Dying from cancer: results of a national population-based investigation

District nurses' triggers for referral of patients to the Macmillan nurse

This study aimed to identify the triggers which motivate district nurses to refer patients to the Macmillan nursing service and resulted from observation within the researcher's clinical practice, when it was noted that referral patterns from district nurses to the Macmillan nursing service were very inconsistent. A qualitative exploratory descriptive design was utilised and the analysis of the findings identified three 'key' themes, which motivate district nurses to refer: knowledge and skills, interprofessional issues and perception of Macmillan. Within each theme emerged an amalgam of triggers which were complex in nature, pertaining not only to patient need, but also to the needs of the district nursing service. However, it became apparent during the analysis that there was also a lack of knowledge regarding the role of the Macmillan nurse. This lack of knowledge relating to the Macmillan nurse role had been affirmed previously by several authors (Graves and Nash 1993, Clark et al 2002, Ahmed et al 2004) but the literature also reported that the Macmillan nurse role was open to confusion (Clark et al 2002, Corner 2003). This confusion may potentially affect referrals and prevent patients from receiving the services of the Macmillan nurse. This study has established a need for the development of referral criteria into the Macmillan nursing service and that there is also an identified need for further research, providing scope for the Macmillan nurse and district nurse to work collaboratively to improve palliative services in the community.

A pragmatic 2×2×2 factorial cluster randomized controlled trial of educational outreach visiting and case conferencing in palliative care—methodology of the Palliative Care Trial [ISRCTN 81117481]

The demand for palliative care is increasing, yet there are few data on the best models of care nor well-validated interventions that translate current evidence into clinical practice. Supporting multidisciplinary patient-centered palliative care while successfully conducting a large clinical trial is a challenge. The Palliative Care Trial (PCT) is a pragmatic 2 x 2 x 2 factorial cluster randomized controlled trial that tests the ability of educational outreach visiting and case conferencing to improve patient-based outcomes such as performance status and pain intensity. Four hundred sixty-one consenting patients and their general practitioners (GPs) were randomized to the following: (1) GP educational outreach visiting versus usual care, (2) Structured patient and caregiver educational outreach visiting versus usual care and (3) A coordinated palliative care model of case conferencing versus the standard model of palliative care in Adelaide, South Australia (3:1 randomization). Main outcome measures included patient functional status over time, pain intensity, and resource utilization. Participants were followed longitudinally until death or November 30, 2004. The interventions are aimed at translating current evidence into clinical practice and there was particular attention in the trial's design to addressing common pitfalls for clinical studies in palliative care. Given the need for evidence about optimal interventions and service delivery models that improve the care of people with life-limiting illness, the results of this rigorous, high quality clinical trial will inform practice. Initial results are expected in mid 2005.

A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease

Little attention has been paid to the symptom management needs of patients with life-threatening diseases other than cancer. In this study, we aimed to determine to what extent patients with progressive chronic diseases have similar symptom profiles. A systematic search of medical databases (MEDLINE, EMBASE, and PsycINFO) and textbooks identified 64 original studies reporting the prevalence of 11 common symptoms among end-stage patients with cancer, acquired immunodeficiency syndrome (AIDS), heart disease, chronic obstructive pulmonary disease, or renal disease. Analyzing the data in a comparative table (a grid), we found that the prevalence of the 11 symptoms was often widely but homogeneously spread across the five diseases. Three symptoms-pain, breathlessness, and fatigue-were found among more than 50% of patients, for all five diseases. There appears to be a common pathway toward death for malignant and nonmalignant diseases. The designs of symptom prevalence studies need to be improved because of methodological disparities in symptom assessment and designs.

