What are the core elements of oncology spiritual care programs?

Objective:

Tending to the spiritual needs of patients has begun to be formally recognized by professional spiritual care providers, health care councils, and health delivery systems over the last 30 years. Recognition of these programs has coincided with evidence-based research on the effect of spirituality on health. Palliative care has served as a forerunner to an integrated professional spiritual care approach, recognizing the importance of addressing the spiritual needs of the dying from its inauguration within Western medicine almost 50 years ago. Oncology programs have also begun to recognize the importance of spirituality to patients along the cancer continuum, especially those who are approaching the end of life. Although standards and best practice guidelines have been established and incorporated into practice, little is known about the actual factors affecting the practice of spiritual care programs or professional chaplains working within an oncology setting.

Methods:

Participant observation and interactive interviews occurred at five cancer programs after we conducted a literature search.

Results:

This study identified underlying organizational challenges, cultural and professional issues, academic program development challenges, administrative duties, and therapeutic interventions that determined the success of oncology spiritual care programs in practice.

Significance of results:

Although spiritual care services have developed as a profession and become recognized as a service within oncology and palliative care, organizational and operational issues were underrecognized yet significant factors in the success of oncology spiritual care programs. Spiritual care programs that were centrally located within the cancer care center, reported and provided guidance to senior leaders, reflected a multifaith approach, and had an academic role were better resourced, utilized more frequently, and seen to be integral members of an interdisciplinary care team than those services who did not reflect these characteristics.

Associations between physical activity and quality of life in cancer patients receiving palliative care: a pilot survey

The primary aim of this study was to examine the association between physical activity and quality of life (QoL) in cancer patients receiving palliative care. Fifty advanced cancer patients aged 18 years or older with clinician-estimated life expectancy of 3-12 months and Palliative Performance Status Scale scores greater than 30% were recruited from an outpatient palliative care clinic and palliative home care. Participants completed a cross-sectional survey by means of face-to-face interview assessing self-reported QoL (McGill Quality of Life Questionnaire [MQOL]), self-reported physical function (Late-Life Function and Disability Instrument), symptoms (Edmonton Symptom Assessment System), and physical activity behavior. Seventy-six percent (38 of 50) of the participants were deceased at the time of data analysis, with a median survival of 104 days from time of survey to time of death. Walking was the most common reported physical activity. Analyses of variance indicated that participants who reported walking more than 30 minutes per day also reported higher existential subscores (+/-0.8 [95% CI, 0.0-1.5]; P=0.045), support subscores (+/-0.7 [95% CI, 0.1-1.4]; P=0.027), and total scores (+/-0.5 [95% CI, 0.0-0.9]; P=0.046) on the MQOL. There were no significant differences for self-reported physical function or symptoms. Our findings show a significant positive association between physical activity and QoL scores in this sample of patients with advanced cancer. A pilot intervention trial testing the causal effects of physical activity on QoL in cancer patients receiving palliative care is warranted.

Quality-of-life assessment in a palliative care setting in Germany: an outcome evaluation

Quality-of-life (QoL) assessment is crucial for the evaluation of a palliative care outcome. This article investigates the applicability of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) on a German sample of terminally ill cancer patients receiving palliative care in different settings. Patients were randomly selected in 10 palliative homecare services and one palliative care unit in a general hospital and 'evaluated' among the consecutively 'registered' patients. The random sample of patients (n-121) was representative of the general patient population cared for by the palliative care services in Germany. The EORTC QLQ-C30 was administered to the terminally ill cancer patients on their first day in hospital or upon their first contact with the specialized palliative homecare team. The clinical variable assessed was the Karnofsky performance status. The questionnaire was well accepted in the present patient population. In addition, the questionnaire was found to be useful in detecting the effectiveness of palliative treatment over a period of time. This study shows that QoL measures can be used to assess the outcome in palliative care.

