Patients with cancer and their spouse caregivers. Perceptions of the illness experience

Perceptions about perceived functional disabilities and pain of people with rheumatoid arthritis: differences between patients and their spouses and correlates with well-being

OBJECTIVE

In this study we examined the differences in perceptions of the patient's health status between rheumatoid arthritis (RA) patients and their spouses, and correlates of these differences with patients' and spouses' well-being.

METHODS

A sample of 188 couples with one member receiving treatment for RA were selected from the rheumatology clinics in Twente, The Netherlands. The mean age of both RA patients and spouses was 56 years. Respondents completed questionnaires, including estimations of both patients and spouses on the patient's functional disabilities and pain, and scales on affect and marital commitment for patients and spouses.

RESULTS

Differences in estimations of patients and spouses were considerable. Both over- and underestimations of the patient's functional disabilities by the spouse were associated with the patient's poorer mental health status. Overestimations of the patient's functional disabilities were associated with poorer mental health among spouses.

CONCLUSION

It is essential that any support intended by the spouse is in accordance with the patient's needs. If the patient's condition is misperceived by the spouse, this can lead to ineffective and inappropriate support being given.

Family caregiver perspective-taking and accuracy in estimating cancer patient symptom experiences

As family caregivers assume more prominent roles in the provision of home care to persons with serious illness, investigators must test the effectiveness of novel interventions to facilitate family caring for cancer patients. This article is based on results derived from a larger study carried out in Canada that was designed to compare 98 advanced cancer patient and family caregiver perceptions of 32 patient symptom experiences as captured by the Memorial Symptom Assessment Scale. We examined two main questions: (1) whether "natural" family caregivers' perceptions of patient lack of energy and worrying are more closely related to a self- or patient-oriented viewpoint and (2) whether induced "imagine-patient" perspective-taking can assist caregivers to achieve better perceptual accuracy. The caregiver's natural responses to neutral instructions that neither encouraged nor discouraged perspective-taking served as the baseline comparison with three other instructional sets, in which caregivers were prompted to: (1) provide a self-report on their own symptom experiences, (2) imagine how they would feel in the patient's situation (imagine-self), or (3) imagine how the patient would respond to his or her symptom situation (imagine-patient). Findings suggested that the family caregivers' natural judgments correspond most closely to what they do under an imagine-patient set than to what they do under any other set. Findings with respect to accuracy indicated that instructions to imagine the patient's perspective helped to prompt adjustments down from a self-oriented viewpoint, although definitive conclusions were precluded by difficulties with order effects.

Continued parental attendance at a clinic for adult survivors of childhood cancer

PURPOSE

Adult survivors of childhood cancer have been an underserved and understudied population. Few clinics are available to take care of them, unlike the numerous ones that exist for children. The authors established a clinic that would take care of all survivors diagnosed before the age of 25 years, ensuring the participation of a significant number of adults. The authors observed that many adult patients came to their annual visits accompanied by one or both of their parents. The rate was almost three times as high compared with parents in either a primary care or subspecialty internal medicine clinic.

METHODS

The authors investigated this phenomenon by asking parents of adult survivors to fill out a questionnaire that collected demographic information as well as reasons for parents accompanying their adult children to doctors' appointments. Open-ended comments were also solicited.

RESULTS

Most parents who came with their adult survivor children did not accompany their other children to doctor visits and commented that they felt there was a unique bond created by the cancer experience that did not diminish with increasing age of their children. The rate of parental attendance was independent of diagnosis or demographic indicators. Many parents stated that they continued to be concerned about their child's diagnosis, overall health, and risk for cancer recurrence.

DISCUSSION

Parents of adult survivors of childhood cancer may harbor deep feelings of protectiveness that continue well beyond the initial treatment and off-treatment periods when the threat of primary cancer recurrence is a realistic concern. This can be manifested in them by accompanying their adult children to doctors' appointments and deserves further study.

Symptom control

Symptom control has become increasingly recognized as an important goal in patient care. In this article, advances in symptom assessment, and various definitions of symptom improvement are reviewed. Theoretical concepts underlying symptom control and clinically significant change are presented, as well as the role of symptom control as an endpoint in clinical trials. Symptom control is then surveyed in two broad categories for selected symptoms. The first area is therapy related symptoms, secondary to chemotherapy, radiation, hormonal therapy, and surgery. Symptoms reviewed include chemotherapy related mucositis, emesis, fatigue; hot flashes; and radiation related dermatitis, xerostomia, and mucositis. The second area is palliative oncologic approaches to disease-related symptoms. Results in palliative chemotherapy, palliative radiation therapy, cancer pain, and lack of appetite are summarized. Areas requiring further research are noted. Findings are presented in both a clinical and research context to help guide the reader with interpreting symptom control studies.

Role and gender differences in cancer-related distress: a comparison of survivor and caregiver self-reports

PURPOSE/OBJECTIVES

To examine role and gender differences on measures of psychological distress as a consequence of dealing with cancer.

DESIGN

Cross-sectional, descriptive, quantitative analyses of retrospective survey data.

SETTING

A large, nonprofit, volunteer-based cancer organization. The sample was recruited through an online cancer survivor's network (61%), a rural event (24%), and hospital registries (15%).

SAMPLE

Convenience sample of 135 cancer survivors matched to their family caregivers (N = 270).

METHODS

Dyads (i.e., survivors and family caregivers) completed matched questionnaires requesting demographic and medical information and measures of cancer-related distress.

MAIN RESEARCH VARIABLES

Role (i.e., survivor or caregiver), gender, and psychological distress.

