A Burden to Others: A Common Source of Distress for the Terminally Ill

Test of a Dignity Model in patients with heart failure

BACKGROUND

Identifying, maintenance, and promotion of dignity in different patients of various cultures is an ethical responsibility of healthcare workers.

RESEARCH QUESTIONS

This study was conducted to investigate factors related to dignity in patients with heart failure and test the validity of Dignity Model.

DESIGN

The study had a descriptive-correlational design, and data collection was carried out by means of four specific questionnaires. Participants and context: A total of 130 in-patients from cardiac wards in hospitals affiliated with Tehran and Shahid Beheshti University of Medical Sciences participated. Ethical consideration: This study was approved by the Research Committee of Shahid Beheshti University of Medical Sciences.

FINDINGS

Significant correlation showed the following: between illness related worries with dignity conserving repertoire score, between illness related worries with social dignity, between illness related worries with dignity conserving repertoire score, and between social dignity with dignity score. Goodness Fit Index and Comparative Fit Index were calculated greater than 0.9.

DISCUSSION

This study affirms the importance of careful evaluation of individual patients to determine their needs related to dignity.

CONCLUSION

According to the results, the necessity of using appropriate tools to assess various aspects of patients' dignity by clinical healthcare staff and design activities with particular focus on the main factors affecting dignity such as illness related worries and social dignity is recommended. Attention to this issue in everyday clinical practice can facilitate health professionals/nurses to potentially improve their patients' dignity, develop quality of care and treatment, and improve patients' satisfaction.

Impact of high self-perceived burden to others with preferences for end-of-life care and its determinants for terminally ill cancer patients: a prospective cohort study

BACKGROUND/OBJECTIVE

Self-perceived burden to others (SPB) is a major concern of terminally ill cancer patients and is frequently factored into end-of-life (EOL) care decision-making. However, changes in and determinants of SPB and its longitudinal impact on preferences for EOL care over the dying process have not been investigated. Our study was aimed at filling this gap in knowledge.

METHODS

A convenience sample of 325 cancer patients was followed until death. High SPB was identified as scoring >20 on the Self-perceived Burden Scale. Preferences for EOL care included EOL-care goals, life-sustaining treatments, and hospice care. Factors potentially precipitating/minimizing patients' high SPB included demographics, disease characteristics and burden, and social support and were examined by multivariate logistic regression modeling with the generalized estimating equation.

RESULTS

Prevalence of high SPB increased as death approached (51.78%, 58.26%, 62.66%, and 65.38% for 181-365, 91-180, 31-90, and 1-30 days before death, respectively). High SPB was precipitated by women, younger age, having inadequate financial resources, without religious affiliation, and suffering from severe symptom distress and heavy functional dependence but was independent of time proximity to patient death, disease characteristics, and social support. Furthermore, high SPB was not associated with EOL-care preferences, whether aggressive life-sustaining treatments or hospice care.

CONCLUSIONS

High SPB was prevalent among terminally ill cancer patients but independent of preferences for EOL care. Cancer patients' SPB may be lessened by adequate symptom relief to facilitate functional independence. These strategies to ease SPB may improve the quality of death and dying. Copyright © 2016 John Wiley & Sons, Ltd.

Factors associated with self-perceived burden to the primary caregiver in older patients with hematologic malignancies: an exploratory study

OBJECTIVE

Although cancer patients frequently experience self-perceived burden to others, this perception has not been enough studied. The aim of this study was to investigate the prevalence of self-perceived burden to the primary caregiver (SPB-PC) and associated factors in an older patient population with hematologic malignancies at the time of chemotherapy initiation.

METHODS

In total, 166 consecutive patients with hematologic malignancies aged ≥65 years were recruited at the time of chemotherapy initiation. Patients' SPB-PC was assessed using a 100-mm visual analogue scale (VAS). Characteristics potentially associated with SPB-PC, including sociodemographic and medical characteristics, physical functioning status (Karnofsky performance score, activities of daily living (ADL)/instrumental ADL), symptoms (fatigue, pain, nausea, quality of life), psychological distress (Hospital Anxiety and Depression Scale (HADS)), perceived cognitive function (Functional Assessment of Cancer Therapy Cognitive (FACT-Cog) Scale), and patients'/primary caregivers' personal relationship characteristics (family tie, support), were assessed.

RESULTS

Thirty-five percent of patients reported moderate to severe SPB-PC (VAS ≥ 50 mm). Patients' SPB-PC was associated with lower Karnofsky performance (β = -0.135, p = 0.058) and ADL (β = -0.148, p = 0.037) scores, and higher HADS (β = 0.283, p < 0.001) and FACT-Cog perceived cognitive impairments subscale (β = 0.211, p = 0.004) scores. The proportion of explained variance was 23.5%.