Reliability and validity of Japanese version of the McGill Quality of Life Questionnaire assessed by application in palliative care wards

The McGill Quality of Life Questionnaire (MQOL), which consists of 16 items constructing physical, psychological, existential and support subscales and one item of overall quality of life (QOL), has been developed to assess QOL of terminal cancer patients. To examine if MQOL Japanese version (MQOL-J) is applicable, it was administered to 83 terminal cancer patients in palliative care wards several days after admission and then 7 to 10 days after the first interview. Cronbach's alpha coefficient for four subscales was 0.584-0.860. Sixteen items were classified into four factors by factor analysis, similar to the original English version. The results indicated that psychological and existential domains of the MQOL-J significantly related to overall QOL. Existential and support domains as well as overall QOL were significantly improved between the first and second interviews, although performance status assessed by Eastern Cooperative Oncology Group worsened. It is suggested that MQOL-J can reflect perceived health status of terminal cancer patients.

Understanding patients' lived experience following photodynamic therapy for the treatment of advanced cancer

AIM

To gain an understanding of patients' lived experience following photodynamic therapy (PDT) for the treatment of advanced cancer.

BACKGROUND

Existing literature on PDT tends to be predominantly grounded in basic science and mainly associated with the effect of PDT on the cancer rather than the individual's experience. An appreciation of the impact on patients' day-to-day life may enhance the support and advice offered to patients undergoing this treatment.

METHOD

A Heideggerian hermeneutic phenomenological approach was used as the philosophical framework. Semi-structured interviews were conducted with a purposive sample of six participants. Thematic content analysis was adopted to analyse the data, which yielded six themes.

FINDINGS

Analysis of the data yielded six themes: the impact on day-to-day life; existential meaning; the physical effects of treatment; kaleidoscope of emotions; information gap; and family burden.

CONCLUSION

PDT offers palliation of symptoms for some participants while offering hope of enhanced quality of life. Patients and their families have to be willing and well-informed of the need to comply with the guidance provided by healthcare professionals and information leaflets to avoid any photosensitive reaction. There is a need for education for healthcare professionals as PDT is not well recognized or understood as a treatment for advanced cancer.

A first step in the development of an international self-report instrument for physical functioning in palliative cancer care: a systematic literature review and an expert opinion evaluation study

Decline in physical functioning (PF) in progressive cancer increases risk of psychological problems, dependence, and distress, and it considerably affects quality of life. Despite this, assessment of PF has received little attention. Standardized, internationally endorsed assessment tools are needed that assess activities of relevance to palliative cancer patients from very low to high levels of PF. This study was done in cooperation with the European Association for Palliative Care Research Network. It was initiated to develop a computer-based symptom-assessment tool and aimed to 1) identify relevant existing PF-assessment instruments, 2) extract relevant items and classify them into meaningful subdimensions, and 3) construct unidimensional scales of selected PF domains. A systematic literature review was performed to detect relevant PF items from existing instruments. The International Classification of Functioning and Health was used to decide relevant subdimensions of PF, and expert panels within palliative cancer care were consulted to make decisions on activities to be included. One hundred and thirty-five instruments containing 743 items were included from the literature review. Two relevant PF subdimensions were revealed: Mobility (386 items representing 65 different activities) and Self-Care (143 items representing 30 different activities). The final PF tool consisted of two unidimensional scales: 24 hierarchically ranked Mobility items ranging from turning in bed to running, and 16 non-hierarchically ranked Self-Care items. Further testing of the instrument in a palliative cancer population is needed to develop the final PF instrument.

An evaluation of Canada's Compassionate Care Benefit from a family caregiver's perspective at end of life

Background

The goal of Canada's Compassionate Care Benefit (CCB) is to enable family members and other loved ones who are employed to take a temporary secured leave to care for a terminally ill individual at end of life. Successful applicants of the CCB can receive up to 55% of their average insured earnings, up to a maximum of CDN$435 per week, over a six week period to provide care for a gravely ill family member at risk of death within a six month period, as evidenced by a medical certificate. The goal of this study is to evaluate the CCB from the perspective of family caregivers providing care to individuals at end of life. There are three specific research objectives. Meeting these objectives will address our study purpose which is to make policy-relevant recommendations informed by the needs of Canadian family caregivers and input from other key stakeholders who shape program uptake. Being the first study that will capture family caregivers' experiences and perceptions of the CCB and gather contextual data with front-line palliative care practitioners, employers, and human resources personnel, we will be in a unique position to provide policy solutions/recommendations that will address concerns raised by numerous individuals and organizations.

