End-of-life care in patients with lung cancer

Evidence-based practice guidelines for end-of-life care for patients with lung cancer have been previously available only from the British health-care system. Currently in this setting, there has been increasing concern in attaining control of the physical, psychological, social, and spiritual distress of the patient and family. This American College of Chest Physicians'-sponsored multidisciplinary panel has generated recommendations for improving quality of life after examining the English-language literature for answers to some of the most important questions in end-of-life care. Communication between the doctor, patient, and family is central to the active total care of patients with disease that is not responsive to curative treatment. The advance care directive, which has been slowly evolving and is presently limited in application and often circumstantially ineffective, better protects patient autonomy. The problem-solving capability of the hospital ethics committee has been poorly utilized, often due to a lack of understanding of its composition and function. Cost considerations and a sense of futility have confused caregivers as to the potentially important role of the critical care specialist in this scenario. Symptomatic and supportive care provided in a timely and consistent fashion in the hospice environment, which treats the patient and family at home, has been increasingly used, and at this time is the best model for end-of-life care in the United States.

U.S. end-of-life care gets a (barely) passing grade

The vast majority of Americans would prefer to die at home. A minority of hospitals offer hospice or palliative care services. Report card enables state-to-state comparisons, benchmarking.

Symptom control and palliative care in Chile

As in other developed and developing countries, the most common chronic disorders affecting the Chilean population are cardiovascular disease, cancer, cirrhosis, diabetes, chronic obstructive pulmo- nary disease and external injuries. Availability of oncology services is not extensive and there are no academic programs to adequately train practitioners in either palliative medicine or comprehensive palliative care for allied health professionals including nurses, psychologists and chaplains. Major efforts have been made to incorporate palliative care as an important health care focus in the last decade and in the development of effective policies for opioid availability. Chile now meets 84% of the 17 criteria outlined by the World Health Organization and the International Narcotics Control Board for opioid availability. Postgraduate medical education in symptom control, clinical use of opioids and end-of-life care remains relatively poor as judged by the results of a questionnaire administered to 158 resident physicians at the Pontificia Universidad Católica de Chile. Improvements in symptom control and the development of palliative care in Chile will depend on the effective assessment of symptom control effectiveness and improved education and training of health professionals in clinical pharmacology, symptom control, clinical ethics, and end-of-life care.

Judging the quality of care at the end of life: can proxies provide reliable information?

A major challenge in research into care at the end of life is the difficulty of obtaining the views and experiences of representative samples of patients. Studies relying on patients' accounts prior to death are potentially biased, as they only represent that proportion of patients with an identifiable terminal illness, who are relatively well and therefore able to participate, and who are willing to take part. An alternative approach that overcomes many of these problems is the retrospective or 'after death' approach. Here, observations are gathered from proxies, usually the patient's next of kin, following the patient's death. However, questions have been raised about the validity of proxies' responses. This paper provides a comprehensive review of studies that have compared patient and proxy views. The evidence suggests that proxies can reliably report on the quality of services, and on observable symptoms. Agreement is poorest for subjective aspects of the patient's experience, such as pain, anxiety and depression. The findings are discussed in relation to literature drawn from survey methodology, psychology, health and palliative care. In addition to this, factors likely to affect levels of agreement are identified. Amongst these are factors associated with the patient and proxy, the measures used to assess palliative care and the quality of the research evaluating the validity of proxies' reports. As proxies are a vital source of information, and for some patients the only source, the paper highlights the need for further research to improve the validity of proxies' reports.

Impact of a proactive approach to improve end-of-life care in a medical ICU

STUDY OBJECTIVES

To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients experiencing global cerebral ischemia (GCI) after cardiopulmonary resuscitation and multiple organ system failure (MOSF) in comparison to historical control subjects.

DESIGN

Comparative study of retrospective and prospective cohorts.

SETTING

Medical ICU of a university hospital.