CONCLUSIONS

Health care professionals should be aware that about one third of older cancer patients experience moderate to severe SPB-PC at the time of chemotherapy initiation. They should adapt their support of patients who report such a feeling. Copyright © 2016 John Wiley & Sons, Ltd.

"I hate being a burden": The patient perspective on carer burden in amyotrophic lateral sclerosis

Research has shown that family caregivers of ALS patients encounter carer burden. Studies that have investigated the impact of caring on family in ALS have reported predominantly from the family caregiver perspective. We undertook in-depth qualitative interviews with a diverse group of ALS patients (n = 34) sampled from the Irish ALS population-based register and explored their experiences of receiving care from family members and from formal service providers. Interviews were audio recorded and transcribed and data were coded to identify psychosocial processes. Findings showed that patients perceived their care as a burden on family and had concerns about the adverse effects that caring had on family caregivers. However, participants also resisted being a burden on family and they provided emotional support to their family. Participants felt a strong sense of obligation towards family and their concern about family members shaped their expressed preferences for care. We identified that the caring process between ALS patients and their family is often bi-directional, leading in some cases to the patient experiencing carer burden. In conclusion, greater attention in ALS research and practice to patients' supportive roles in family is required to counterbalance the already strong focus on family caregiver burden.

"Doctors Shouldn't Underestimate the Power that they Have": NZ Doctors on the Care of the Dying Patient

Rapidly aging populations and increased prevalence of chronic rather than acute illnesses have seen growing public and professional interest in medical decision making at the end of life and greater attention being paid to the factors that influence how individuals make such decisions. This study comprised 2 components: The first, a postal survey, based on the Remmelink questionnaire was sent in May 2013 to 3420 general practitioners (GPs) in New Zealand. Results from this component are reported elsewhere. The second component (reported here) sought information by inviting GPs to ring a free-phone number to be interviewed about their experiences caring for their dying patients. Interviews were recorded then transcribed with identifying information deleted to preserve anonymity. With an aging population, the provision of end-of-life care will increase in general practice. There is no doubt that hospice and specialist palliative care have transformed the quality of care for the dying and their families in New Zealand. However, while respondents in this study seemed realistic about what palliative care can and cannot achieve, patients and their families may have unrealistic expectations of both hospice and palliative medicine. Many GPs appear confused over the legality of the assistance they provide to the terminally ill, concerned that actions such as increasing medication to address refractory symptoms, or stopping food and fluids may put them at risk of legal censure when they foresee that their actions may hasten death.

Trajectories of the multidimensional dying experience for terminally ill cancer patients

CONTEXT

Studies exploring the trajectories of physical-psychological-social-spiritual dying experiences frequently treat changes in these experiences as consistent across different domains and over time.

OBJECTIVE

This prospective, longitudinal investigation was designed to characterize trajectories of the multidimensional dying experience for cancer patients in their last year of life.

METHODS

Trajectories of physical-psychological-social-spiritual/existential dimensions and overall quality of life (QOL) were identified among 313 cancer patients using mixed-effects models to test for linear, quadratic, or cubic changes. Changes in each variable were evaluated for clinical significance using minimal important difference.

RESULTS

When patients transitioned to their end of life, symptom distress, functional dependence, anxiety, and depressive symptoms slightly increased, followed by a stable status for approximately four to six months, and accelerated dramatically to the first clinically significant changes at three to four months before death. Perceived social support and post-traumatic growth declined gradually to clinically significant changes at one and four months before death, respectively. Perceived sense of burden to others increased steadily in the last year of life, with no clinically significant changes identified. Overall QOL deteriorated gradually in the last year but did not reach a clinically significant change until 2.5 months before death.

CONCLUSION

All dimensions deteriorated in the last year of life but with distinctive physical-psychological-social-spiritual/existential and overall QOL trajectories. Recognizing trajectory patterns and tipping points of accelerating deterioration in each dimension can help clinicians anticipate times of increased distress, initiate timely, effective interventions to relieve patient suffering, and facilitate high-quality end-of-life care tailored to patients' needs and preferences.

Perceived burdensomeness and suicide-related behaviors in clinical samples: current evidence and future directions

CONTEXT

The interpersonal-psychological theory of suicide identifies perceived burdensomeness as a primary component of suicidal desire and a possible point of intervention for suicide prevention. A growing literature has explored the relationship between perceived burdensomeness and suicide-related behaviors.

OBJECTIVE

The aim of this review is to integrate the evidence, identify critical gaps in the evidence-base, and explore implications for translation to prevention and intervention science.

METHODS

Papers published that reported on the association between perceived burdensomeness and suicide-related behaviors were included.

RESULTS

The literature indicates (a) significant cross-sectional associations between perceived burdensomeness and suicidal ideation and suicide attempts and (b) that perceived burdensomeness acts as either a moderator or a mediator of the association between risk and protective factors and suicide-related behaviors.