Methods

We will achieve the research goal and objectives through employing utilization-focused evaluation as our methodology, in-depth interviews and focus groups as our techniques of data collection, and constant comparative as our technique of data analysis. Three respondent groups will participate: (1) family caregivers who are providing or who have provided end of life care via phone interview; (2) front-line palliative care practitioners via phone interview; and (3) human resources personnel and employers via focus group. Each of these three groups has a stake in the successful administration of the CCB. A watching brief of policy documents, grey literature, media reports, and other relevant items will also be managed throughout data collection.

Discussion

We propose to conduct this study over a three year period beginning in October, 2006 and ending in October, 2009.

Determinants of overall quality of life in preterminal cancer patients

Recently, a few studies reported that fatigue was a predominant contributor to patient-perceived overall QoL in patients with different types of cancer in a relatively early stage of disease. In the present study, we aimed to investigate whether fatigue is also a major contributor to overall QoL in preterminal cancer patients. Ninety-eight preterminal cancer patients, mainly lung (44%) and gastrointestinal cancer (25%), with an estimated life expectancy of 1-6 months were included. QoL domains as well as overall QoL were measured using the EORTC QLQ-C30 questionnaire. Data were analysed by Pearson's correlations and multivariate modelling. Fatigue showed the strongest correlation with overall QoL (r = -0.63, p < 0.001), followed in decreasing order by role functioning (r = 0.53), physical functioning (r = 0.47), social functioning (r = 0.44), nausea (r = -0.37), cognitive functioning (r = 0.33), appetite loss (r = -0.31), dyspnea (r = -0.26) and emotional functioning (r = 0.24). Multivariate analysis confirmed that the fatigue scale paid by far the highest individual contribution to overall QoL (standardized regression coefficient (SRC): -0.41, p = 0.002), followed by social functioning (SRC: 0.18, p = 0.05). None of the other domains or symptom scales contributed independently to overall QoL. Our results clearly demonstrate that, in preterminal cancer patients, fatigue is a major contributor of overall QoL, corroborating reports in cancer patients in earlier disease stages.

Relationships among communicative acts, social well-being, and spiritual well-being on the quality of life at the end of life in patients with cancer enrolled in hospice

BACKGROUND

The importance of communication in close, personal relationships has been well-documented. At the end of life, communication, social relationships, and spirituality seem to have greater importance. Some studies suggest that the quality of life at the end of life (QOLEOL) involves these components.

OBJECTIVE

The primary aim of this study was to investigate the communicative acts of love, gratitude, and forgiveness, and to explore the extent to which the communicative acts, social well-being, and spiritual well-being predict the overall QOLEOL when controlling for physical symptoms.

DESIGN

Cross-sectional, descriptive, correlational design.

SETTING/SUBJECTS

A convenience sample of all adult hospice patients, aged 35-80, with a cancer diagnosis, residing in their private home in a community setting, was recruited from a large, non-profit hospice program in the midwestern United States.

MEASUREMENTS

Patients completed the Functional Assessment of Cancer Therapy-General (FACT-G) social/family well-being subscale, the JAREL Spiritual Well-Being tool, an investigator-designed tool to measure communicative acts, and the global, single-item QOL indicator of the QUAL-E.

RESULTS

Strong, positive correlations among social and spiritual well-being, communicative acts, and QOLEOL were found (p < 0.01). Spiritual well-being most significantly predicted the QOLEOL, explaining 53.5% of explained variance in the QOLEOL. Although not statistically significant, the communicative acts of love and gratitude made a small contribution to the overall model. The communicative act of forgiveness did not perform well.

CONCLUSIONS

The knowledge gained through this investigation laid the groundwork for future studies in identifying the importance of explicitly assessing relationships and supporting patients and families in their communication. In order to learn more about this phenomenon and establish a foundation for intervention, confirmation is required regarding the connections between the spiritual and social domains, the relationships between the specific communicative acts and the QOLEOL, as well as establishment of valid measurement approaches.

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.