Knowledge of treatment intent among patients with advanced cancer: a longitudinal study

Increasingly, patients with cancer wish to be more fully informed about their disease, treatment and prognosis, and to participate in decision making. The objective of this study was to assess knowledge of diagnosis and goals of treatment among patients with advanced cancer, and also to assess whether this knowledge changed over time. A cohort of 181 subjects with advanced cancer receiving palliative therapies were interviewed at entry and again 12 weeks later. Knowledge of disease diagnosis, treatment intent, and the main sources of information were determined. Twenty per cent of subjects considered their illness to be non-life threatening, and 46% correctly perceived treatment intent as non-curative; 29% believed the intent of treatment was cure. Subjects resident in rural areas were more likely to misunderstand the goal of their treatment. Treatment modality was significantly associated with knowledge of treatment intent, and subjects in the last 6 months of life had clearer understanding that treatment intent was non-curative. Many patients with advanced cancer do not understand the goals of treatment. Excessive optimism may lead to impaired decision making. Further empirical research into information transfer and predictors of accurate patient understanding would assist clinicians in their discussions of prognosis and potential treatment outcomes with patients.

Measuring End-of-Life Care Outcomes Retrospectively

Fundamental to measuring both the processes and outcomes of end-of-life care is that one understand the context and distinct differences of that care. Measurement plays an important role in clinical assessment, research, quality improvement, and public accountability. Some of the unique challenges that confront investigators using prospective research designs to assess quality of end-of-life care can be addressed with retrospective approaches or follow-back designs. Retrospective research avoids reliance on the difficult task of prospectively identifying the terminally ill, avoids burdening very sick participants, minimizes missing data because of poor functional status, creates a clear time frame for the purpose of comparing settings of care, and is a cost-effective way to collect population-based data about individuals who have died. This paper reviews research using a retrospective design and analyzes the reliability and validity issues associated with a follow-back design. Although methodological challenges beset both prospective and retrospective data collection, use of both methods in combination or in sequence provides a clearer understanding of the complex, multidimensional issues involved in providing care to dying individuals.

Loss of appetite: a poetic exploration of cancer patients’ and their carers’ experiences

AIM

To explore the experience of loss of appetite among palliative care cancer patients and their carers supported by a specialist palliative care team in the community.

METHOD

Semistructured interviews were conducted with seven palliative care cancer patients and their carers in the community. A poetic transcription of participants' words was made to capture and communicate the essence of each person's experience before the thematic analysis was undertaken.

FINDINGS

Six common themes emerged from the data: a fickle phenomenon; the cost of caring; facing uncertainty and death; adaptations; accepting limitations; and what patients want: 'listen to me'. These were illustrated by the poetic transcriptions.

CONCLUSION

Meeting the differing needs of palliative care patients with loss of appetite and their carers is challenging. It demands a thorough assessment of symptoms, an understanding of the underlying pathophysiology and of the role food plays in society. An understanding of the experience of loss of appetite is essential to the provision of appropriate care and support to those affected by it. The study demonstrated that, although unusual, poetic transcriptions can be an effective method of presenting data in terms of acceptability to participants and communicating their experience to others.

Terminal Care: The Last Weeks of Life

BACKGROUND

The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period.

METHOD

A systematic review of published literature and expert opinion related to care in the last weeks of life.

RESULTS

The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement.

CONCLUSION

While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.

How people die in hospital general wards: a descriptive study

To describe how patients die in hospital, 370 patients (age >18 years; in hospital for>24 hours) who died on the general wards of 40 Italian hospitals were assessed. Differences between patients whose death was expected and patients whose death was unexpected were evaluated. Data on treatments and care in proximity of death were collected after interviewing the nurse responsible for the patient within 72 hours of the patient's death, and from clinical and nursing records. For 58% of patients, death was highly expected. Symptom control was inadequate for the most severely ill patients: 75% experienced at least one "severe" symptom (42% pain and 45% dyspnea). Nurses tended to judge patients' global care as "good" or "very good" (76%), in spite of the persistence of symptoms and the scant use of analgesics. Despite some encouraging signs of sensitivity to end-of-life problems, acute inpatient institutions in Italy still deal inadequately with the needs of dying persons.