INTERVENTIONS

Patterns of end-of life care for patients with MOSF and GCI obtained through a retrospective chart review were compared to proactive case finding facilitated by the inpatient palliative care service. Interventions included identification of patient's advance directives or preferences about end-of life care, if any; assistance with discussion of the prognosis and treatment options with patients or their surrogates; and implementation of palliative care strategies when treatment goals changed to a focus on comfort measures.

RESULTS

Although our retrospective data demonstrated a high percentage of do-not-resuscitate decisions for the patients under investigation, a considerable time lag elapsed between identification of the poor prognosis and the establishment of end-of-life treatment goals (4.7 +/- 2.4 days and 3.5 +/- 0.5 days for patients with MOSF and GCI, respectively [mean +/- SE]). The proactive case finding approach decreased hospital length of stay (mean, 20.6 +/- 4.1 days vs 15.1 +/- 2.5 days and 8.6 +/- 1.6 days vs 4.7 +/- 0.6 days for MOSF and GCI patients, respectively; p = 0.063 and < 0.001, respectively). More importantly, a proactive palliative care intervention decreased the time between identification of the poor prognosis and the establishment of comfort care goals (7.3 +/- 2.9 days vs 2.2 +/- 0.8 days and 6.3 +/- 1.2 days vs 3.5 +/- 0.4 days for MOSF and GCI patients, respectively; p < 0.05 for both), decreased the time dying patients with MOSF remained in the ICU, and reduced the use of nonbeneficial resources, thus reducing the cost of care.

CONCLUSIONS

Proactive interventions from a palliative care consultant within this subset of patients decreased the use of nonbeneficial resources and avoided protracted dying.

The role of oncology nursing to ensure quality care for cancer survivors: a report commissioned by the National Cancer Policy Board and Institute of Medicine

PURPOSE

To examine the roles of oncology nurses in improving quality care for cancer survivors.

DATA SOURCES

A content analysis of textbooks, journals, and key documents; surveys of graduate oncology nursing programs and the Oncology Nursing Society's Survivorship Special Interest Group; review of the nursing licensure examination and oncology nursing certification; review of undergraduate and graduate nursing standards; and review of currently funded nursing research.

DATA SYNTHESIS

Ten critical content areas of cancer survivorship were used for the analysis: description of population of cancer survivors, primary care, short- and long-term complications, prevention of secondary cancer, detecting recurrent and secondary cancers, treatment of recurrent cancer, quality-of-life issues, rehabilitative services, palliative and end-of-life care, and quality of care. Although findings within each source indicated significant information related to the roles of nurses in caring for cancer survivors, deficits also were identified.

CONCLUSIONS

Review of key literature and resources suggests significant contributions by oncology nursing over the past two decades to the area of cancer survivorship.

IMPLICATIONS FOR NURSING

Support is needed to expand education and research to ensure quality care for future cancer survivors.

Achieving excellence in end-of-life care

Nurses in practice have verified the need for nursing education curricula to include content related to care of the dying patient. Nurse educators are initiating curricular changes to assure students have the knowledge and attitudes needed to provide quality care at the end of life. The authors discuss one university undergraduate program's development of both a theory and practicum course.

Relieving non-pain suffering at the end-of-life

We discuss non-pain problems at end-of-life in this paper. Management of these problems is key to ensuring relief of suffering. Much of this paper is a reiteration of the material on common physical symptoms, which is presented in module 10 of the Education for Physicians on End-of-life Care (EPEC) project of the American Medical Association in conjunction with the Robert Wood Johnson Foundation.

A model of hypnotic intervention for palliative care

The World Health Organization defines palliative care as "the active total care of patients whose disease is not responsive to curative treatment." One of the primary issues of palliative care for patients with advanced cancer is symptom control and quality-of-life issues. The purpose of the hypnotic model presented here is to improve the patient's total psychological, social, and spiritual well-being. There exists a need for a broad and inclusive model of mind-body interventions for palliative care. This is supported by the observation that symptoms related to psychological distress and existential concerns are even more prevalent than pain and other physical symptoms among those with life-limiting conditions. The following model integrates naturalistic, solution-oriented hypnosis within the framework of a situational 4-stage crisis matrix. The four stages of the matrix are: (1) The Initial Crisis, (2) Transition, (3) Acceptance, and (4) Preparation for Death. Hypnotic interventions are tailored to each stage in the crisis matrix.