FINDINGS

Caregiver means on overall psychological distress were significantly higher than those shown for survivors. Caregiver scores were significantly higher on distress for diagnosis and fear of cancer recurrence. Females scored higher than male caregivers on cancer-related anxiety, future uncertainties, fear of recurrence, and future diagnostic tests. Gender differences were not found for survivor distress.

CONCLUSIONS

Results suggest a need for gender-specific, dyad-tailored cancer support services.

IMPLICATIONS FOR NURSING

As expert caregivers, nurses can provide valuable assistance with the caregiving process that may decrease distress during the family's cancer experience and adaptation period.

Couples' ratings of chronic obstructive pulmonary disease patients' quality of life

The purpose of this study was to compare perceptual differences between chronic obstructive pulmonary disease (COPD) patients and their non-COPD spouses regarding the patients' health-related quality of life (HRQOL). Sixty-seven community-dwelling COPD patients and their non-COPD spouses participated. Participants completed the Sickness Impact Profile (SIP) and the St. George's Respiratory Questionnaire (SGRQ). On both questionnaires, spouses' perceptions of patients' HRQOL were lower than those of the patients themselves. At the bivariate level, statistically significant differences were found on the SIP in the physical domain and on the SGRQ in the psychosocial domain. At the multivariate level, the age and gender of both the patients and spouses accounted for 22% of score differences in the psychosocial domain of HRQOL for the SGRQ. Discordance was greatest among the oldest couples with female non-COPD spouses. Domain-specific HRQOL differences provide direction for supportive nursing interventions to enhance coping among COPD couples.

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.

Conducting intervention research through the Cancer Information Service: a feasibility study

PURPOSE/OBJECTIVES

To determine the feasibility of conducting trials of educational interventions regarding pain and quality of life (QOL) with people who call the National Cancer Institute's Cancer Information Service (CIS).

DESIGN

Descriptive.

SETTING

North Central CIS, located at the University of Wisconsin Comprehensive Cancer Center in Madison.

SAMPLE

Callers to the North Central CIS who self-identified as people diagnosed with cancer or as family members or friends of people diagnosed with cancer were eligible. 102 people with cancer and 103 significant others answered questions concerning the feasibility of a pain study, and 101 significant others completed questions about the feasibility of a QOL study.

METHODS

Eligible CIS callers were invited at the end of usual service to participate in a research study. Those who agreed were asked structured questions regarding pain or QOL.

MAIN RESEARCH VARIABLES

Response rate, length of time to complete recruitment, concerns about reporting pain and using analgesics, concerns about QOL, demographic variables, and willingness to join a hypothetical study.

FINDINGS

The majority of callers had concerns about pain and QOL, and the vast majority (78%-89%) of participants indicated a willingness to join a future educational intervention study.

CONCLUSIONS

Using subjects recruited through CIS, conducting trials of brief telephone interventions designed to help patients overcome barriers to pain management or assist families in addressing QOL concerns may be feasible.

IMPLICATIONS FOR NURSING

Researchers may wish to consider the opportunities afforded by collaborating with CIS colleagues in planning and conducting studies of educational interventions.

Use of family proxies in quality of life research for cancer patients at the end of life: a literature review

One of the main goals of end-of-life care is to achieve the best quality of life (QOL) for patients and their families. Quality of life, therefore, represents a significant outcome indicator to evaluate end-of-life care interventions. However, nonresponse bias and nonrandom missing data in QOL research at the end-of-life limits the generalizability and threatens the internal validity of the study findings. The use of family proxy of patients' QOL has been suggested as a solution. Demonstration of satisfactory levels of agreement between proxies and patients is warranted before family caregivers' or other proxies' assessments can be employed when patients cannot provide their own information. Contrary to the conclusion made by Sprangers and Aaronson [The Role of Health Care Providers and Significant Others in Evaluating the Quality of Life of Patients with Chronic Disease: A Review. J. Clin. Epidemiol. 1992, 45, 743-760], it is suggested from this review of literature that terminal cancer patients and their family caregivers agreed at least moderately well on the patients' QOL. The bias introduced by the use of family informants is generally of a modest magnitude. When discrepancies existed, without exception, family caregivers held a more negative view of patients' QOL than did patients. When using family proxies, this is important to remember. The degree of agreement between terminal cancer patients' and their family caregivers' assessments varies as a function of the dimensions of QOL being measured and the patient's health status. However, the accuracy of family caregivers' assessments can be improved by assessing both patients and family caregivers concurrently over time. Several suggestions for future research are provided to better understand the influencing factors of agreement between patients and family assessments and to enhance the quality of statistical analyses on this topic.

The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease

Health-related quality of life (HRQL) studies sometimes rely, in part, on proxy information obtained from patients' significant others (spouse or close companion) or health care providers. This review: (1) provides a quantitative analysis of the results that have been reported in recent studies assessing the level of agreement between patient and proxy HRQL ratings, and (2) addresses a number of key methodological issues surrounding the use of proxy raters in HRQL research. This review concentrates on 23 studies, published between 1991-2000, that describe patient-proxy agreement for a number of well-known multidimensional HRQL instruments. In general, moderate to high levels of patient-proxy agreement were reported. Lower levels of agreement were found predominantly in studies employing a small sample size (approximately 50 patient-proxy pairs or less). In larger studies comparing patients and their significant others, median correlations were between 0.60-0.70 for physical HRQL domains and about 0.50 for psychosocial domains. Mixed results were reported in studies comparing patients and their health care providers, but most of these studies employed a relatively small sample size. Proxy raters tended to report more HRQL problems than patients themselves, but the magnitude of observed differences was modest (median standardized differences of about 0.20). Based on the current evidence, we conclude that judgements made by significant others and health care providers about several aspects of patients' HRQL are reasonably accurate. Substantial discrepancies between patient and proxy ratings occur in a minority of cases. We recommend that future studies focus on: (a) the reliability and validity of proxy ratings according to common psychometric methods, and (b) the balance between information bias due to proxy ratings and potential selection bias due to exclusion of important patient subgroups from HRQL studies.