CONCLUSION

Research is needed to examine the longitudinal association between perceived burdensomeness and suicide-related behaviors, develop additional measurement approaches, generalize findings to other samples, and begin translating findings to prevention and intervention science.

Prevalence and factors associated with desire for death in patients with advanced disease: results from a Portuguese cross-sectional study

BACKGROUND

Desire for death (DFD) within the context of palliative care has become a prominent medical issue and remains the subject of much controversy.

METHODS

Cross-sectional study designed to assess the prevalence and associated demographic, physical, psychiatric, and psychosocial factors for DFD in patients with advanced disease.

RESULTS

Seventy-five terminally ill patients were included in the analyses in a 28-month period. The prevalence of DFD was 20% (95% CI [11.7-30.8]). No statistical differences were observed between patients with and without DFD with respect to sex, age, race, education, religion, type of family, medical diagnosis, and medication. There were associations between DFD and being married/cohabitating (OR = 4.0; 95% CI [1.21-13.29]) and being socially isolated (OR = 0.3; 95% CI [0.06-0.98]). Significant positive correlations were found between moderate to severe Edmonton Symptom Assessment Scale (ESAS) scores and DFD for tiredness (OR = 10.1; 95% CI [1.57 ± inf]) and drowsiness (OR = 6.0; 95% CI [1.77-20.37]). DFD was also correlated with depression (DSM-IV criteria: OR = 5.5; 95% CI [1.56-19.47]; Hospital and Anxiety Depression Scale (HADS) depression subscale ≥11: OR = 8.6; 95% CI [1.33 ± inf]). In exact multivariate regression analyses predicting DFD, three independent factors emerged: marital status (OR = 5.3; 95% CI [1.16-29.89]); HADS depression sub-scale score ≥11 (OR = 8.3; 95% CI [1.11 ± inf]); drowsiness (OR = 5.8; 95% CI [1.29-32.85]).

DISCUSSION

Prevalence of DFD was high in this sample of patients. Identifying factors associated with DFD could help provide medical and social interventions capable of diminishing suffering in terminal ill patients.

Comparative Risk Factors for Accidental and Suicidal Death in Cancer Patients

Background: Cancer patients appear at higher risk of accidental death and suicide. The reasons for this and how suicide and accidental death relate remain unclear. Aims: To clarify and contrast risk factors for such deaths among cancer patients. Methods: A SEER (1973–2007) analysis was conducted on 4,449,957 cancer patients comparing all causes of death (COD) to accidental and suicidal deaths through competing hazards, relative risk and proportional hazards models. SEER did not provide psychological assessments; the analysis was confined to their standard epidemiological and clinicopathological parameters. Results: 2,557,385 overall deaths yielded 16,879 (0.66%) accidents and 6,589 (0.26%) suicides. Mortality reached its highest incidence immediately after diagnosis and obeyed Pareto type II distributions. The major identifiable risk factor for suicide was male gender; for accidental death, First Nations ethnicity; and all COD, metastases. Minor factors for suicide included metastases, advanced age, and respiratory as well as head and neck tumors, whereas for accidental death they were male gender, metastases, advanced age, and brain tumors. Conclusions: Differences were observed in the risk patterns of suicide and accidental death, suggesting distinct etiologies. A high incidence of suicides and accidental deaths following diagnosis (attributed by some to stress from the diagnosis of cancer) correlated here with overall mortality and indicators of physical morbidity. Cancer patients with the above identifiable risk factors warrant supportive attention.

A literature review of suicide in cancer patients

BACKGROUND

Cancer survivors have a higher suicide rate than the general population. Oncology nurses need to have knowledge and skills in assessing risk for suicide in this population.

OBJECTIVE

This study aimed to conduct a literature review on risk factors for and incidence of suicide in patients with cancer and to identify potential screening tools.

METHODS

PubMed, CINAHL, and PsycINFO databases were searched to identify research articles in peer-reviewed journals from 1999 to 2009. The variables under study included suicide rate, cancer type, demographic characteristics, and signs and symptoms associated with suicide. In addition, articles focused on suicide risk assessment tools were also included.

RESULTS

Twenty-four articles met the inclusion criteria. As in the general population, suicide risk was higher among men with cancer as compared with women with cancer. Patients aged 65 years or older with cancer have a higher rate of suicide compared with those younger than 65 years, with rates highest among men 80 years or older. Specific diagnoses associated with higher suicide rates include prostate, lung, pancreatic, and head and neck cancers. The first year after diagnosis carries a higher risk for completed suicide. Multiple risk assessment tools have been developed and are effective in identifying patients with depression or hopelessness, factors associated with higher risk for suicide. However, no tools exist that sensitively and specifically predict suicide.