The Kansas Living Initiatives for End-of-Life Care

The Kansas Living Initiatives for End-of-Life Care (LIFE) project was formed in 1999 by over 70 Kansas organizations, agencies and associations to further the cause of dignified, comfortable and peaceful end of life in terminally ill patients. LIFE developed a module on end-of-life care that was added to the Kansas year 2000 Behavioral Risk Factor Surveillance system, convened meetings of partners including health professional licensing boards, reviewed state laws and regulations, and published a joint policy statement of the Kansas Boards of Healing Arts, Nursing and Pharmacy on the use of controlled substances for pain management. Activities of Project LIFE and outcomes are described.

A good death in rural Kenya? Listening to Meru patients and their families talk about care needs at the end of life

What constitutes a good death sub-Saharan Africa? In Meru District in Eastern Kenya, we listened to 32 patients with ongoing cancer or AIDS, and to their carers as they talked about end-of-life experiences and care needs. Patients described how the support of close family relationships, and the care shown by their community and religious fellowships helped meet many of their emotional, social, and spiritual needs. But physical needs often went unmet. Patients died in pain. Some suffered in poverty, others were troubled by the guilt of using all available family resources to pay for treatment and care. Accessible pain relief, affordable clinic or inpatient care when required, and help to cope with the burden of care were among the key needs of patients. Until these are available, many will not die well.

Community perspectives on advance care planning: report from the Community Ethics Program

The objectives of the Community Ethics Program are to increase community awareness about advance care planning to address patient preferences concerning future care, and to improve hospital-community collaboration around care at end of life in diverse communities. As part of this educational program, community forums and focus groups were held with African-American, Korean-American, and Latino communities in Philadelphia between 2000 and 2001. In this paper, we discuss concerns related to end of life and advance care planning specific to each community, as well as themes that cut across communities. Increasing our understanding of community views and perspectives on potential barriers to advance care planning, particularly through a hospital-community partnership, is an important step toward enhancing the quality of end of life care for all patients.

Uniting to improve end-of-life care

Survey results measure the impact of a national invitational nursing conference on end-of-life care.

A comparative study of the law of palliative care and end-of-life treatment

Since the Supreme Court of New Jersey decided the Quinlan case a quarter of a century ago, three American Supreme Court decisions and a host of state appellate decisions have addressed end-of-life issues. These decisions, as well as legislation addressing the same issues, have prompted a torrent of law journal articles analyzing every aspect of end-of-life law. In recent years, moreover, a number of law review articles, many published in this journal, have also specifically addressed legal issues raised by palliative care. Much less is known in the United States, however, as to how other countries address these issues. Reflection on the experience and analysis of other nations may give Americans a better understanding of their own experience, as well as suggest improvements to their present way of dealing with the difficult problems in this area.

This article offers a conceptual and comparative analysis of major legal issues relating to end-of-life treatment and to the treatment of pain in a number of countries. In particular, it focuses on the law of Australia, Canada, the United Kingdom, Poland, France, the Netherlands, Germany, and Japan.

New report card compares end-of-life care initiatives across the country

A report card from Last Acts and the Robert Wood Johnson Foundation takes a first look on a state-by-state basis at how end-of-life care and related issues are approached by healthcare organizations across the country.

Policies designed to enhance the quality of life of children with cancer at the end-of-life

This study evaluated preventive intervention designed to enhance the quality of life of children with cancer at the end-of-life, based on a theoretical model of crises denoted as the Perceived Personal Control Crisis Model. Preventive intervention on the Social Action level consists of introducing policies and services in the pediatric hemato-oncology department designed to enhance the quality of life of children with cancer at the end-of-life.