Perceptual consistency of pain and quality of life between hospice cancer patients and family caregivers: a pilot study

AIMS

Clinicians usually adjust medical management based on caregivers' observation when caring for seriously ill or cognitive-impaired patients. The purpose of this study is to research the differences in perceptual congruence of patients and caregivers when assessing patients' global pain (GP) and quality of life (QOL) in a hospice ward.

METHODS

From July 2002 to June 2004, hospice inpatients and their family caregivers were invited to participate in this study at a medical centre in Southern Taiwan. The survey was cross-sectional, incorporating patients' bio-psycho-social factors so as to understand their impacts on patients' pain perception and QOL. The bio-psycho-social factors included biological pain, physical dependence, financial difficulty, anxiety over family, existential meaning of life, uncontrolled outcome of disease and insufficient emotional support.

RESULTS

Fifty-eight patient/caregiver dyads were recruited in the study. The mean of patients' self-reported GP was higher than caregivers' rating (5.9 +/- 1.7 vs. 5.1 +/- 1.9, p < 0.05); however, the score of patients' QOL was lower in the patients than in the caregivers (6.9 +/- 1.6 vs. 7.9 +/- 1.4, p < 0.001). The result of regression analyses showed that 'biological pain', 'religion' and 'gender' were independent variables for patients' GP; however, 'biological pain' and 'gender' were factors for patients' QOL. No psychosocial factor was revealed as a factor in patient's perception of GP or QOL in this survey.

CONCLUSION

This study indicates that caregivers have the propensity to under-rate patients' pain and overvalue QOL; moreover, 'religion' and 'gender' influence patients' perception near the end-of-life. Therefore, reassessment and proper holistic approach are important in hospice care.

Healing connections: on moving from suffering to a sense of well-being

Life-threatening illness is an assault on the whole person--physical, psychological, social, and spiritual. It frequently presents caregiver and sufferer with a paradox--suffering does not correlate with physical well-being alone. Drawing on a purposive sample of 21 participants, a phenomenological study was carried out to explore the relevance of the existential and spiritual domains to suffering, healing, and quality of life (QOL). The phenomenological method was used to achieve an in-depth description of both existential suffering, and conversely, the experience of integrity and wholeness, in persons with life-threatening illness; identify "inner life" and existential contributors to suffering and subjective well-being in advanced illness; and develop a narrative account of these QOL extremes. The importance of meaning-based adaptation to advanced illness was supported, as were Frankl's sources of meaning and Yalom's sources of existential anguish. Divergent themes characteristic of the two QOL extremes were identified. Four types of "healing connections" involving a sense of bonding to Self, others, the phenomenal world, and ultimate meaning, respectively, were identified. They situated the participant in a context that was greater and more enduring than the self, thus leading to enhanced meaning and QOL. The assumptions underlying the construct "health-related QOL" are questioned.

Feeling like a burden to others: a systematic review focusing on the end of life

Research into the burden of illness has focused predominantly on family caregivers, with little consideration of the other side of the caregiving relationship-care recipients' perspectives on having become a 'burden to others'. However, there is now a small but growing body of evidence to suggest that worry about creating burden to others is a common and troubling concern for people who are nearing the end of their lives. This concern is referred to as 'self-perceived burden'. The present study provides a systematic review of the literature, addressing self-perceived burden at the end of life. Using standard methods, literature was searched for relevant studies in palliative care and related fields. The review revealed that self-perceived burden is reported as a significant problem by 19- 65% of terminally ill patients. It is correlated with loss of dignity, suffering, and a 'bad death'. Self-perceived burden has also been identified as a relevant factor in death-hastening acts among patients with life-threatening illness, as well as in clinical decisions, such as the choice of place of care at the end of life, advance directives, and acceptance of treatment. Given the unique challenges faced by patients with advanced disease and their families, there is a need for further investigation into this under-researched area.