CONCLUSION

The incidence of suicide in someone with a cancer diagnosis is approximately double the incidence of suicide in the general population. Early detection of depression in special cancer populations, such as older male patients, may help identify those at greatest suicide risk.

IMPLICATIONS FOR PRACTICE

Oncology nurses should be aware of cancer patients considered at higher risk for suicide. Systematic screening for suicidal ideation and behavior may identify cancer patients at high risk and facilitate appropriate mental health evaluation and treatment.

Self-perceived burden in chronic pain: relevance, prevalence, and predictors

Chronic pain is a debilitating condition that can have an impact on various facets of interpersonal functioning. Although some studies have examined the extent to which family members are affected by an individual's chronic pain, none have examined patients' perceptions of feeling that they have become a burden to others. Research on self-perceived burden in different medical populations, such as cancer, amyotrophic lateral sclerosis, and stroke, has shown that it is associated with physical symptoms and, more robustly, with psychological difficulties and concerns. The present study examined the prevalence and predictors of self-perceived burden in a tertiary chronic pain sample. Participants were consecutive patients (N = 238) admitted to an outpatient, interdisciplinary, chronic pain management program at a rehabilitation hospital. At admission, participants completed a battery of psychometric questionnaires assessing self-perceived burden, as well as a number of clinically relevant constructs. Their significant others (n = 80) also completed a measure of caregiver burden. Self-perceived burden was a commonly reported experience among chronic pain patients, with more than 70% of participants endorsing clinically elevated levels. It was significantly correlated with pain intensity ratings, functional limitations, depressive symptoms, attachment anxiety, pain self-efficacy, and caregiver burden. Self-perceived burden was also correlated with an item assessing suicidal ideation. In a hierarchical regression model, depressive symptoms, pain self-efficacy, and adult attachment significantly predicted self-perceived burden after controlling for demographic and pain-related variables. In conclusion, self-perceived burden is a clinically relevant and commonly reported interpersonal experience in patients with longstanding pain.

Does perceived burdensomeness erode meaning in life among older adults?

BACKGROUND

Identification of risk factors for the loss of meaning in life among older adults is needed. In this article, we test hypotheses derived from the Interpersonal Theory of Suicide concerning the role of perceptions that one is a burden on others as a risk factor for lower meaning in life.

METHODS

A prospective design was used to examine the temporal associations between perceptions of burdensomeness on others and perceived meaning in life among older adults (n=65) seeking mental health treatment (primarily for depression and/or anxiety) at an outpatient geriatric mental health clinic. Participants completed self-report questionnaires within a month following intake. Follow-up questionnaires were completed over the phone two months later.

RESULTS

Perceived burdensomeness predicted lack of meaning in life two months later, while accounting for depression severity. In contrast, baseline levels of meaning in life did not significantly predict the levels of burdensomeness at two months.

CONCLUSION

The findings suggest that burdensomeness may contribute to suicide morbidity and mortality in late-life by eroding meaning in life. Empirically supported treatments for late-life depression could be adapted to focus on perceptions of burdensomeness and its connections with meaning in life.

The impact of the nature of relationships on perceived burdensomeness and suicide ideation in a community sample of older adults

Older adults die by suicide at very high rates, and previous research indicates that perceived burdensomeness may contribute to deaths by suicide. In this study, the impact of the nature of relationships on perceived burdensomeness and suicide ideation was examined. Results indicated that older adults' perceptions of burden on younger generations were associated with greater overall perceived burdensomeness and suicide ideation when compared to the older adults' own or older generations. Thus, clinicians should examine general perceived burdensomeness as well as the types of relationships the older adult perceives himself or herself to be a burden on.

Perceived burdensomeness and suicide ideation in older adults

Older adults have the highest risk of death by suicide in the United States. Improving our understanding of the factors that lead to increased risk of suicide in older adults will greatly inform our ability to prevent suicide in this high-risk group. Two studies were conducted to test the effect of perceived burdensomeness, a component of the interpersonal-psychological theory of suicide (Joiner, 2005), on suicide ideation in older adults. Further, gender was examined as a moderator of this association to determine if perceived burdensomeness exerted a greater influence on suicide ideation in males. The results of these studies suggest that perceived burdensomeness accounts for significant variance in suicide ideation, even after predictors such as depressive symptoms, hopelessness, and functional impairment are controlled. Gender did not moderate the association. The implications of these findings for treatment of older adults with suicide ideation and elevated suicide risk are discussed.

Concerns and quality of life before surgery and during the recovery period in patients with rectal cancer and an ostomy

PURPOSE

Rectal cancer is the most common reason for a person to undergo ostomy surgery. The aim of this study was to assess concerns and health-related quality of life (HRQOL) before surgery and during the first 6 months following ostomy surgery in the presence of rectal cancer.

