Assessment of the need for palliative care as perceived by individual cancer patients and their families: a review of instruments for improving patient participation in palliative care

Patient autonomy problems in palliative care: systematic development and evaluation of a questionnaire

No instrument to assess autonomy problems in palliative care is currently available. The purpose of this study was to develop a comprehensive and concise questionnaire to measure autonomy problems in palliative cancer patients and to study its validity and reliability. We systematically developed a questionnaire through: a) a literature review of the concepts and elements of autonomy; b) qualitative analysis of interviews with patients and professional carers; c) the construction of questionnaires; and d) testing validity and reliability. The basic conceptual elements were: dependency, losing control, and limitation of activities. Patients with disseminated cancer in the palliative stage of the disease (n = 64) participated in the study. A 9-item Patient Autonomy Questionnaire (PAQ) was developed (Cronbach's alpha 0.86), followed by a concise 4-item version (PAQs) (Cronbach's alpha 0.71). Autonomy problems were more prevalent than pain problems. The development of the PAQ may help draw attention to autonomy problems.

Health needs assessment tools: Progress and potential

Objectives:Health needs has attracted the interest of policy-makers, health economists, and health professionals as modern health services try to satisfy individual and population health needs to optimize resource utilization. Health needs can be assessed by administering various types of survey or interview-based instruments. If health needs are to be satisfied in changing health agendas in developed and developing countries, it is essential to employ valid and reliable tools. Despite the importance of needs assessment, no comprehensive review of tools is currently available. We carried out a literature search to define and categorize existing health needs assessment tools.

Methods:We reviewed medical and social search engines for items containing specific health needs–related words to identify needs tools across a range of specialties. Papers were reviewed in terms of design, subject matter, psychometric features, and method of administration method.

Results:Thirty-one employed in 52 studies including cancer, mental health, palliative care, multiple sclerosis, and cardiovascular disease tools were identified.

Conclusions:This report summarizes available health needs instruments in a range of diseases to assist researchers in accessing health needs resources more easily and to encourage further research in this field.

The problems experienced by patients with cancer and their needs for palliative care

OBJECTIVES

To investigate the problems that patients experience and their met- and unmet needs for professional help. This information is necessary to tailor palliative care to patient needs.

PATIENTS AND METHODS

Patients (n=94) with disseminated cancer completed a validated checklist with 90 potential problems and needs for palliative care (PNPC questionnaire).

MAIN RESULTS

On average, patients experienced 37 problems (range 0-68) and required more professional attention for eight problems (range 0-71). The five most prevalent problems were: fatigue, heavy housework, coping with the unpredictability of the future, fear of metastases, and frustrations because I can do less than before. The five issues most in need of extra attention were: informational needs, coping with the unpredictability of the future, fear of metastases, fear of physical suffering, and difficulties remembering what was told (during consultations). Younger patients experienced more social, psychological, and financial problems. Some 10% of patients expressed a multitude of problems and needs.

CONCLUSIONS

While patients with metastasized cancer experienced a wide variety of problems, they asked for more support for only a few specific problems. Evidently, "problems" are not synonymous with unmet needs. Therefore, not only problems but also needs for care should be assessed. A structural need for support to cope with fears of suffering and loss of autonomy was found. Ten percent of patients expressed a multitude of problems and needs and might benefit either from psychological counseling or better palliative care.

Psychosocial interventions for patients with advanced cancer - a systematic review of the literature

Advanced cancer is associated with emotional distress, especially depression and feelings of sadness. To date, it is unclear which is the most effective way to address these problems. This review focuses on the effects of psychosocial interventions on the quality of life (QoL) of patients with advanced cancer. It was hypothesised that patients will benefit from psychosocial interventions by improving QoL, especially in the domain of emotional functioning. The review was conducted using systematic review methodology involving a systematic search of the literature published between 1990 and 2002, quality assessment of included studies, systematic data extraction and narrative data synthesis. In all, 10 randomised controlled studies involving 13 trials were included. Overall interventions and outcome measures across studies were heterogeneous. Outcome measures, pertaining to the QoL dimension of emotional functioning, were most frequently measured. A total of 12 trials evaluating behaviour therapy found positive effects on one or more indicators of QoL, for example, depression. The results of the review support recommendation of behaviour therapy in the care of patients with advanced cancer.