Feeling like a burden: Exploring the perspectives of patients at the end of life

The issue of caregiver burden within the context of end-of-life care has received considerable attention. Less focus has been directed at the corresponding issue of care recipients' perceptions of being a burden to others, referred to as "self-perceived burden". The purpose of this interpretative phenomenological study was to gain a better understanding of self-perceived burden from the patient's perspective. Fifteen patients (ten women, five men) from Ottawa, Canada, receiving palliative care for advanced cancer were interviewed. Participants' experiences of self-perceived burden were reflected in two major interrelated categories. "Concern for Others" included the physical, social, and emotional hardships participants believed they were creating for others, as well as concerns about the future and likely effect of their death on those around them. "Implications for Self" reflected feelings of responsibility for causing hardships to others, resulting in distress and a diminished sense of self. A third category, "Minimizing Burden", was also identified, which described coping strategies used by participants to alleviate the burden on others and to reduce the negative impact on themselves. These categories and themes are discussed from the perspective of social psychology theory pertaining to the maintenance of equity in relationships.

QOLLTI-F: measuring family carer quality of life

BACKGROUND

The primary goal of palliative care is to optimize the quality of life (QOL) of people living with a life-threatening illness and that of their families. While there have been important advances in measurement of the QOL of palliative care patients, little attention has been paid to the QOL of their carers (family caregivers). To develop and deliver the most effective services to these carers, their QOL needs to be measured with acceptable and psychometrically sound instruments that have content validity.

METHODS

This study reports three phases of the development and testing of such a measure: QOLLTI-F, Quality of Life in Life Threatening Illness--Family Carer Version, simultaneously in English and French. Participants were carers from 12 Canadian palliative care services who were asked to complete QOLLTI-F on three occasions.

RESULTS

The final version of QOLLTI-F consists of 16 items. It was deemed acceptable by the vast majority of carers and a longer, 24-item version was completed in a median of 12 min. Content validity was assured by inclusion of all domains reported by carers to be important to their QOL: state of carer, patient wellbeing, quality of care, outlook, environment, finances and relationships. Construct validity was demonstrated, as principal components analysis indicated that the 16 items did indeed reflect these seven domains. Furthermore, the seven domain scores predicted 53% of the variance in global QOL, although the QOLLTI-F Total score predicted less well (43%). The test-retest reliability for the QOLLTI-F Total score was 0.77-0.80 and ranged from 0.50 to 0.79 for the seven domain scores. All QOLLTI-F scores were shown to be significantly different between days the carers considered bad, average and good, demonstrating responsiveness to change, with the exception of the Financial Concerns submeasure, which did not distinguish between average and good days.

CONCLUSIONS

QOLLTI-F is unique in that in measuring one person's QOL (the carer's) it includes their perception of the condition of another (the patient). This attests to the close relationship between the two. It is also unique in that its content is derived from a qualitative study asking carers what is important to their own QOL, rather than focusing on the changes or burdens related to caregiving. QOLLTI-F also has the advantage of being briefer than other carer QOL measures. It contains measures of seven different domains that are determinants of carer QOL, in addition to a summary score. All these measures are valid, reliable and responsive to change in QOL.

Religious coping is associated with the quality of life of patients with advanced cancer

BACKGROUND

For patients confronting a life-threatening illness such as advanced cancer, religious coping can be an important factor influencing their quality of life (QOL).

OBJECTIVE

The study's main purpose was to examine the association between religious coping and QOL among 170 patients with advanced cancer. Both positive religious coping (e.g., benevolent religious appraisals) and negative religious coping (e.g., anger at God) and multiple dimensions of QOL (physical, physical symptom, psychological, existential, and support) were studied.

DESIGN

Structured interviews were conducted with 170 patients recruited as part of an ongoing multi-institutional longitudinal evaluation of the prevalence of mental illness and patterns of mental health service utilization in advanced cancer patients and their primary informal caregivers.

MEASUREMENTS

Patients completed measures of QOL (McGill QOL questionnaire), religious coping (Brief Measure of Religious Coping [RCOPE] and Multidimensional Measure of Religion/ Spirituality), self-efficacy (General Self-Efficacy Scale), and sociodemographic variables.

RESULTS

Linear regression analyses revealed that after controlling for sociodemographic variables, lifetime history of depression and self-efficacy, greater use of positive religious coping was associated with better overall QOL as well as higher scores on the existential and support QOL dimensions. Greater use of positive religious coping was also related to more physical symptoms. In contrast, greater use of negative religious coping was related to poorer overall QOL and lower scores on the existential and psychological QOL dimensions.