Patients with cancer and next-of-kin response comparability on physical and psychological symptom well-being: trends and measurement issues

Next of kin (NOK) play an integral role in fostering optimal quality of life in symptomatic patients who are coping with cancer in the home setting. Often when patients in advanced stages of cancer are no longer able to meaningfully communicate their illness and symptom needs, healthcare professionals turn to NOK to provide sound estimates of patients' symptom experiences. This overview is based on 37 research studies written between 1987 and 2002 and updates an earlier overview of 13 studies on patient-NOK response comparability. The purpose is to, first, promote a better comprehension of methodologies and statistical techniques commonly employed to measure patterns of response comparability (or levels of agreement) between patient self-reports and NOK estimates on patient quality-of-life experiences of physical or symptom and emotional or psychological well-being. The second aim is to identify conditions where NOK may pose as reasonably accurate judges of patients' health-related quality of life, particularly symptom experiences arising from various diagnoses, including cancer. Third, subsequent to identifying the gaps in current research knowledge and limitations in study designs, recommendations for statistical and methodological techniques are outlined.

Symptom experiences: perceptual accuracy between advanced-stage cancer patients and family caregivers in the home care setting

PURPOSE

This study used a comparative descriptive design to compare family caregivers' and advanced-stage cancer patients' perceptions of patients' multidimensional symptom experiences on presence, frequency, severity, and distress.

PATIENTS AND METHODS

A convenience sample of 98 dyads, composed of advanced-stage heterogeneous cancer patients and their caregivers, completed the Memorial Symptom Assessment Scale in the home care setting on a one-time basis. This scale is a 32-item Likert-type scale for assessing the presence, frequency, severity, and distress arising from symptoms in cancer patients.

RESULTS

There was confirmation of trends previously described in related studies where, for example, caregivers tend to overreport on symptom experiences. However, the degree of absolute difference between patient and caregiver responses was normally around 1 unit (on a theoretical range of 0 to 4 units). Levels of patient-caregiver agreement were better on more concrete questions related to symptom frequency, severity, and distress than on broad questions related to the presence of a symptom. Patients and caregivers achieved better levels of agreement on physical versus psychological symptoms.

CONCLUSION

The findings indicated that family caregivers can provide reasonable proxy or complementary reports on patient symptom experiences of frequency, severity, and distress. However, family caregivers have greater difficulty in achieving high levels of accuracy on psychological versus physical symptoms.

Perceptions of patients' self-efficacy for managing pain and lung cancer symptoms: correspondence between patients and family caregivers

This study examined the degree of correspondence between lung cancer patients and their family caregivers in their perceptions of the patients' self-efficacy for managing pain and other symptoms of lung cancer, and the association of this correspondence to demographic, disease, and psychosocial variables. Thirty patients who were newly diagnosed with lung cancer and their primary family caregivers completed telephone interviews assessing the patient's symptoms, the patient's self-efficacy for managing symptoms, the quality of the relationship between the patient and caregiver, patient and caregiver psychological distress, and caregiver strain. Although patients and their caregivers showed a moderate degree of agreement in their perceptions of the patient's self-efficacy for managing pain and other symptoms, there was considerable variability in the degree of congruence. Factors that contributed to lower levels of congruence included low patient-rated self-efficacy, female gender of the patient, high patient psychological distress, and high caregiver strain. Caregivers were about evenly split in their tendency to overestimate versus underestimate the patient's self-efficacy. A poorer quality of relationship between the caregiver and the patient (as rated by the patient), high levels of patient-rated symptoms, and high levels of caregiver strain were associated with caregivers overestimating patient self-efficacy.

Measuring agreement between patient and proxy responses to multidimensional health-related quality-of-life measures in clinical trials. An application of psychometric profile analysis

When patients cannot provide responses to health-related quality-of-life (HRQOL) measures in clinical trials, family or friends may be asked to respond. We present a simple, comprehensive method for assessing agreement between patients with head injury and their proxy responders. In contrast to more traditional approaches, this method defines agreement separately for each patient-proxy pair, and compares HRQOL profiles along three dimensions-level, or the average of the ratings; scatter, or the variability in the ratings; and shape, or the ranks of the ratings. We demonstrate this method in the context of a clinical trial of a treatment for traumatic head injury and compare the results to those obtained using traditional analyses. Options for incorporating proxy responses into clinical trial analyses are discussed.

Evolution in measuring the quality of dying

PURPOSE

Despite multiple efforts to improve the experience for dying patients, researchers still struggle to identify appropriate outcome measures that assess patients' and families' experiences. If health care systems are to provide excellent, compassionate care to dying patients and their families, there must be a valid means of assessing the quality of those experiences and interventions to improve care. The purpose of this paper is to evaluate quality-of-life instruments currently used to assess the experiences of dying patients, and to offer a design for a next generation instrument to measure quality at the end of life.

DESIGN

Sources were attained through a review of the quality of life, quality of dying, and end-of-life care literatures. The terms quality of life, quality of care, terminal care, hospice, assessment, and measurement were used singly and in combination in the MEDLINE database from 1966 to 2001.