Study of unmet needs in symptomatic veterans with advanced cancer: incidence, independent predictors and unmet needs outcome model

Veteran patients possess distinctive characteristics such as a higher mortality rate, lower socioeconomic status and poorer health status. We report the prevalence and predictors of unmet needs and examine the association between unmet needs and quality of life (QOL). Two hundred ninety-six male cancer patients who presented with distressing symptom(s) completed the following instruments: a 14-item multidimensional unmet needs questionnaire, Functional Assessment of Cancer Therapy (FACT-G), Memorial Symptom Assessment Scale-Short Form (MSAS-SF) and other validated measurements of function, depression, health and social support. Multiple linear regression models were used to identify independent predictors of each unmet needs domain and of total unmet needs. The relationships between total unmet needs, QOL and multidimensional variables were also explored. The median number of total unmet needs was three, and the most frequently reported unmet needs areas were physical (80.0%), activities of daily living (53.3%), nutrition (46.1%) and emotional (32.5%). Different predictors of each unmet needs domain were identified. Younger age was associated with a higher risk of unmet needs in physical, economic and medical domains. Higher psychological symptom distress was associated with more unmet needs in the emotional/social, economic and medical domains. Physical symptom distress, extent of disease and health measure were only significant in the physical unmet needs domain. The depression, psychological and physical symptom distress scores, confident and affective social support scores, total unmet needs and age independently predicted FACT-G total QOL score (R(2)=63%, P < 0.00001). Patients with higher psychological, physical symptom distress and depression scores, younger age, lower functional status and metastatic disease were more likely to report more unmet needs. The total number of unmet needs was predictive of QOL. The unmet needs and QOL outcomes model was developed but needs further validation.

Towards a new clinical tool for needs assessment in the palliative care of cancer patients: the PNPC instrument

This study describes a new clinical tool for needs assessment in palliative care: the Problems and Needs in Palliative Care questionnaire (PNPC). It was developed to support the provision of care tailored to the specific demands of patients, which only can be provided when their needs are clearly identified. To test validity and reliability, 64 patients with metastatic cancer living at home completed the PNPC. Of 140 initial items, 2 were deleted because of low response. No important topics were missing. Dimensions were proposed to organize the problems and needs in a logical and practical array for use in individual patients, and to enable statistical analysis of patient-groups. Reliability analysis supported the proposed dimensions, with Cronbach's alpha coefficient >0.70 for dimensions with > or = 5 items, and alpha >0.65 for the 3- and 4-item dimensions. However, the dimensions 'physical symptoms' and 'social issues' lacked coherency with some low item-total correlations. The PNPC demonstrated convergent validity with the European Organization for Research and Treatment of Cancer (EORTC) and COOP-WONCA quality-of-life measures. These data are a first step in validating the PNPC, although the 'social issues' dimension needs reconsideration. Further studies are needed to evaluate clinical use.

Measuring the quality of structure and process in end-of-life care from the bereaved family perspective

Measurement of the structure/process of care is the first step in improving end-of-life care. The primary aim of this study was to psychometrically validate an instrument for directly measuring the bereaved family's perception of the necessity for improvement in structural/procedural aspects of palliative care. Different sets of questionnaires were sent to 800 and 425 families who lost family members at one of 70 certified palliative care units in Japan in the development and validation phases, respectively, and 281 families of the latter group in the follow-up phase. The participants were requested to fill out a newly-developed Care Evaluation Scale (CES), along with outcome measures (the perceived experience and satisfaction levels) and potential covariates (the degree of expectation, the Center for Epidemiologic Studies Depression Scale, and the Social Desirability Scale). We obtained 485, 310, and 202 responses in the development, validation, and follow-up phases (response rates: 64%, 75%, and 72%, respectively). The 28-item CES had an overall Cronbach's coefficient alpha of 0.98; the intra-class correlation coefficient in the test-retest examination was 0.57. A confirmatory factor analysis revealed 10 subscales: physical care (by physicians, by nurses), psycho-existential care, help with decision-making (for patients, for family), environment, family burden, cost, availability, and coordination/consistency. The CES subscales were only moderately correlated with the perceived-experience and satisfaction levels of corresponding areas (r=0.36-0.52 and 0.39-0.60, respectively). The CES score was not significantly associated with the degree of expectation, the changes of depression, or the Social Desirability Scale. The CES is a useful tool to measure the bereaved family's perception of the necessity for improvement in structural/procedural aspects of palliative care. The advantages of the CES are: 1) it specifically evaluates the structure and process of care, 2) it directly identifies needed improvements, 3) it is not affected by the degree of expectation, depression, or social desirability, and 4) it has satisfactory psychometric properties.

The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures

CONTEXT

Cancer is a leading cause of morbidity and mortality in the USA and despite many recent advances in detection and treatment, over half a million cancer patients in this country will die from their disease each year.