CONCLUSIONS

Findings show that religious coping plays an important role for the QOL of patients and the types of religious coping strategies used are related to better or poorer QOL.

Palliative in-patient cancer treatment in an anthroposophic hospital: II. Quality of life during and after stationary treatment, and subjective treatment benefits

BACKGROUND

There is an increasing demand for comprehensive forms of palliative cancer care, meeting physical as well as emotional, cognitive, spiritual and social needs. Therapy programs of anthroposophic hospitals are aimed at improving health and quality of life (QoL) at these levels. However, data on the influence of these programs on QoL of patients with advanced cancer are scarce.

PATIENTS AND METHODS

144 in-patients with advanced epithelial cancers were treated at the anthroposophic Lukas Klinik, Arlesheim, Switzerland. QoL was assessed upon admission, discharge and after 4 months, using 20 functional scales from the questionnaires EORTC QLQ-C30, HADS and SELT-M. Statistical testing was performed with the Wilcoxon signed rank test. At month 4, subjectively perceived benefits from anthroposophic medicine (AM) and conventional cancer therapy (CCT) were assessed by telephone.

OBJECTIVE

The aim was to provide an account of global, physical, emotional, cognitive-spiritual and social QoL developments in advanced cancer patients, during and after in-patient AM treatment, and to investigate subjective benefits from AM and CCT.

RESULTS

QoL improvements were observed in all 20 dimensions (12 significant). Compared to related studies, improvements were fairly high. At month 4, QoL scores had decreased but were still above baseline in all 20 dimensions. Both AM and CCT were perceived as beneficial.

CONCLUSION

Our data provide evidence that in-patient therapy at an anthroposophic hospital can lead to significant QoL improvements, especially in emotional, but also global, physical, cognitive-spiritual and social aspects. Benefits of AM were experienced on the physical, emotional, cognitive- spiritual and social level. Benefits of CCT were tumor-focused.

The effect of a physical exercise program in palliative care: A phase II study

The purpose of this pilot study was to assess the effects of a physical exercise program on physical performance and quality of life (QOL) in a population with incurable cancer and a short life expectancy. Thirty-four patients participated in a 50-minute group exercise program twice a week for 6 weeks. Physical performance was measured by three tests: "6-minute walk test," "timed repeated sit to stand," and "functional reach." Fatigue was measured by the Fatigue Questionnaire. QOL was assessed by the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire. The outcome variables were assessed before and after the intervention. The walk length increased and the "timed repeated sit to stand" was reduced (P < 0.05). Emotional functioning improved and physical fatigue was reduced (P < 0.05). Physical exercise seems to be a feasible way to improve well-being among patients with incurable cancer. Future randomized trials are needed to confirm the results.

Confirmation of the "disability paradox" among hospice patients: preservation of quality of life despite physical ailments and psychosocial concerns

OBJECTIVE

The purpose of this study was to describe quality of life (QOL) and psychosocial and spiritual issues among patients receiving hospice care.

METHODS

A questionnaire addressing QOL, spirituality, optimism, loss, fears about the terminal process and death anxiety was administered to 66 adults receiving care from 14 hospices. The physical components of QOL (physical symptoms and physical well-being) were rated lower than the psychosocial and spiritual aspects (support, existential well-being, psychological symptoms).

RESULTS

Respondents had a strong spiritual connection and a strong sense of hope. Although these individuals did not express anxiety or fear about death, there were concerns about the dying process itself. Also, although most felt at ease with their current situation, respondents were concerned about how their illness was affecting their family. Financial and legal issues did not concern most of these individuals.

SIGNIFICANCE OF RESULTS

There were few significant associations between patient characteristics and the QOL or other psychosocial or spiritual issues addressed. Among this older terminally ill population receiving hospice care, whose functional status was fair and for whom physical symptoms were troublesome, QOL persisted and a positive outlook prevailed.