DISCUSSION

An appropriate clinical quality of dying instrument must be derived from the perspectives of end-of-life care participants and include the multiple domains of experience important to patients and families. Because dying patients are often too ill to communicate, nonresponse bias is a major problem in this population. Researchers must identify additional objective and subjective measures that clearly reflect, correspond well (or predictably) with, and serve as alternatives to patients' self-ratings. Additionally, an appropriate assessment tool must accommodate individual definitions of the quality of dying and demonstrate sensitivity to change over time.

Factors associated with the accuracy of family caregiver estimates of patient pain

This study identified factors associated with inaccurate family caregiver assessments of patient pain. Participants were 31 caregiver-patient dyads receiving hospice home care. All patients had a primary diagnosis of end-stage cancer. As expected, caregivers overestimated patient pain. The degree of disparity for each dyad was calculated by subtracting the patient's pain rating from the caregiver's rating of patient pain. Caregiver knowledge of cancer pain management was not related to the degree of disparity in pain ratings, but caregivers' experience of patient pain was significantly related to accuracy of caregivers' pain ratings. Those caregivers who 1) perceived their loved one to be in a great deal of distress secondary to pain, 2) associated greater efforts at pain relief (i.e., more medication) with greater levels of pain, and 3) were themselves distressed by the patient's pain had the most inaccurate estimates of patient pain. There was a trend for greater disparity in pain estimates to be related to poorer existential quality of life for patients. Overall, the findings suggest that health care providers need to take into consideration family members' interpretation of patient pain when providing pain management education services.

Assessment and measurement of pain in older adults

Although the empiric base is still limited when providing clear directions for pain assessment and management in older adults, it is possible to identify recommendations for guiding practice based on consensus and a developing scientific base to support best practice activities. A brief overview of the epidemiology and consequences of pain is offered, followed by a summary of issues and approaches relevant to pain assessment in older adults. Cohort-specific recommendations for comprehensive pain assessment and measurement based on current evidence are then addressed, including strategies for assessment of pain in cognitively impaired older adults.

Spouse ratings of quality of life in patients with metastatic prostate cancer of lower socioeconomic status: an assessment of feasibility, reliability, and validity

OBJECTIVES

To examine the reliability and validity of spousal assessments by evaluating the collateral quality-of-life (QOL) ratings of patients of lower socioeconomic status with metastatic prostate cancer because collateral ratings provide supplemental information when advanced cancer limits patient self-report.

METHODS

Patients with Stage D2 prostate cancer (n = 36) of lower socioeconomic status completed validated QOL instruments (Functional Assessment of Cancer Therapy-General [FACT-G], European Organization for Research and Treatment of Cancer-Quality of Life-30, and Quality of Life Index). Spouses completed a modified FACT-G, and physicians rated performance status using Karnofsky's scale.

RESULTS

The internal consistency reliability was moderate to high for patient ratings on all FACT-G subscales and for spousal ratings on the modified FACT-G physical, functional, and emotional subscales. The spouses' ratings of the patients on the social and doctor relationship subscales were below the accepted criterion for a measure's use in group comparisons. The comparisons of the mean values of the FACT-G revealed agreement between patients and spouses, except that the spouses rated the patients as having poorer emotional function than did the patients. The intraclass correlations were moderate to high for the functional and emotional subscales and were low, but significant, for the physical and social subscales. The patient and spouse FACT-G ratings correlated with the patient ratings and physician ratings across the instruments for the functional and physical domains (r = 0.48 to 0.77, for patients; r = 0.31 to 0.70, for spouses), with less consistent relationships for the social and emotional domains.

CONCLUSIONS

The collateral QOL assessments from spouses are potentially useful in assessing the functional status in patients of lower socioeconomic status with metastatic prostate cancer. For subjective domains, such as the social domain, direct patient assessments are needed.

Congruity of cancer pain perceptions between Taiwanese patients and family caregivers: relationship to patients' concerns about reporting pain and using analgesics

The purposes of this study were twofold: first, to examine the congruity of cancer pain perceptions between Taiwanese cancer patients and their family caregivers and second, to determine if there was a relationship between this congruity of perception and patients' concerns about reporting pain and using analgesics. A total of 89 dyads of oncology inpatients and their primary family caregivers participated in this study. The instruments completed by patients consisted of Barriers Questionnaire Taiwan Form, the Brief Pain Inventory Chinese version (BPI), the Eastern Cooperative Oncology Group (ECOG) performance status scale, and a demographic questionnaire. Family caregivers completed the Brief Pain Inventory short form and a demographic questionnaire. The Pearson's correlation, intraclass correlation coefficients, and the kappa statistics between family caregivers and patients' pain ratings were statistically significant. Patients in the noncongruent group (difference of >1 on "pain now" scale of the BPI) experienced higher levels of pain and poor levels of performance status. Family caregivers in the noncongruent group were more likely to be older and less educated. A patient's greater concerns about reporting pain and using analgesics were related to a lower level of congruity concerning pain perception between them and their family caregivers. Interventions aimed at overcoming patients' concerns about reporting pain and using analgesics may have beneficial effects on the congruency between pain perceptions of patients and family caregivers.

Health-related quality of life in pediatric bone marrow transplant survivors: according to whom?

