Palliative care: a review of past changes and future trends

Palliative care arose out of the change from acute to chronic causes of death and the emphasis of health care on improving quality of life. In the United Kingdom, specialist palliative care is provided mainly for cancer patients through hospices and support teams, which have grown rapidly in the last 30 years. Single sites and more recently several units have demonstrated their effectiveness, acceptability and efficiency. However, the majority of people who die will not receive these services but will receive much of their care in hospital, nursing home and community settings. The growing numbers of people who are likely to die from HIV/AIDS and the growing numbers of older people make it important that palliative care becomes more integrated with hospital, community and general practitioner services. Palliative care should become a gradually increasing part of care from diagnosis to death, rather than being concerned only with the terminal phase. A palliative care component and appropriate standards could be included in the needs assessment and the contracts for many hospital and community services. In research on new treatments, particularly for cancer and HIV/AIDS, palliative aspects should be measured along with survival and the usually fairly basic estimates of quality of life. Hospices, and in particular support teams and day care, require further evaluation if they are to extend their role to providing care for the younger people with HIV/AIDS and the older people who are dying from chronic diseases such as cardiovascular disease.

Palliative/hospice care in Poland

The first hospice in eastern Europe was the Hospicium in Krakow, which was created 10 years ago. Three years later the leading independent Polish hospice, Hospitium Pallotinum, was founded in Gdansk. This hospice helped to organize more than 20 similar groups, usually Catholic agencies which offer home care programmes. The University Palliative Care Service in the Academy of Medical Sciences in Poznan, which was created in 1988, consists of a home care team caring for 600 patients a year and has a seven-bed inpatient unit. It offers an education programme for physicians, nurses, medical and pharmacy students as well as a research programme. There is currently an academic link between the Poznan Palliative Care service and Sir Michael Sobell House in Oxford, sharing medical and nursing education in palliative care. The educational courses and conferences have been attended by international speakers offering education which will help to change the attitudes of professional health care workers and the public. We hope that the Polish Ministry of Health and Welfare and the government will be interested in establishing policies that will cover the cost of palliative care in the newly developing health care system.

Home palliative care: results in 1991 versus 1988

Home care is greatly expanding because of the savings it offers by avoiding unnecessary hospitalization and also because patients benefit from being in their own home environments. Since 1988, Societa Assistenza Malato Oncologico Terminale (SAMOT) has organized a pain relief and home palliative care unit for terminal cancer patients. Objectives, difficulties, protocols, and achievements of 4 years of experience were examined, and the findings of the various years were compared. Our results suggest that considerable progress has been made in home palliative care. There are still social and cultural difficulties to overcome, however.

Patterns and trends in referrals to a palliative nursing service

This is an analysis of patterns and trends in referrals and deaths in a palliative nursing service. Comparisons are made over a 10-year period and with national and district statistics. Results show numerical increases in patients referred, a trend towards medical referrals, small numbers of referrals from other professional groups and from hospitals, and death trends which are not significantly different from national statistics. Possible reasons for these patterns and trends are explored in the context of the developing Macmillan Nurse role.

Place of death in South Australia. Patterns from 1910 to 1987

OBJECTIVES

To portray the changes in the place of death of South Australians during the 20th century and to examine the effects of sociodemographic and cause of death variables.

DESIGN

Data relating to 2566 deaths from 1910 to 1987 were extracted from the records of funeral directors. A comparison of our sample of deaths with State mortality statistics, in terms of age, sex and diagnosis, was made to assure the representativeness of the sample.

RESULTS

The proportion of deaths which occurred at home decreased from 55.6% in 1910 to 26.2% in 1970, and thereafter about a quarter of all deaths occurred at home. Most of the "institutionalisation of death" was due to increasing proportions of deaths in public hospitals; by 1970 over two-thirds of all deaths occurred in hospitals. After 1970 death has been transferred from hospitals to nursing homes and inpatient hospices. Multivariate analyses indicated that the institutionalisation trend was present after taking account of confounders (age, sex, marital status, occupation, number of children, and cause of death).

CONCLUSIONS

Mortality patterns are determined by social and demographic characteristics of those who die, the availability of hospital and nursing home beds, changes to health insurance schemes, and the emergence of hospice care and related services. Further study is required to determine whether patterns of terminal care are cost-effective and medically appropriate.

