 20 from A & E) were recruited from a district general hospital and nearby hospice. Both sites had the same mean annual death rate of 150 patients. Death anxiety was measured by the Death Attitude Profile-Revised Questionnaire and coping responses were elicited by a semi-structured interview. As hypothesized, hospice nurses had lower death anxiety and they were more likely to recall both good and difficult experiences related to patient care. Unlike the hospice nurses, a subgroup (20%) of A & E nurses reported that they were unable to discuss problems with colleagues. The study has implications for the development of institutional support for staff to enable nurses to provide good quality care for dying patients and bereaved people.

Analysis of an intracavity-doubled diode-pumped Q-switched Nd:YAG laser producing more than 100 W of power at 0.532 microm

A diode-pumped Nd:YAG laser was frequency doubled to 0.532 microm with an intracavity KTiOPO(4) crystal in a V-cavity arrangement, achieving an output power of 140 W. Acousto-optic Q switching was employed at repetition rates of 10-30 kHz, and the beam quality was assessed at M(2) approximately 50. It was deduced on the basis of our model that the strength of the nonlinear frequency conversion is the main parameter determining the pulse width.

Dissonant Loss: the experiences of donor relatives

Narrative type interviews were carried out with a purposive sample of 24 relatives of organ donors. Relatives were recruited through 3 Regional transplant co-ordinating centres in England. The study examined in-depth the relatives': emotional reactions to the death and donation, perceptions of the decision-making process, assessment of the problems donation caused for them, as well as the benefits it provided. An understanding of what the experience meant to them was elicited, as was the identification of their needs. The interviews were audiotaped and transcribed. The transcripts were analysed using a grounded theory approach, based on the constant comparative method. Themes emerging from the data were named to form categories. Categories were defined and integrated around the central theme of the research to form an analytical version of the story. Donor relatives' experiences were found to revolve around a process of conflict and resolution. Their experience is explained as a theory of "Dissonant Loss".

Dissonant Loss: the experiences of donor relatives

Narrative type interviews were carried out with a purposive sample of 24 relatives of organ donors. Relatives were recruited through 3 Regional transplant co-ordinating centres in England. The study examined in-depth the relatives': emotional reactions to the death and donation, perceptions of the decision-making process, assessment of the problems donation caused for them, as well as the benefits it provided. An understanding of what the experience meant to them was elicited, as was the identification of their needs. The interviews were audiotaped and transcribed. The transcripts were analysed using a grounded theory approach, based on the constant comparative method. Themes emerging from the data were named to form categories. Categories were defined and integrated around the central theme of the research to form an analytical version of the story. Donor relatives' experiences were found to revolve around a process of conflict and resolution. Their experience is explained as a theory of "Dissonant Loss".

Perceptions of a 'good' death: a comparative study of the views of hospice staff and patients

The literature suggests that health professionals working in palliative care have developed an idealised concept of dying which has been labelled the 'good' death. This paper reports the results of a preliminary qualitative study which compared the concepts of a 'good' death used by patients and staff in a palliative care unit. Semistructured interviews designed to elicit perceptions of 'good' and 'bad' deaths were conducted with 18 patients and 20 health professionals. The transcribed interviews were content analysed. There were major differences between the views of patients and staff. The patients' descriptions of a "good' death were diverse and included: dying in one's sleep, dying quietly, with dignity, being pain free and dying suddenly. In comparison, staff characterised a "good' death in terms of adequate symptom control, family involvement, peacefulness and lack of distress, while a "bad' death was described as involving uncontrolled symptoms, lack of acceptance and being young. The findings suggest that patients and staff differ in their conceptualisations of a "good' death.

Properties of Cr:LiSrAIF(6) crystals for laser operation

We have performed several physical and optical measurements on the Cr:LiSAF (LiSrAlF(6)) laser material that are relevant to its laser performance, including thermal and mechanical properties, water durabilities, and Auger upconversion constants. The expansion coefficient, Young's modulus, fracture toughness, thermal conductivity, and heat capacity are all used to determine an overall thermomechanical figure of merit for the crystal. An investigation of the water durability suggests that the cooling solution should be maintained at pH = 7 to ameliorate problems associated with water dissolution. The Auger constant was found to become much more significant at higher Cr doping, in which excited-state migration leads to a substantial increase in the upconversion rate. We propose a design for a 50-W Cr:LiSAF laser system that is based on a detailed knowledge of all the relevant material parameters.

Gift Exchange Theory: a critique in relation to organ transplantation

Organ transplantation is becoming more important as a viable method of treatment for certain severe medical conditions. It is a complex and demanding process for all involved. Nursing as a developing science must respond to cultural and economic changes. Therefore, a need exists to develop a body of empirically based knowledge to understand and support the process of organ transplantation. This paper will argue that as trading in organs is unacceptable to the moral standards of western society and outlawed in many countries, an alternative framework must be considered for understanding the mechanisms through which organs are donated and utilized. The donating and receiving of organs may be equated with gift-giving, as there is no barter of commodities involved. Therefore, a useful framework to explore this phenomenon will be one that underpins the process of giving and receiving of gifts. Gift Exchange Theory will be evaluated and critically examined in relation to organ transplantation and the role of nurses in this process.

A study of quality of life in cancer patients receiving palliative chemotherapy

Although primary treatment for cancer has been associated with psychosocial distress, less research has focused on patients with advanced disease. Traditionally, the outcomes of treatment have been assessed using biomedical criteria, including tumour regression, progression and survival. It is argued that these data are inadequate to understand the impact of cancer upon the patient. Instead, quality of life considerations are crucial when treatments are aversive, especially when the aims are palliative rather than curative. Fifty-three patients with advanced breast cancer or ovarian cancer were studied prospectively for 6 months to assess whether the site and method of chemotherapy administration influenced their quality of life. Patients received palliative chemotherapy either at home or in hospital. Quality of life was operationalized as measurement of anxiety, depression, self-esteem, health locus of control, physical performance and symptoms. In addition, semi-structured interviews explored social roles, relationships, and perceptions of treatment. Hospital administered chemotherapy was perceived to be most distressing. Regression analysis indicated that anxiety and depression accounted for most of the variance in quality of life. Patients who died during the study 13 (24%) experienced considerable psychological and physical morbidity. Women over 60 years, experienced less psychological and physical distress. Quality of life broadens the criteria by which cancer treatments are evaluated, to include the experience of the patient.

Dispersion effects in four-wave mixing measurements of ions in solids

We have performed nondegenerate four-wave mixing measurements on Cr(3+) ions in three crystals: BeAl(2)O(4), Gd(3)Sc(2)Ga(3)O(12), and LaMgAl(11)O(19). Two laser beams of the same frequency were used to resonantly pump one of the absorption bands of Cr(3+), and probe beams with three different wavelengths ranging from 442 to 1064 nm were used to generate a signal from the laser-induced population grating. The observed four-wave mixing signal strength was found to increase as the wavelength of the probe beam was decreased. A model was utilized to explain these results based on the change in polarizability of the Cr(3+) ions when they are in the metastable state versus the ground state, and it was found that the dispersion effects can be described by a single-oscillator model with the lowest-energy charge-transfer transition of Cr(3+) making the dominant contribution to the signal.