Historically, health-related quality of life (HRQL) assessment in pediatrics, including the few validated instruments in pediatric oncology, has been based on proxy reporting, relying primarily on parental assessment. Children have been deemed incapable of providing consistent and reliable information about their level of functioning or state of well-being. Previous studies have been hampered by either limited or poor correlation among the proxy reporters, i.e., teachers, parents and physicians, and in comparisons to disease severity. Simply stated, proxy reporters have greater agreement about what the child can do vs. what the child thinks or feels. Comparisons among proxy reporters have been hindered also by a lack of parallel content in the instruments used, which may result in poorly congruent assessments simply because the instruments measure different constructs. In addition to the measurement issues, the emotional milieu of the parent, particularly the mother, has been shown to influence assessments of the child's functioning. Maternal distress, marital adjustment and health locus of control all co-vary with reports of the child's behavior. What, then, is the proxy reporter telling us about the child? We conducted a cross-sectional study of school-aged pediatric bone marrow transplant (BMT) patients at our institution to evaluate children's self-reported HRQL and functional status. We formally tested the Child Health Rating Inventories (CHRIs), a recently developed generic health-status measure, with its companion measure, the Disease Impairment Inventories-Bone Marrow Transplant (DSII-BMT). Separate questionnaires were administered to patients, parents and physicians at a scheduled outpatient visit after BMT. The questionnaires were designed to have parallel content. All responses were confidential. The psychometric properties of the CHRIs and DSII-BMT are reported elsewhere. In brief, the responses of all raters were reliable, based on measurements of internal consistency. The children's self-reported health status was correlated significantly with the physicians' disease severity rating (DSR) across all generic and disease-specific domains. In contrast, parental reports of child health status were not correlated significantly with the DSR for disease-specific problems or the child's pain. Parental ratings deviated most from the children's ratings within the dimensions of mental health and quality of life (p < 0.001). For the entire sample, parental ratings were significantly lower than the children's ratings. Within the subgroup "early after transplant (<6 months)", parental ratings were significantly lower than the children's self-reports in all categories. In the subgroup ">12 months after transplant", with the exception of mental health and quality of life, parental scores were the same as or higher than the children's ratings. Our results confirm previous studies that the parental reporting of children's health status is a complex construct and that valuable information can be elicited directly from the children. Further research is needed to substantiate these findings, particularly in longitudinal applications with adequate sample sizes.

Men's perspectives on individual and family coping with their wives' breast cancer and chemotherapy

Little research has examined the impact of cancer and chemotherapy treatment for breast cancer from men's perspectives as partners, fathers, and caregivers. This research, part of a larger study describing women's, partners', and children's perspectives, aims to describe men's perspectives on their experiences and how their wives' breast cancer and chemotherapy impacted them and their families, to describe what facilitated and hindered their coping, and to suggest interventions to assist men and their families to manage the experience with less stress. This participatory action study used qualitative naturalistic inquiry methods. Semistructured interviews were conducted with 11 male partners. Two major themes were identified: focusing on a wife's illness and care, and focusing on the family to keep life going. Nine sub-themes cut across the major themes: being there, relying on health care professionals, being informed and contributing to decision making, trying to keep patterns normal and family life going, helping out and relying on others, being positive, putting self on hold, adapting work life, and managing finances.

Measuring quality in end-of-life care

Scrutiny of the quality of medical care near the end of life is increasing. Experts have begun to define and conceptualize quality of care for dying patients and are developing measurement tools to assess quality of care in this population. Definitions and conceptual models of quality of care at the end of life are reviewed. Approaches for measuring the processes and outcomes of end-of-life care are discussed. Approaches for initiating quality assessment of end-of-life care among geriatric patients are suggested.

Palliative care and end-of-life issues

As stated, the goal of palliative care is the achievement of the best quality of life for patients and their families. It incorporates many aspects of care: providing physical comfort, psychosocial and spiritual support, and providing various services in order to achieve this goal. The skills described should be a priority in the practice of all types of medicine because the goal of palliative care is among the central tenets of the medical profession.

The management of nausea and vomiting in advanced cancer

Nausea and vomiting represent a significant problem in patients with advanced cancer, which not only affects their quality of life but also the lives of informal carers. The application of nursing assessment tools, underpinned by a thorough knowledge regarding the physiology and aetiology of nausea and vomiting in this group of patients enables nurses to plan and provide effective interventions, in collaboration with other members of the multidisciplinary team. This article describes the physiological basis of nausea and vomiting. Epidemiological data informs the subsequent discussion, which focuses on assessment in terms of identifying the problem and its cause(s), setting goals with the patient and his/her carers, planning appropriate nursing intervention to support medical interventions and evaluating clinical outcomes. Pharmacological and non-pharmacological interventions for nausea and vomiting are discussed.

Fatigue among elders in caregiving and noncaregiving roles

Fatigue is a complex symptom prevalent in informal caregiving. When role demands exceed caregiver resources, fatigue ensues and caregiving can be compromised. The purpose of this study was to compare perceptions of fatigue among older adults (N = 92) caring for spouses with Alzheimer's disease, Parkinson's disease, or cancer with a control group of older adults (N = 33) whose spouses required no extra care. Caregiving elders reported more fatigue, less energy, and more sleep difficulty than did control participants. All caregiving groups reported similar levels of fatigue, energy, sleep, and self-reported health even though there were marked differences regarding spousal status. Health care providers can support older caregivers in monitoring their own health and in recognizing the need for services that support the caregiving role.

Family reports of cancer pain, pain relief, and prescription access

PURPOSE

The authors 1) describe family caregiver reports of degree of pain, pain relief, and prescription access in persons with advanced cancer during the last 4 weeks of life and 2) test for differences according to geographic location and care setting.

DESCRIPTION OF STUDY

A randomized, stratified sample of 375 caregivers was produced from a list of all state residents who died of cancer in 1994. Written informed consent was received from 170 family caregivers (46%) who were then interviewed by telephone. Caregiver responses regarding pain intensity, pain relief, prescription access, and care setting were analyzed.