SUBJECTS AND SETTINGS

The sample comprised 57 patients at a university hospital in Gothenburg, Sweden. Their median age was 66 years (range, 30-87); 35 men and 22 women participated in the study.

METHODS

Participants prospectively answered questionnaires preoperatively, and at 1, 3, and 6 months postoperatively. Concerns were assessed using the rating form of the Inflammatory Bowel Disease Patient Concerns, and HRQOL was evaluated using the 36-Item Short Form Health Survey. Results were compared with population norms.

RESULTS

Participants expressed concerns associated with developing cancer, being a burden on others, and related to the uncertain nature of disease. Health-related quality of life scores dropped significantly in 6 of 8 domains when preoperative scores were compared to those obtained 1 month postoperatively, but scores improved at 6 months. There were significant differences between preoperative study group scores and population norms on physical and emotional role function, social function, and for mental health domains. Significant differences persisted when population norms were compared to study group scores 6 months following surgery on all these domains except mental health. Participants identified good relations with significant others, social and leisure activities, psychological issues, and health as important for maintaining QOL. Obstacles to maintaining QOL included fatigue, pain, illness-induced limitations in life, and worries over what their new life would entail.

CONCLUSION

Surgical management of rectal cancer raises concerns and profoundly impairs QOL during the first several postoperative months.

Can’t Live with You, Can’t Live without You: Negative Family Exchanges and Adaptation in End-stage Renal Disease Patients

The present study examined associations between negative family exchanges (patient perceptions of family overprotection and negative expressiveness, and patient feelings of being a burden), and two indicators of adaptation to illness (mental health and negative affect) in patients with end-stage renal disease (ESRD). Data were collected using the perceptions of illness-related family exchanges questionnaire, the SF36 and the PANAS in a structured interview with 127 patients with ESRD in Greece. Findings indicate that patient perceptions of negative family exchanges are related to outcomes, even after controlling for demographic and clinical factors. It is important to consider caregivers in intervention programmes of ESRD patients.

Assessing the risk for suicide in patients with cancer

The Joint Commission publishes its annual National Patient Safety Goals to guide accredited organizations in addressing high-risk, low-volume concerns related to patient safety. The 2010 list includes a goal to identify patients at risk for suicide, but do oncology nurses need to be concerned about the risk of suicide in patients with cancer?

Self-perceived burden in terminally ill cancer patients: a categorization of care strategies based on bereaved family members' perspectives

CONTEXT

Terminally ill cancer patients often experience a self-perceived burden that affects their quality of life; however, no standard care strategy for coping with this form of suffering has ever been established.

OBJECTIVES

The objectives of this present study were 1) to investigate the prevalence of self-perceived burden among terminally ill cancer patients based on a survey of family members, 2) to assess the level of family perceived usefulness of expert-recommended care strategies, and 3) to categorize the care strategies.

METHODS

The subjects were bereaved family members of patients who had died in certified palliative care units throughout Japan. The Good Death Inventory was used to evaluate patients' self-perceived burden based on the proxy ratings of family members. The perceived usefulness of care was assessed using a 27-item questionnaire developed by a focus group of palliative experts and a systematic review.

RESULTS

A total of 429 responses (64%) received from a member of each of 666 bereaved families was analyzed. In their responses, 25% of the bereaved family members reported that the patient had experienced a mild self-perceived burden, whereas 25% reported that the patient had experienced a moderate to severe self-perceived burden. The family members recommended the following as particularly effective care strategies: "Eliminate pain and other symptoms that restrict patient activity (53%);" "Quickly dispose of urine and stools so that they are out of sight (52%);" and "Support patients' efforts to care for themselves (45%)." A factor analysis showed that the expert-recommended care strategies could be categorized into seven different components.

CONCLUSION

Many terminally ill cancer patients suffer from a self-perceived burden. Family members recommended a variety of care strategies to alleviate patient-perceived burden. Palliative care specialists should have adequate knowledge of promising care strategies for alleviating patient-perceived burden.

Efficacy of short-term life-review interviews on the spiritual well-being of terminally ill cancer patients

CONTEXT

There is a little information about effective psychotherapies to enhance the spiritual well-being of terminally ill cancer patients.

OBJECTIVES

The primary aim of the study was to examine the efficacy of a one-week Short-Term Life Review for the enhancement of spiritual well-being, using a randomized controlled trial. The secondary aim was to assess the effect of this therapy on anxiety and depression, suffering, and elements of a good death.

METHODS

The subjects were 68 terminally ill cancer patients randomly allocated to a Short-Term Life-Review interview group or a control group. The patients completed questionnaires pre- and post-treatment, including the meaning of life domain from the Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp) scale, the Hospital Anxiety and Depression Scale (HADS), a numeric scale for psychological suffering, and items from the Good Death Inventory (Hope, Burden, Life Completion, and Preparation).