OBJECTIVE

Using cancer as a prototype, we provide a conceptual framework to identify and review barriers to optimal end-of-life care and propose examples of linked process and outcome measures that could be used to evaluate whether standards of optimal end-of-life care are being achieved.

METHODS

We propose a conceptual model of end-of-life care and use this model to review the published literature to identify the key goals of optimal end-of-life care and summarize existing barriers to optimal end-of-life care. We then provide examples of process and outcome measures linked to the goals of optimal end-of-life care and domains within the conceptual framework.

RESULTS

Within all components of care at the end-of-life--societal attitudes, health care system(s), providers, and patients and their families--there are significant barriers to the quality of care. Some of the most critical barriers to optimal care at the end-of-life in the USA are limited availability, and coverage of, co-ordinated service delivery; poor provider communication and diagnostic skills; limited opportunities for training in palliative care; patient fears and attitudes towards the sick role, and a lack of, or inadequate health insurance. Proposed patient, provider, and system level measures of the quality of care were guided by goals of optimal end-of-life care, and focus on communication about prognosis and risks and benefits of treatment, development of clear and informed treatment goals, delivery of services consistent with treatment goals, and promotion of quality of life.

CONCLUSIONS

At present, there are substantial societal, health care system, provider, and patient barriers to obtaining optimal cancer care at the end-of-life. Ongoing discussions about appropriate measures of the quality of end-of-life care are gaining momentum, however. The proposed process and outcome measures for assessing optimal end-of-life care use cancer as a prototype, but are broadly applicable to other patient populations with life-threatening disease.

Concerns of family caregivers of patients with cancer facing palliative surgery for advanced malignancies

PURPOSE/OBJECTIVES

To describe the concerns of family caregivers of patients undergoing palliative surgeries for advanced malignancies.

DESIGN

Descriptive study with repeated measures.

SETTING

A National Cancer Institute-designated Comprehensive Cancer Center in the western United States.

SAMPLE

Family caregivers (N = 45) of patients with cancer.

METHODS

Family caregivers were assessed prior to planned palliative surgery and at two weeks and six weeks postsurgery. Quantitative assessment of caregiver quality of life (QOL) occurred at each interval. A subset of nine caregivers also participated in a structured interview presurgery and at two weeks postsurgery.

MAIN RESEARCH VARIABLES

Caregiver concerns, QOL, decision making.

FINDINGS

Family caregivers have important QOL concerns and needs for support before and after surgery for advanced disease. Psychological issues were most pronounced, and common concerns included uncertainty, fears regarding the future, and loss. Family caregivers have concerns about surgical risks and care after surgery and voiced recognition of the declining status of patients.

CONCLUSIONS

Surgery is an important component of palliative care and profoundly impacts family caregivers of patients with cancer. The needs of family caregivers are multiple and complex, requiring ongoing assessment to provide interventions that help them cope and ultimately improve their QOL. This important topic requires further research and clinical attention.

IMPLICATIONS FOR NURSING

Findings suggest that family caregivers experience their own trajectory during the course of their loved ones' cancer, with surgery being a part of the course. This includes their profound emotions that may swing like a pendulum from one minute to the next. Nurses need to assess family caregivers in addition to patients to provide support and resources that will help increase caregivers' QOL.

Is quality of life measurement likely to be a proxy for health needs assessment in patients with coronary artery disease?

BACKGROUND

The identification of patients' health needs is pivotal in optimising the quality of health care, increasing patient satisfaction and directing resource allocation. Health needs are complex and not so easily evaluated as health-related quality of life (HRQL), which is becoming increasingly accepted as a means of providing a more global, patient-orientated assessment of the outcome of health care interventions than the simple medical model. The potential of HRQL as a surrogate measure of healthcare needs has not been evaluated.

OBJECTIVES AND METHOD

A generic (Short Form-12; SF-12) and a disease-specific questionnaire (Seattle Angina Questionnaire; SAQ) were tested for their potential to predict health needs in patients with acute coronary disease. A wide range of healthcare needs were determined using a questionnaire specifically developed for this purpose.