RESULTS

Eighty-six percent (n = 147) of caregivers reported that pain was a problem, and 61% (n = 103) recalled a great deal to quite a bit of pain compared with 25% (n = 44) who recalled some or little pain. The mean degree of pain was 2.23 (SD +/- 1.32) on a scale of 1 (a great deal) to 5 (no pain). Of 140 caregivers reporting pain relief data, 46% (n = 64) reported that interventions either stopped the pain or that pain became much better, whereas 54% (n = 76) reported that interventions made the pain a little better, had no effect, or made it worse. The overall mean of pain relief was 2.62 (SD +/-.87) on a scale of 1 (usually stopped the pain) to 5 (made it worse). Greater degrees of pain were associated with reports of less pain relief (r = -19; P =.02). No differences in pain or pain relief were found across county type or patient care setting. Caregivers in the institution-only group (n = 18) recalled lower degrees of pain and the home-only group (n = 61) reported the most pain relief. Many in this latter group were served by hospice and home health nurses, and only 4% of the entire sample were served by physicians alone. Notably, 12% (n = 21) of the sample reported problems filling prescriptions. Of these, half had difficulty obtaining medicine because it was "not available." A total of 48 problems with prescription access were found that were distributed evenly across county types and patient care settings.

CLINICAL IMPLICATIONS

Findings suggest that caregiver reports about the degree of pain or the effectiveness of pain interventions do not vary by residence or care setting at the end of life. Pain relief is moderate at best. Health professionals in all patient care settings should routinely address the issue of obtaining and paying for prescriptions, and local cancer pain task forces should be formed to advocate for better pain relief. An additional solution is to equip families with problem-solving skills specific to cancer pain.

Comparison of patient and proxy EORTC QLQ-C30 ratings in assessing the quality of life of cancer patients

The aim of this study was to examine whether significant others can provide useful proxy information on the health-related quality of life (QL) of cancer patients. We examined the level and pattern of agreement between patient and proxy ratings of the EORTC QLQ-C30, the reliability and validity of both types of information, and the influence of several factors on the extent of agreement. QL ratings were obtained for 307 and 224 patient-proxy pairs (at baseline and follow-up, respectively). Agreement was moderate to good (ICC = 0.42 to 0.79). Multitrait-multimethod analysis showed good convergence and discrimination of specific QL domains. Comparison of mean scores revealed a small but systematic bias between patient and proxy ratings. The maximum level of disagreement was found at intermediate levels of QL, with smaller discrepancies noted for patients with either a relatively poor or good QL. Both patient and proxy QL ratings were reliable and responsive to changes over time. Several characteristics of the patients and their significant others were found to be associated with the level of agreement, but explained less than 15% of the variance in patient-proxy differences. In conclusion, the present findings lend support to the viability of employing significant others as proxy respondents of cancer patients' quality of life where this is necessary.

Spouses' view during their partners' illness and treatment

Nine spouses of people who had suffered from acute leukemia or highly malignant lymphoma were interviewed about their everyday life experiences throughout their partner's illness and treatment, and concerning their view of the professional care provided. The transcribed texts were subjected to phenomenological-hermeneutic analysis. The spouses felt they were in a situation of overall severe crisis (i.e., experiencing feelings of distress, restrictions, and limited or lack of support). The analysis revealed three family types: the couple acting as a unit, the couple acting independently on equal terms, and the couple acting separately with the spouse in a subordinate position. The spouses' evaluation of the entire experience varied according to the family type and the spouses' personal resources, which influenced the availability and utilization of their social network as well as the support of health-care staff. Contentment was related to the couple acting as a unit or the couple acting independently on equal terms and taking control over the situation, actively asking for support and requiring the staff to meet their needs. Discontentment was related to subordination of the spouse to the partner or to health-care staff, and failure of the couple to obtain support between them or from others. Empowering the spouses may mean helping them develop their skills, providing them with opportunities and authority, and assisting them in gaining access to resources based on knowledge of the family type, the consent of the partner, and the spouse's freedom to make choices. This may well lead to increased efficiency and have positive effects for the patient, for the spouse, and for them both as a couple.

Perceptions of symptom distress in lung cancer patients: I. Congruence between patients and primary family caregivers

Part I of this two-part paper employs a comparative design to compare primary family caregivers' assessments of lung cancer patients' symptom distress with patients' own perceptions of symptom distress in the home setting. Part II describes the results of the qualitative component of this research. A convenience sample of 37 patient-family caregiver dyads completed the McCorkle and Young Symptom Distress Scale (SDS). Family caregivers' global scores were moderately correlated with patients' global scores (r = 0.71; P < 0.001). No significant differences in ratings were found for ten of the 13 symptoms assessed. Therefore, when the patient is unable to provide a self-report of symptom distress, health-care professionals may seriously consider family caregivers' assessments of patients' symptom distress to be reasonable estimates for at least ten of the 13 symptoms on the SDS.

Disclosure of concerns by hospice patients and their identification by nurses

As part of an evaluation of the training of hospice nurses in communication skills, the selectivity of patients in disclosing their concerns and the ability of nurses to register all the concerns disclosed were studied. Forty-two nurses were recruited from two hospices in the north of England. They were asked to determine and write down patients' current concerns before and after training, and nine months later. Their interviews were tape recorded to permit rating of the concerns disclosed. After each interview a research nurse used a semistructured interview and the Concerns Checklist to elicit patients' concerns. The Spielberger State Anxiety Scale and Hospital Anxiety and Depression Scale were then administered to assess patients' mood. In total, 87 patients were thus assessed. Patients were highly selective in what they disclosed and showed a strong bias towards disclosing physical symptoms. Overall, 60% of concerns remained hidden and concerns about the future, appearance and loss of independence were withheld more than 80% of the time. Patients who were more anxious or depressed were less likely to disclose concerns. The nurses registered only 40% of the concerns disclosed to them at interview, and less than 20% of patients' concerns were identified appropriately. The nurses were selective in the categories of concerns that they registered. Pain, family worries, appetite and weight loss, nausea and vomiting were noted most frequently, while concerns about cancer, bowel function, treatment and emotional worries were not registered. The patients' main concern was identified and recorded in only 45% of cases. Overall, it was found that hospice patients selectively disclosed physical symptoms while nurses did not elicit or register patients' concerns accurately. Nurses therefore need to improve their ability to elicit and register all of their patients' concerns and to pay particular attention to those who are anxious and depressed.