RESULTS

The FACIT-Sp, Hope, Life Completion, and Preparation scores in the intervention group showed significantly greater improvement compared with those of the control group (FACIT-Sp, P<0.001; Hope, P<0.001; Life Completion, P<0.001; and Preparation, P<0.001). HADS, Burden, and Suffering scores in the intervention group also had suggested greater alleviation of suffering compared with the control group (HADS, P<0.001; Burden, P<0.007; Suffering, P<0.001).

CONCLUSION

We conclude that the Short-Term Life Review is effective in improving the spiritual well-being of terminally ill cancer patients, and alleviating psychosocial distress and promoting a good death.

Prevalence and correlates of pain in the Canadian National Palliative Care Survey

BACKGROUND

Pain is a common problem for people with cancer who are nearing the ends of their lives.

OBJECTIVE

In the present multicentre Canadian study of palliative cancer care, the prevalence of pain, its perceived severity and its correlates across a range of physical, social, psychological, and existential symptoms and concerns were examined.

METHODS

Semistructured interviews were conducted with 381 patients. In addition to inquiring about pain, the interview also assessed 21 other symptoms and concerns, and collected information about demographic characteristics, functional status and medication use.

RESULTS

Pain of any intensity was reported by 268 (70.3%) participants, although for 139 (36.5%), the severity was rated as minimal or mild. For 129 (33.9%) individuals, pain was reported as moderate to extreme, and considered by the respondents to be an important ongoing problem. Patients who reported moderate to extreme pain were younger than other participants, but had lower functional status and a shorter median survival duration. They were more likely than other participants to be treated with opioid medications (P<0.001) and, less reliably, with benzodiazepines (P=0.079). Compared with participants with no, minimal or mild pain, those with moderate to extreme pain had a higher prevalence of distressing problems on 11 of 21 other symptoms and concerns. The strongest correlations were with general malaise (rho = 0.44), suffering (rho = 0.40), nausea (rho = 0.34), weakness (rho = 0.31), drowsiness (rho = 0.29) and anxiety (rho = 0.29).

CONCLUSIONS

Pain continues to be a difficult problem for many patients who are receiving palliative cancer care, particularly younger individuals who are nearing death.

Prognostic Acceptance and the Well-Being of Patients Receiving Palliative Care for Cancer

Purpose

To identify the impact of prognostic acceptance/nonacceptance on the physical, psychological, and existential well-being of patients with advanced cancer.

Patients and Methods

A Canadian multicenter prospective national survey was conducted of patients diagnosed with advanced cancer with an estimated survival duration of 6 months or less (n = 381) receiving palliative care services.

Results

Of the total number of participants, 74% reported accepting their situation and 8.6% reported accepting with “moderate” to “extreme” difficulty. More participants with acceptance difficulties than without acceptance difficulties met diagnostic criteria for a depressive or anxiety disorder (χ2 = 8.67; P < .01). Nonacceptors were younger (t = 4.13; P < .000), had more than high school education (χ2 = 4.69; P < .05), and had smaller social networks (t = 2.53; P < .05) than Acceptors. Of the Nonacceptors, 42% described their experience as one of “moderate” to “extreme” suffering compared with 24.1% of Acceptors (χ2 = 5.28; P < .05). More than one third (37.5%) of Nonacceptors reported feeling hopeless compared with 8.6% who had no difficulty accepting (χ2 = 24.76; P < .000). Qualitatively, participants described active and passive coping strategies that helped them accept what was happening to them, as well as barriers that made it difficult to come to terms with their current situation.

Conclusion

The challenge of coming to terms with a terminal prognosis is a complex interplay between one's basic personality, the availability of social support, and one's spiritual and existential views on life. Nonacceptance appears to be highly associated with feelings of hopelessness, a sense of suffering, depression, and anxiety, along with difficulties in terms of social–relational concerns.

Distress in older patients with cancer

PURPOSE

To determine the predictors of distress in older patients with cancer.

PATIENTS AND METHODS

Patients age >or= 65 years with a solid tumor or lymphoma completed a questionnaire that addressed these geriatric assessment domains: functional status, comorbidity, psychological state, nutritional status, and social support. Patients self-rated their level of distress on a scale of zero to 10 using a validated screening tool called the Distress Thermometer. The relationship between distress and geriatric assessment scores was examined.

RESULTS

The geriatric assessment questionnaire was completed by 245 patients (mean age, 76 years; standard deviation [SD], 7 years; range, 65 to 95 years) with cancer (36% stage IV; 71% female). Of these, 87% also completed the Distress Thermometer, with 41% (n = 87) reporting a distress score of >or= 4 on a scale of zero to 10 (mean score, 3; SD, 3; range, zero to 10). Bivariate analyses demonstrated an association between higher distress (>or= 4) and poorer physical function, increased comorbid medical conditions, poor eyesight, inability to complete the questionnaire alone, and requiring more time to complete the questionnaire. In a multivariate regression model based on the significant bivariate findings, poorer physical function (increased need for assistance with instrumental activities of daily living [P = .015] and lower physical function score on the Medical Outcomes Survey [P = .018]) correlated significantly with a higher distress score.