Measuring the psychosocial characteristics of family caregivers of palliative care patients: psychometric properties of nine self-report instruments

Researchers and clinicians have experienced substantial difficulties locating measures that are suitable for use within palliative care settings. This article details the psychometric properties of nine instruments designed to assess the following psychosocial characteristics of family caregivers: competence, mastery, self-efficacy, burden, optimism, preparedness, social support, rewards, and mutuality. Results are based on the responses of 106 primary family caregivers caring for relatives dying of cancer. Principal components extraction with varimax rotation was used to explore the underlying structure of each measure. Following the exclusion of complex variables, suggested components for most measures comprised relatively homogenous items, which were good to excellent measures of each component. Some components comprised only two items; however, Cronbach's alphas typically indicated moderate to high levels of internal consistency. Overall, the results of this study suggest that most of the measures analyzed, excepting the mastery and mutuality scales, can be recommended to examine the family caregiver experience and test supportive interventions.

Validation of the McGill Quality of Life Questionnaire in home hospice settings in Israel

Given that the meaning and significance of 'quality of life' can differ among language and cultural groups, it is incumbent upon researchers to assess whether the tool they have chosen is appropriate to the population under study. This study aimed to test the reliability and validity of the McGill Quality of Life Questionnaire (MQOL) translated into Hebrew for use with palliative care patients in Israel. In this, as in previous studies, the 16 questions of the tool clustered into four domains (physical, psychological, existential well-being and support), although the distribution of items among them differed somewhat. The existential well-being and psychological domains had an independent effect on the overall quality of life of patients in Israel, as in other countries. It seems that this tool produces similar responses in metastatic cancer patients around the world, and hence can be used to compare palliative care services in different countries.

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

Recent research into the desire for death among people with terminal illness has begun to recognize the importance of "feeling oneself a burden to others" as a factor in suicidal behaviour. In this study, 69 patients with advanced cancer underwent semi-structured interviews. The sense of self-perceived burden was found to be a common experience, reported by 39.1% of participants as a minimal or mild concern and by 38% as a moderate to extreme concern. The sense of burden showed a low correlation with physical symptoms (r = 0.02-0.24) and higher correlations with psychological problems (r = 0.35-0.39) and existential issues (r = 0.45-0.49). Comparisons of participants with high or low levels of self-perceived burden showed the importance of this factor for overall quality of life. In summary, self-perceived burden is an important but underestimated dimension of social cognition in the medically ill.

An empirical analysis of the decision-making of limiting life-sustaining treatment for patients with advanced chronic obstructive pulmonary disease in Hong Kong, China

OBJECTIVES

To understand the prognostic and quality-of-life considerations surrounding life-sustaining treatment decisions for patients with advanced chronic obstructive pulmonary disease (COPD) in Hong Kong China.

METHODS

A documentary review of 49 COPD patients and 19 patient case studies from the medical departments of 2 hospitals were undertaken to examine the practices of DNI decision-making (do not perform mechanical ventilation and cardiopulmonary resuscitation). Statistical, event, and thematic analyses were conducted to delineate the prognostic and quality-of-life factors that shaped the not for intubation and mechanical ventilation (DNI) decisions.

RESULTS

Three major treatment-limiting decision-making patterns existed in practice: 1) Patient-initiated and shared decision-making with physician (n = 14); 2) Physician-initiated and shared decision-making with the patient/family members (n = 24); and 3) Physician-initiated DNI decision-making with patient family, but without patient participation due to mental incapacity (n = 11). Prognostic considerations include physiological parameters, performance status, concomitant diseases, therapeutic regimens, and the utilization of medical services. Three major themes were delineated regarding the way in which the patients evaluated their life quality in the context of DNI status. They are prognostic awareness, illness burdens, and existential concerns.

DISCUSSION

A decision-making framework used by patients/families/physicians to limit life-sustaining treatments in patients with advanced COPD is delineated. Observations regarding how treatment limiting decision-making for patients with advanced chronic illnesses can be improved in Hong Kong are discussed.

Research methodology: cancer cachexia syndrome

Cachexia is a syndrome and therefore does not have a specific definition. Patients are characterized by the presence of anorexia, early satiety, weight loss, weakness, anaemia and oedema. These features occur to a variable extent in different patients and may change in severity during the course of a patient's illness. The multifactorial origin of cachexia precludes a uniform pathophysiological definition. Taken together these factors have hindered clinical studies both at a fundamental level and in terms of the introduction of effective therapy. The advent of novel therapeutic targets (e.g., ubiquitin-proteasome pathway) and biological response modifiers has opened possibilities for new clinical trials in cachexia. Regulatory authorities feel it is important not only to demonstrate efficacy in terms of patients' nutritional status (e.g., lean body mass) but also functional status (e.g., performance status). This article reviews current methods to assess the latter. Methods focused on measuring physical activity level (e.g., doubly labelled water technique or physical activity meters) promise objective data which can be readily interpreted in terms of clinically meaningful benefit.