The use of significant others as proxy raters of the quality of life of patients with brain cancer

OBJECTIVES

The use of self-report questionnaires for the assessment of health-related quality of life (HRQOL) is increasingly common in clinical research. This method of data collection may be less suitable for patient groups who suffer from cognitive impairment, however, such as patients with brain cancer. In such cases, one can consider employing the patients' significant others as proxy raters of the patients' health-related quality of life. The authors examined the response agreement between patients with brain cancer and their significant others on a health-related quality of life instrument commonly used in cancer clinical trials, the EORTC QLQ-C30, and on a brain cancer-specific questionnaire module, the QLQ-BCM.

METHODS

The study sample consisted of 103 pairs of patients, with either recently diagnosed or recurrent brain cancer, and their significant others (75% spouses, 22% relatives, and 3% friends). Patients and proxies independently completed the EORTC QLQ-C30 and the QLQ-BCM at three different times.

RESULTS

Approximately 60% of the patient and proxy scores were in exact agreement, with more than 90% of scores being within one response category of each other. For most HRQOL dimensions assessed, moderate to good agreement was found. Statistically significant differences in mean scores were noted for several dimensions, with proxies tending to rate the patients as having a lower quality of life than the patients themselves. With the exception of fatigue ratings, this response bias was of a limited magnitude. Less agreement and a more pronounced response bias was observed for the more impaired patients, and particularly for patients exhibiting mental confusion. This finding was confirmed by longitudinal analyses, which indicated lower levels of patient-proxy agreement at follow-up for those patients whose physical or neurologic condition had deteriorated over time.

CONCLUSIONS

In general, patients and their significant others provide similar ratings of the patients' quality of life. Lower levels of agreement and more biased ratings can be expected among those patients for whom the need for proxies is most salient. It is argued, however, that discrepancies between patient-proxy ratings should not be interpreted, a priori, as evidence of the inaccuracy or biased nature of proxy-generated data. Future studies are needed to examine the relative validity and reliability of patient-versus proxy-generated health-related quality of life scores.

Is the wish to participate in a cancer rehabilitation program an indicator of the need? Comparisons of participants and non-participants in a randomized study

In parallel with a randomized study of the 'starting again' rehabilitation program for cancer patients, a group of 73 non-participants were monitored (another 20 patients declined monitoring). In comparison with participants (intervention + control), gender, diagnosis, and 10 out of 18 dependent measures differed significantly at baseline. The non-participants group included more men, mostly with cancer of the prostate and irrespective of gender, they showed lower problem levels than participants throughout. Thus, the wish to participate seems to be an indicator of the need for assistance in the rehabilitation process. Social validation of effects was performed by comparing the non-participants with the intervention group. The rationale for this comparison is that non-participants presumably felt so well that they were in no need of rehabilitation. Effects on three variables were socially validated: patients' appraisal of having received sufficient information, physical strength and fighting spirit. No negative effects on outcome variables resulting from being randomized to the control condition (resentful demoralization) were detected when non-participants were compared with controls over one year. Further analysis showed that although a few patients in the control group may have experienced resentful demoralization, this did not significantly affect the outcome variables.

Perceived control and well-being in Parkinson's disease

Sense of control in the context of an uncontrollable chronic illness is explored by analyzing the impact of the patient's perceived control over symptoms (PCS) and perceived control over disease progression (PCDP) on patient and caregiver outcomes. PCS was significantly associated with patient well-being, caregiver well-being, and less caregiver burden. No relationship was found between PCDP and patient well-being, caregiver well-being, or caregiver burden. Findings support the importance of symptom management, viewing the patient-caregiver dyad as a unit, and the need for future research on control and transition points in chronic illness.

Pain and pain relief experienced by hospice patients with cancer

The purpose of this descriptive study was to explore the pain intensity and pain relief experienced by hospice patients with cancer and the variables that might be associated with that pain. The sample consisted of 118 consenting patients and their primary caregivers receiving hospice care in their homes. Methods involved a secondary analysis of data from a study of quality of life. The Hospice Quality of Life Index (HQLI), used in the study, assesses multidimensional aspects of quality of life including pain relief. Each item is assessed on a 1 (worst) to 10 (best) scale. To eliminate pain-free patients from the analysis, an additional item asks how severe pain is when it is at its worst. Both patients and caregivers were asked to evaluate the patient's quality of life on admission and after 3 weeks of hospice care. Relationships were sought among items on the HQLI and between pain and demographic characteristics. Results revealed that most patients experience pain (82%) but that caregivers were not able to accurately estimate that pain. Pain relief, even after 3 weeks of hospice care, was less than optimal, with many patients (42%) reporting pain relief at a level of 5 or less. A significant difference in pain at its worst was found by type of cancer. Although there were differences by gender, these were not significant. Pain was found to be weakly related to enjoyable activity, sleeping, fatigue, physical care, hope, and anger. Results support the idea that pain is important to overall quality of life, but despite its importance, pain in hospice patients with cancer still is not well managed.