CONCLUSION

Significant distress was identified in 41% of older patients with cancer. Poorer physical function was the best predictor of distress. Further studies are needed to determine whether interventions that improve or assist with physical functioning can help to decrease distress in older adults with cancer.

Associations of social networks with cancer mortality: a meta-analysis

This meta-analysis integrates results of 87 studies on the associations of perceived social support, network size, and marital status with cancer survival. In controlled studies, having high levels of perceived social support, larger social network, and being married were associated with decreases in relative risk for mortality of 25%, 20%, and 12%, respectively. Moderator analyses revealed that never married patients had higher mortality rates than widowed and divorced/separated patients. Associations of social network with mortality were stronger in younger patients, and associations of marital status with mortality were stronger in studies with shorter time intervals, and in early-stage cancer. Relationships varied by cancer site, with stronger associations of social support observed in studies of patients with leukemia and lymphomas and stronger associations of network size observed in studies of breast cancer. Further randomized intervention studies are needed to test causal hypotheses about the role of social support and social network for cancer mortality.

Symptom indicator of severity of depression in cancer patients: a comparison of the DSM-IV criteria with alternative diagnostic criteria

OBJECTIVE

The objective of this study was to explore the performances of several diagnostic criteria items for judging the severity of major depression among cancer patients.

METHOD

Using modern item response theory, we examined the performances of the diagnostic criteria outlined by the DSM-IV and two sets of conceptual diagnostic criteria (the Endicott and the Cavanaugh criteria) in a series of 728 cancer patients who had been diagnosed with major depression using an inclusive approach.

RESULTS

While all the DSM-IV diagnostic criteria, including feelings of worthlessness and suicidal ideation, had a low ability for discriminating the severity of depression, two proposed items (not participating in medical care and social withdrawal) appeared to be good markers of moderately severe major depressive disorder among cancer patients. In addition, the items "fearfulness or depressed appearance in face or body posture" and "brooding, self-pity or pessimism" may be good markers for mild major depressive disorders, while the item "cannot be cheered up, doesn't smile, no response to good news or funny situations" may be a good marker for severe major depressive disorder.

CONCLUSIONS

The findings of the present study suggest that alternative criteria may have utility in diagnosing depression severity in cancer patients.

The Legacy Project Intervention to Enhance Meaningful Family Interactions: Case Examples

Manualized reminiscence and life review therapies are supported as an evidence-based, effective treatment for depression among older adults, but this therapeutic approach is usually individually administered and has rarely been applied in palliative care settings. We combined mutual reminiscence and life review with engagement in meaningful activity and examined the efficacy of this family-based dyadic intervention to decrease caregiving stress and increase family communication. Seventeen individuals living with chronic, life-limiting illnesses in the community and their family caregivers received three home visits with a master's-level interventionist. During these sessions and through structured homework activities, the interventionist actively worked with the family to construct a personal Legacy Project, usually a scrapbook with photos, a cookbook, or audiotaped stories that celebrated the life of the ill individual. All participants in the intervention group initiated a Legacy Project and reported that Legacy activities improved family communication. Participation in Legacy creation also resulted in increased positive emotional experiences in patient and caregiver groups. These results are illustrated through careful examination of three case studies.

Legacy activities as interventions approaching the end of life

We examined the efficacy of an innovative family-based intervention designed to decrease caregiving stress and increase family communication among individuals with chronic, life-limiting illnesses and their family caregivers in a randomized, contact control group design. The intervention group received three home visits in which the interventionist actively worked with the family to construct a personal Legacy, usually a scrapbook with photographs or audiotaped stories. Control group families received three supportive telephone calls. Of the 42 families that entered the project, 31 families completed follow-up assessments within 9 to 10 weeks (14 control; 17 intervention; 72% African American) for a retention rate of 74%. Intervention caregivers showed reduced caregiving stress in comparison with control group caregivers, who showed increases in stress. Intervention patients reported decreased breathing difficulty and increased religious meaning. Caregivers and patients reported greater social interaction on the part of the patient. All participants in the intervention group initiated a Legacy activity and reported that Legacy improved family communication. Legacy interventions hold promise and are simple to implement.