Physical exercise results in the improved subjective well-being of a few or is effective rehabilitation for all cancer patients?

Physical exercise as an intervention in cancer patients has attracted increasing interest. This review examines the published randomised controlled trials on physical exercise, during and after cancer treatment, focusing primarily on recruitment of patients, patient compliance, content of the intervention programmes and outcome measures. We performed systematic searches of PubMed, PsychInfo, Cancerlit and the Cochrane Library using the MESH terms exercise, neoplasms, cancer, rehabilitation and intervention. We identified 12 randomised trials with sample sizes ranging from 21 to 155 patients. Only four studies reported the number of patients assessed for eligibility and the reasons for exclusion; 15% to 30% of patients assessed for eligibility were randomised into the intervention programmes. Drop-out rates in the trials ranged from 0% to 34%. Most studies included female breast cancer patients (nine studies, 62% of total number of patients). Interventions included aerobic exercise training (10 studies) and resistance exercise (two studies). The studies used a wide range of instruments to assess health-related quality of life (HRQOL) and the physical exercise capacity. The studies indicated promising effects on both physiological and psychological outcomes. Randomised clinical studies are few, small in scope, and mainly focus on breast cancer patients. Complete knowledge about the type of physical exercise most beneficial for patients at different stages of the disease progression is still lacking. Future work should identify fewer and more specific endpoints.

Measuring quality of life at the end of life: Validation of the QUAL-E

Objectives:To validate the QUAL-E, a new measure of quality of life at the end of life.

Methods:We conducted a cross-sectional study to assess the instrument's psychometric properties, including the QUAL-E's associations with existing measures, evaluation of robustness across diverse sample groups, and stability over time. The study was conducted at the VA and Duke University Medical Centers, Durham, North Carolina, in 248 patients with stage IV cancer, congestive heart failure with ejection fraction ≤20%, chronic obstructive pulmonary disease with FEV1≤ 1.0 l, or dialysis-dependent end stage renal disease. The main outcome measures included QUAL-E and five comparison measures: FACIT quality of life measure, Missoula-VITAS Quality of Life Index, FACIT-SP spirituality measures, Participatory Decision Making Scale (MOS), and Duke EPESE social support scales.

Results:QUAL-E analyses confirmed a four-domain structure (25 items):life completion(α = 0.80),symptoms impact(α = 0.87),relationship with health care provider(α = 0.71), andpreparation for end of life(α = 0.68). Convergent and discriminant validity were demonstrated with multiple comparison measures. Test–retest reliability assessment showed stable scores over a 1-week period.

Significance of results:The QUAL-E, a brief measure of quality of life at the end of life, demonstrates acceptable validity and reliability, is easy to administer, performs consistently across diverse demographic and disease groups, and is acceptable to seriously ill patients. It is offered as a new instrument to assist in the evaluation of the quality and effectiveness of interventions targeting improved care at the end of life.

Health Problems Encountered by Dying Patients Receiving Palliative Home Care Until Death

Many of the studies reviewing the needs of the dying patient have used specified time points rather than following the patients through the last span of their lifetime, until death. This prospective study, using clinical records and nursing anecdotes, examined the health problems encountered by dying patients receiving home care from referral to home care until death. Thirty-two subjects were recruited in the study. The clinical records were content-analyzed using the Omaha system, and the anecdotes of the nurses were used to illuminate the numerical findings. This study reveals that patients who were discharged home were living in good environmental and social conditions. The physical symptoms were generally well controlled, except for dyspnea. The psychological aspects caused the most concern to patients, families, and healthcare professionals. The severity of the psychological signs and symptoms was moderate at the time of the initial visits, but improved toward the final visits. Understanding the needs of palliative home care patients can facilitate the healthcare team to plan care to support "good dying" of these patients.