Criterion-based validation of the EORTC QLQ-C36 in advanced melanoma: the CIPS questionnaire and proxy raters

An extensive quality of life (QOL) investigation of the effects of chemotherapy in patients with generalized malignant melanoma included a validation study of involved questionnaires. The QOL domains of the three basic quality of life questionnaires, the EORTC QLQ-C36 (European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire), a study-specific malignant melanoma (MM) module and the Hospital Anxiety and Depression (HAD) scale vs. the Cancer Inventory of Problem Situations (CIPS) were validated by correlation analyses. The value of using attending nurses and/or next of kin to assess the patients situation was also examined. Functional and symptom scales of the C36 and the subscales of the HAD showed appropriate convergent and discriminant validity when compared with the CIPS. The subscales of the MM module had less clear relationships, probably due to lack of accordance in the CIPS. Assessments of attending nurses revealed very low correlations with the patients' measures. They underestimated significantly series of specific symptoms and overestimated nausea and the overall quality of life of the patients. However, assessments of close relatives, mostly spouses, showed moderate to high correlations and no significant difference. These results further strengthen the overall validity of the modular approach of the EORTC QLQ technique. In this context of active chemotherapy in patients with advanced cancer disease, relatives seem to be better surrogates than the attending nurses in assessing the patients' quality of life.

Telephone and in-person proxy agreement between stroke patients and caregivers for the functional independence measure

This study examined patient/proxy agreement for telephone administration of the Functional Independence Measure (FIM) to a sample of 25 community-living stroke patients 18 mo post-stroke and their caregivers. Patients had all received in-patient rehabilitation for stroke. Because use of the FIM is increasing for follow-up purposes, it is important to document whether it is appropriate to administer a telephone version to proxy caregivers in situations in which patients cannot answer for themselves. Proxy agreement results were then compared with those obtained for in-person administration of the FIM to the same sample 1 yr earlier. Overall, proxy agreement for telephone administration was excellent for total scores (intraclass correlation was 0.91) and the physical dimension (0.94) and lower for the cognitive dimension (0.52), closely paralleling results obtained for the earlier in-person administration. Reasons for lower agreement on the cognitive dimension are discussed.

Quality of final care for terminal cancer patients in a comprehensive cancer centre from the point of view of patients' families

The aim of this study was to evaluate the quality of care for terminal cancer patients at our institution, as assessed by families in a questionnaire sent 6 months after the death of the patient. We evaluated the quality of information given to the patients and to their families, the patients' "comfort" at the end of their lives (nursing, pain, psychological support) and the families' opinions about the practical conditions at the time of death (in our institution or at home). A total of 105 consecutive patients who died in our institution between January and June 1989 were included in the study; the vast majority had breast or head and neck cancers. We obtained a total of 48 answers from the 105 families that received the questionnaire. Of these, 87.5% were satisfied with the terminal nursing care, 77% were satisfied with the information given to patients and 60% with the information given to families. The treatment for pain was considered to be inefficient or incomplete by 21% of the families; 32 families (67%) considered that the death of terminal cancer patients should occur in the hospital where the patient had been treated and 12% felt that it should occur at home. This study led us to examine various means for improving the quality of care for our terminal cancer patients.

Adjustment of women and their husbands to recurrent breast cancer

The psychosocial adjustment of women with recurrent breast cancer (N = 81) and their husbands (N = 74) were compared to determine if they report different levels of adjustment, support, symptom distress, hopelessness, and uncertainty. Women with recurrent breast cancer reported more emotional distress than their husbands, but both had a similar number of psychosocial role problems. Women and husbands differed in the amount of support and uncertainty they reported but not in the levels of symptom distress or hopelessness they perceived. Women, in contrast to their husbands, expressed more surprise that their cancer recurred and found the recurrent phase of illness more distressing than the initial diagnosis.

The McGill Quality of Life Questionnaire: a measure of quality of life appropriate for people with advanced disease. A preliminary study of validity and acceptability

This is the first report on the McGill Quality of Life Questionnaire (MQOL), a questionnaire relevant to all phases of the disease trajectory for people with a life-threatening illness. This questionnaire differs from most others in three ways: the existential domain is measured; the physical domain is important but not predominant; positive contributions to quality of life are measured. This study was conducted in a palliative care setting. Principal components analysis suggests four subscales: physical symptoms, psychological symptoms, outlook on life, and meaningful existence. Construct validity of the subscales is demonstrated through the pattern of correlations with the items from the Spitzer Quality of Life Index. The importance of measuring the existential domain is highlighted by the finding that, of all the MQOL subscales and Spitzer items, only the meaningful existence subscale correlated significantly with a single item scale rating overall quality of life.

Measuring quality of life in hospice patients using a newly developed Hospice Quality of Life Index

The purpose of this study was to evaluate the validity and reliability of the newly developed Hospice Quality of Life Index (HQLI). Sixty-eight patient/caregiver dyads from one hospice were asked to fill out the HQLI on admission and after 3 weeks of hospice care. Hospice experts evaluated the items on the tool to assess content validity. The content validity index (0.83) and the alpha coefficients (r = 0.87 and 0.83) supported the validity and reliability of the HQLI. Item analysis revealed items with which patients were most satisfied and aspects of quality of life that were considered to be most important.

Needs of family caregivers of persons with cancer: a review

The focus of cancer patient care has moved from the hospital to the home as a result of shortened acute-care stays and subsequent early discharges. Thus, family members and friends frequently must assume the caregiving role. Research has provided information regarding who in the family assumes the responsibility for care of the cancer patient, the needs of these family caregivers, community resources available, and service gaps within the present health care system.