Family caregivers' assessment of symptoms in patients with advanced cancer: concordance with patients and factors affecting accuracy

The purposes of the study were to examine the concordance between patients' and family caregivers' assessments of patients' symptoms, and to identify demographic and psychosocial factors that affect levels of agreement. Sixty-six patients with advanced cancer receiving palliative care, and their primary, informal caregivers assessed patients' symptoms using the Memorial Symptom Assessment Scale (MSAS). Levels of agreement for individual symptoms ranged from poor to excellent (interclass correlation coefficient 0.07-0.75). Analysis of the group means using paired t-tests revealed significant differences for the MSAS subscales (psychological, physical, and general distress index), and for four of the 12 physical symptoms and five of the six psychological symptoms. The magnitude of the observed differences indicated a small to moderate bias for caregivers to overestimate, which was more marked for psychological than for physical symptoms. A number of factors associated with the caregiver (particularly the emotional state, the burden of providing care, and male gender) and the patient (the perception of being a burden to others) were significantly correlated with levels of disparity on some measures. The findings are consistent with the growing body of literature on the validity of proxy respondents' assessments of patients' symptoms.

Burden to others and the terminally ill

Studies of patients who are terminally ill consistently identify strong associations between "sense of burden to others" and marked end-of-life distress. However, little research has addressed the issue of burden to others among patients nearing death. The aim of this study was to carefully examine "burden to others" and clarify its relationship with various psychosocial, physical, and existential issues arising in patients who are terminally ill. A cohort of 211 patients with end-stage cancer was assessed, using an assortment of validated psychometrics to document psychosocial, physical, and existential aspects of their end-of-life experience. This included an assessment of their sense of "burden to others." Forty percent of participants indicated a negligible sense of burden to others, scoring within the lowest quarter on an ordinal measure of "burden to others;" 25% scored within the second lowest quarter; 12% within the third quarter; and 23% within the highest or most severe range. The most highly correlated variables with "sense of burden to others" included depression (r=0.460; df=201, P<0.0001), hopelessness (r=0.420; df=199, P<0.0001), and outlook (r=0.362; df=200, P<0.0001). Four variables emerged in a multiple regression analysis predicting burden to others, including hopelessness, current quality of life, depression, and level of fatigue [R(2) adj=0.32, F(6,174)=13.76, P<0.0001]. There was no association between sense of burden to others and actual degree of physical dependency. Feeling a sense of burden to others is common among dying patients. Although 40% of the sample reported little in the way of sense of burden to others, the remainder endorsed higher degrees of burden-related distress, with 23% scoring within the most severe range. The lack of association between "sense of burden to others" and the degree of physical dependency suggests this perception is largely mediated through psychological and existential considerations. Strategies that target meaning and purpose, depression, and level of fatigue could lessen this source of distress and enhance quality, dignity-conserving care.

Self-perceived burden in cancer patients: validation of the Self-perceived Burden Scale

Although caregiver burden has been studied extensively, cancer patients' self-perceived burden on caregivers has been an understudied phenomenon. The purpose of this cross-sectional study was to validate the Self-perceived Burden Scale, a 10-item self-report instrument designed to measure chronically ill patients' experience of burden. Participants were 106 cancer patients (site nonspecific) receiving active cancer treatments at a university cancer center. Factor analysis results indicated that a 9-item version of the scale consisted of a single factor and had good reliability (alpha = .938). Convergent validity was demonstrated with global quality of life (r = -0.546, P < .001), physical well-being (r = -0.547, P < .001), emotional well-being (r = -0.549, P < .001), functional well-being (r = -0.404, P < .001), financial satisfaction (r = -0.284, P = .001), and depression (r = 0.414, P <.001). Tests of divergent validity indicated that the Self-perceived Burden Scale was independent of age, number of people living in the household, disease site, cancer treatment, and sociofamilial well-being. Findings indicate that the Self-perceived Burden Scale may be a useful instrument to assess patients' perceptions of burden on their caregivers. Further studies of the role of patient burden in psychosocial well-being and global quality of life, including validation of the Self-perceived Burden Scale on a larger study sample, are warranted.

Attitudes toward euthanasia among Swedish medical students

Attitudes toward euthanasia differ between individuals and populations, and in many studies the medical profession is more reluctant than the general public. Our goal was to explore medical students' attitude toward euthanasia. A questionnaire containing open-ended questions was answered anonymously by 165 first- and fifth-year medical students. Data were analysed using qualitative content analysis with no predetermined categories. The students' arguments opposing euthanasia were based on opinions of 1. euthanasia being morally wrong, 2. fear of possible negative effects on society, 3. euthanasia causing strain on physicians and 4. doubts about the true meaning of requests of euthanasia from patients. Arguments supporting euthanasia were based on 1. patients' autonomy and 2. the relief of suffering, which could be caused by severe illnesses, reduced integrity, hopelessness, social factors and old age. There are several contradictions in the students' arguments and the results indicate a possible need for education focusing on the possibility of symptom control in palliative care and patients' perceived quality of life.