RESULTS

With the exception of information needs, healthcare needs were highly correlated with health-related quality of life. Patients with limited enjoyment of personal interests, weak financial situation, greater dependency on others to access health services, and dissatisfaction with accommodation reported poorer HRQL (SF-12: p < 0.001; SAQ: p < 0.01). Difficulties with mobility, aids to daily living and activities requiring assistance from someone else were strongly associated with both generic and disease-specific questionnaires (SF-12: r = 0.46-0.55, p < 0.01; SAQ: r = 0.53-0.65, p < 0.001). Variables relating to quality of care and health services were more highly correlated with SAQ components (r = 0.33-0.59) than with SF-12 (r = 0.07-0.33). Overall, the disease-specific Seattle Angina Questionnaire was superior to the generic Short Form-12 in detecting healthcare needs in patients with coronary disease. Receiver-operator curves supported the sensitivity of HRQL tools in detecting health needs.

CONCLUSION

Healthcare needs are complex and developing suitable questionnaires to measure these is difficult and time-consuming. Without a satisfactory means of measuring these needs, the extent to which disease impacts on health will continue to be underestimated. Further investigation on larger populations is warranted but HRQL tools appear to be a reasonable proxy for healthcare needs, as they identify the majority of needs in patients with coronary disease, an observation not previously reported in this patient group.

Care for the caregivers: a review of self-report instruments developed to measure the burden, needs, and quality of life of informal caregivers

Significant demands are being placed on the informal caregivers of chronically ill patients, including those suffering from cancer. Health care professionals need to be aware of these demands, and they need effective tools to assess the impact these demands place on the caregivers. Over the past 25 years, researchers have developed self-report instruments to assess informal caregivers. These instruments assess various aspects of the caregiving experience, including caregiver burden, needs, and quality of life. The purpose of this review was to identify and critically evaluate these instruments. MEDLINE and PUBMED were searched from 1966 to 2002. After an extensive literature search and review, and utilizing specific inclusion criteria, 28 instruments were identified and evaluated in terms of their development, content, and psychometric properties. In addition, a history of the construct and measurement development in the areas of caregiver burden, needs, and quality of life are discussed. Although some further development and refinement of instruments could benefit the field, depending on the questions researchers or clinicians seek to pursue, there are many proven tools available for their use. Future research needs to use these instruments to assess the effectiveness of interventions aimed at improving the care of the caregivers.

Gynecologic cancer patients' psychosocial needs and their views on the physician's role in meeting those needs

The aim of this study was to identify the psychosocial needs of patients after treatment for gynecological malignancies and their views concerning the role physicians should take in meeting those needs. Self-administered questionnaires were answered by 95 patients at least 6 months after completion of therapy. Topic areas included emotional needs, spiritual concerns, patient-family communication, patient participation in decision making, and advance directives. In addition, all participants completed the Functional Assessment of Cancer Therapy (FACT-G, version 4) quality of life questionnaire. Fifty-seven percent of respondents stated that they had needed help dealing with emotional problems, and 73% wanted the physician to ask whether help is needed. The most common emotional concerns were feeling nervous (40% of subjects), being worried (34%), fear (25%), needing someone to talk to (24%), sadness (21%), and loss of control (17%). Fifty-nine percent stated that physicians should ask whether help is needed in discussing spiritual matters. Sixty-one percent stated that physicians should ask patients whether they want help starting conversations with their families about difficult-to-raise topics such as the possibility of dying. Forty-six of 86 respondents (53%) stated that discussions about advance directives such as living wills should take place soon after the cancer diagnosis has been established. Most patients surveyed want physicians to take an active role in dealing with psychosocial needs.

Measuring quality of palliative care: psychometric properties of the FAMCARE Scale

This study measures quality of palliative care in 181 family members (i.e. spouse, child) to cancer victims with terminal disease 1 month after the time of death. The specific aim was to explore the underlying factor structure and dimensionality of the 20 items of the FAMCARE Scale, measuring family satisfaction with health care given to the patient and to them. The results from a factor analysis, a Mokken Scaling Program analysis, and a reliability analysis, showed that 19 out of the 20 items form a strong one-dimensional scale. Since the scale is one-dimensional, the possibility of reducing the number of items should be explored in future research. Our recommendation is to measure satisfaction with care 1-2 months after the death of the patient. One should also explore the possibilities of measuring satisfaction with care prospectively as an integral part of the palliative care program.

Implementation of the pain and symptom assessment record (PSAR)

BACKGROUND

Symptom control is a major component of care for the terminally ill patients. Although uncontrolled pain is distressing for patients and families, there are other symptoms that can be distressing such as dyspnea and fatigue. Determining methods to consistently assess and manage pain and other symptoms is a challenge for nurses, physicians and other health care professionals. In the Ottawa Region of Canada, health care providers raised concerns related to inconsistencies in pain assessment due to a variety of formats used, as the patient moved through the health care system. Recognizing the need for a common assessment tool, a working group was formed composed of 14 nurses associated with institutions and agencies delivering palliative care services in the Ottawa region, as well as a faculty member of the School of Nursing of the University of Ottawa. The mandate of the working group was to develop a consistent method to assess patients' pain and symptoms in order to facilitate communication among health care professionals within various health care settings. The Pain and Symptom Assessment Record (PSAR) was developed over 24 months.