Continuing to conduct research in nursing homes despite controversial findings: reflections by a research scientist

To illustrate the potential controversial nature of the research findings, the author first presents data from an ongoing study on the care of terminally ill nursing home residents, then responds to the question: "How can you go into nursing homes, find out all that you do, publish your findings, and continue to gain access to nursing homes?" Strategies used over the past 20 years to gain this access and to develop and maintain harmonious relationships during and after the data collection process are presented. The author emphasizes the importance of conducting research in settings that may generate controversial findings. Furthermore, she states that these findings should be presented to advocates and policy makers who are in a position to bring about changes that will improve the quality of care.

Hospital executive leadership: a critical component for improving care at the end of life

End-of-life care and its planning by individuals, in concert with their families and professional healthcare givers, pose important social, legal, and ethical issues. The authors evaluate the results of a multi-year (1997-2001) collaborative effort among representatives of Georgia healthcare providers, healthcare payers, and the general public that was designed to (a) improve end-of-life care through a community-focused field effort to increase public awareness, execution, and institutional management of advance directives and (b) impact institutional and state government systems and policies around end-of-life care. The authors conclude that a proactive presence of senior management is integral in implementing systematic change in hospital-based end-of-life care and offer practical recommendations to hospital leaders to affect real change in their institutions.

An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care

Functional benchmarking assesses performance and practice across a broad range of settings and carries the potential to effect change in practice. An integrated care pathway (ICP) can assist in the benchmarking process, defining desired outcomes for specific patient groups over a designated time frame. Any variations to the agreed course of care are documented using the 'variance sheet'. This article describes the Wales-wide implementation of an ICP for the last two days of life. The project has enabled an ongoing centralized collection and analysis of variance sheets, which reflect the care of the dying patient in four different care settings crossing the voluntary and statutory sectors. Initial analysis of the first 500 variance sheets to be generated by the ICP for the last two days of life indicates that the management of pain, agitation, excess respiratory secretions and mouth care may be problematic. The same problems were experienced across acute, hospice, specialist inpatient units and community care. Closing the audit cycle involves incorporating the information from the variance analysis into clinical practice.

Pain management problems in patients' terminal phase as assessed by nurses in Finland

BACKGROUND

This study is part of a larger questionnaire survey concerned with the views of nursing staff on physical, emotional and spiritual support for terminally ill patients and decision making on the transition to the terminal phase of treatment.

AIM

This article discusses the results concerning the prevalence of physical pain in patients and with problems in pain management.

METHODS

A total of 328 nurses working on the inpatient wards of 32 municipal health centres in finland took part. Data were collected with multiple-choice items and one open-ended question, which were part of a larger structured questionnaire. The data were analysed by means of the SPSS statistical software and content analysis.

FINDINGS

Dying patients often suffered from pain, which was most commonly because of cancer. Intractable pain was common. The problems of pain management concerned attitudes and qualifications related to treating pain, the assessment of the pain, pain management per se and the organization of pain management.

CONCLUSION

The study highlights the need to increase pain education, discussion and agreement on the principles of pain management in municipal health centres in Finland.

Dehydration in terminally ill patients. Perceptions of long-term care nurses

Dehydration in terminally ill patients has been found to be beneficial and to improve the quality of an individual's last few days of life. As the population continues to age, more individuals are cared for in long-term care (LTC) facilities, where they tend to spend their final days. Previous studies have examined the perceptions and attitudes of hospice nurses, acute care nurses, physicians, and caregivers; however, no such studies have evaluated LTC nurses. It is necessary to know LTC nurses' perceptions and attitudes so they can be offered the education needed to provide the best quality care for terminally ill patients. The purpose of this study was to describe how nurses working with elderly individuals in LTC perceived terminal dehydration (TD). Long-term care nurses (N = 64) were surveyed using a modified version of an established 10-item instrument. Significant findings included a positive correlation between age and positive perception of TD--as nurse age increaSed, a more positive view of TD was expressed. Also, the number of deaths witnessed was positively associated with the belief that TD was beneficial. In general, responses to the individual survey items were quite varied, representing inconsistencies in attitudes and care of dying LTC patients. The results of this descriptive study indicate the debate concerning the benefits of TD continues and remains an important topic for the LTC nurse.