Organizational evolution: a hospice case study

An analysis of the maturation process of a large, multiple site hospice using Greiner's organizational development model is presented. Past and present growth phases and crises are described. The value of such an analysis lies in its insights into organizational growth and the resultant lessons for other, similar agencies. The ability to assess an organization's stage of development means that crises and needs can be anticipated and appropriate resolutions can be planned. Generalizations can be made to multiple site or regionally organized hospice development elsewhere.

Contradictions in the development of new hospices: a case study

Despite a decade of concern about the 'mushrooming' of new hospice developments within the British Isles, we remain remarkably ignorant about the processes which lead to the initiation of new hospice projects and the factors which affect their progress. Three inter-related issues appear important: (1) policy and resource implications; (2) changing models of hospice care; (3) 'community' factors. This paper explores the interconnections between these, using a case study approach and describes in detail the efforts of a single local voluntary group to establish a programme of community care for dying people. It shows that: (1) local 'communities' are likely to make continued demands for hospice type care, despite official scepticism about proliferation; but also that these communities should not be seen as homogeneous in their aspirations and demands; (2) new models of community care will interact with wider policy changes in the NHS and Social Services to raise questions about how terminal care services can be further developed; (3) shifts away from traditional in-patient models of care are likely to high-light divisions between 'lay' and 'professional' groups in their perceptions of how services can be delivered.

Hospice. An essential and growing part of the continuum of care

When hospice was first introduced to America more than 25 years ago, terminal illness was a forbidden subject. Today, there are more than 1,700 hospices in this country; the largest growth in recent years has occurred in home health agency- and hospital-based hospices. There will be an even greater reliance on hospice services in the near future as the baby boomers and their parents confront their mortality.

Continuing care in a medical center: the Cleveland Clinic Foundation Palliative Care Service

Approximately 500,000 people die of cancer in the United States each year. Most attention has focused on curative approaches to cancer management. Despite the fact that 80% of persons with advanced cancer suffer from chronic pain and an equal number have a major problem with anorexia and weight loss, little systematic evaluation of these problems has been conducted, although they have a high medical, psychological, and socioeconomic impact. The need for a palliative care service (PCS) at the Cleveland Clinic Foundation was originally identified by physicians within the Department of Hematology and Medical Oncology. During 1987, a pilot study was conducted to evaluate the service, define its potential patient base, and assess its impact on patient care. It is astonishing that so little attention has been paid to this area by the major institutions and organizations involved in care of patients with advanced cancer, despite the hundreds of thousands dying of the disease each year. A dedicated palliative care service would therefore seem appropriate in any major medical institution dealing with significant numbers of cancer patients. It also seems appropriate that the provision of a PCS should be part of the requirements for a comprehensive cancer center, if a center is to claim to provide the entire spectrum of services, from diagnosis until death.

The hospice concept of care: facing the 1990s

Although hospice is a widely accepted form of care for the terminally ill, there is still a misconception that hospice represents a place, rather than a form of care. Hospice is designed to address three major problems of dying: pain, loneliness, and loss of control. It also emphasizes the role of the family in the caregiving process. The greatest need today in hospice is the increased involvement of the medical profession. Hospice must also expand to include not only cancer patients, but anyone who is dying, including AIDS patients. The future of hospice is bright, but it needs our commitment, our time, and our prayers.

Hospice programs and the hospice movement: an investigation based on general systems theory

This study used General Systems Theory as the framework for examining hospice programs and the hospice movement. Data drawn from program administrators and archival sources were used to test the thesis that two broad types of hospice programs exist in the United States. Results indicate that independent programs tend to be characterized by processes that amplify change in the extant medical delivery system--that is, deviation amplification. Hospices associated with preexisting institutions tend to be characterized by processes that counteract change, thus maintaining the status quo--that is, deviation counteracting processes.

Hospice care of Rhode Island: 1989

Hospice care is an extension of primary care expressly designed to meet the human needs of the terminally ill patients and their families. Its nurses, volunteers, social workers, clergy and physicians, working collaboratively with the primary physician, seek to keep each patient free of pain, in a humane environment and to meet, where possible, immediate social needs.