AIM

To determine the feasibility of implementing the PSAR in a variety of settings.

METHODS

This exploratory study used focus groups and chart audits to gather data related to the utility of the PSAR. Education sessions were used to introduce the tool to nurses in the various settings.

RESULTS

The tool was implemented in 12 settings. Thirty-seven education sessions were given to nurses prior to use of the tool and the feedback revealed that this is an important process in tool introduction. The results of the chart audits indicated that pain was assessed 93% of the time. Symptoms were less documented but fatigue was most prominent. Overall, patients were satisfied with their pain and symptom control. Data from the focus groups were analysed using content analysis and the two themes that emerged related to the tool were 'structure' and 'process'.

CONCLUSION

There were many challenges in this project and lessons learned will be discussed. Based on the results, the tool has been modified and is currently utilized in diverse settings.

[Measure of quality of life in patients with metastatic colorectal cancer: techniques and main results]

PURPOSE

Until the 1990s, the patient's duration of life was the main measure for determining the value of palliative chemotherapy for colorectal cancer. Quality of life recently appeared as a main end point. The aim of this article is to provide an overview of the instruments used to measure quality of life in patients with metastatic colorectal cancer, to review the published data and to analyse the bias and methodological problems.

CURRENT KNOWLEDGE AND KEY POINTS

QoL is a multidimensional subjective concept, which can be measured using psychometric instruments. Quality of life measurement has a descriptive and prognostic value. Results from quality of life assessment in randomized trials have given useful information and help patients and physicians to choose between treatment options. More than half of the patients with palliative chemotherapy had at least stabilization of quality of life. Response to chemotherapy and side-effects influence quality of life. Quality of life assessment clearly requires methodological improvement. Missing data are a particularly difficult problem, which should be improved by a better organization.

FUTURE PROSPECTS AND PROJECTS

Psychometric properties of EORTC QLQ-CR38 et FACT-C should be checked in French language. An international consensus on methods of measurement of quality of life in oncology is warranted to enhance compliance, to better interpret quality of life results et to optimize publications of precise quality of life data.

Problems to discuss with cancer patients in palliative care: a comprehensive approach

This study presents a comprehensive overview of the problems patients experience in a palliative phase of cancer. A two-step qualitative method was used: in-depth interviews with patients and relatives (N=9 patients+7 relatives), followed by interviews (N=31patients+15 relatives) using a checklist to confirm and complete the picture. Quality of life and quality of care domains were addressed. Patients experienced problems in all of these palliative care domains, although individual patients may have experienced only a few problems. Fatigue, feelings of futility, reluctance to accept help, fear of suffering and the fear that help would not be available if needed, were common problems. Communication problems arose when a grudge against a GP had remained, or because one family member tried to spare the other a confrontation with his/her feelings of fear or grief. A comprehensive checklist of relevant problems is presented.

Clinical support for families in the palliative care phase of hematologic or oncologic illness

This article focuses on families' needs for support and care when the patient is receiving palliative care. Health care professionals providing care to patients with hematologic or oncologic illnesses are coming to understand that care for the family must begin at the time of patient's diagnosis and treatment. Families who do not receive adequate information and support in the early phases of the patient's treatment have greater needs, less trust and confidence in the health care system, and cope more poorly in the later stages than families who have been informed and supported throughout the course of the illness. This article documents the needs of families in the palliative phase of a patient's hematologic or oncologic illness and provides empirically based recommendations for assessment and care of the family unit.

Informed choice in cancer pain: empowering the patient

Cancer and palliative care service users can often feel isolated and disempowered. (Tower, 1999). Physical changes, medical interventions and pain can mean that they no longer feel in control of their bodies or their futures. In recognition of this, many health professionals within cancer and palliative care have adopted the mantra of 'patient empowerment', but it is not always clear what it means for either the patients or the professionals. Empowerment is an interactive process that develops and increases power through cooperation, sharing and working together (Marquis and Huston, 2000), and it plays a central role in health professionals' personal and working lives. A person's ability to make decisions and choices demonstrates control of his or her own destiny. This article aims to direct health professionals' participation and involvement in restoring this ability to patients who have pain related to cancer.