Reciprocal suffering: the need to improve family caregivers' quality of life through palliative care

There is growing recognition of the reciprocity of suffering by patients and families experiencing terminal illness and the need to improve the quality of their lives as the patient's illness progresses. Research is presented that addresses the importance of a dyadic perspective in recognizing patients' and families' stress and adjustment and the related physical, emotional, social, spiritual and financial needs at the end-of-life. These aspects of quality of life are specifically addressed by palliative care. The philosophy and goals of palliative care are described, as is its role in promoting the best possible quality of life for patients and their families experiencing terminal illness. This article addresses the importance of assessing the dynamics of the family caregiving system and potential palliative care interventions to enhance the quality of life of family caregivers. Implications for research are also discussed.

Palliative care for patients with cancer: district nurses' experiences

AIM

This paper reports a study exploring district nurses' experiences of providing palliative care for patients with cancer and their families.

BACKGROUND

There is an increasing demand for palliative care in the community, as many patients wish to die at home. District nurses are central to providing palliative care in the community, but there is a dearth of literature on district nurses' experiences in palliative care.

METHOD

A Husserlian phenomenological approach was adopted with a purposive sample of 25 female district nurses. Data were collected using unstructured, tape-recorded interviews and analysed using Colaizzi's seven stages of data analysis.

FINDINGS

Four themes were identified: the communication web; the family as an element of care; challenges for the district nurse in symptom management and the personal cost of caring.

CONCLUSIONS

District nurses' experiences of providing palliative care to family units was challenging but rewarding. The emotive nature of the experience cannot be under-estimated, as many district nurses were touched by the varying situations. Whilst acknowledging the need to maintain an integrated approach to care, district nurses should be identified as the key workers in the complex situation of palliative care.

Patient-related barriers to pain management: the Icelandic Barriers Questionnaire II

The Barriers Questionnaire-II (BQ-II) is used to evaluate eight attitudinal barriers to cancer pain management. The purpose of this study was to evaluate the psychometric properties of the Icelandic BQ-II (IBQ-II). Icelandic adults (n=244) completed the IBQ-II, the Brief-Pain-Inventory, and demographic questions. Half the responders were male (52%), and 42.8% had pain on the day of data collection. Participants had a mean (SD) age of 34.73 (11.78) years and education of 15.08 (3.69) years. Factor analysis of the IBQ-II supported three factors. The alpha was 0.90. The mean (SD) IBQ-II total score was 2.32 (0.78), on a scale of 0 to 5, with higher scores indicating stronger barriers. IBQ-II total scores were inversely related to education (r=-0.21; P<0.01), and positively related to least pain (r=0.24; P<0.05), average pain (r=0.23; P<0.05), and pain interference with life activities (r=0.22; P<0.05) for those who had pain. There is support for reliability, validity, and feasibility of the IBQ-II.

Service Preferences Among Family Caregivers of the Terminally Ill

OBJECTIVE

The ability of families to assume caregiving responsibilities is contingent on material, social, and professional support. Inadequate or inappropriate support to the terminally ill and their family caregivers can result in the misuse of resources and add burden to the family. In this report, we describe service preferences among informal caregivers of the terminally ill.

DESIGN

Three hundred seventy-three caregivers participated in telephone interviews at two points in time: when the terminally ill person was designated as palliative and 5 months subsequent to the first interview. In the case that the care recipient died during the study period, the caregiver participated in the interview three months after the death.

MEASURES

After reviewing possible services received by the care recipients and caregivers, caregivers were asked to identify the five services they found most valuable and which services they would have liked to have had or received more of when caregiving.

RESULTS

The five services caregivers reported as most valuable included: in-home nursing care, (90.7%); family physicians, (45.6%); medical specialists, (46.4%); housekeeping, (23.6%); and, religious support, (11.3%). The five most frequently reported services that family caregivers would have liked to have received or had more available included: housekeeping, (13.1%); caregiver respite, (10.2%); in-home nursing care, (8.0%); personal support workers, (4.6%); and, self-help/support groups, (3.8%). Analyses revealed that most (64.8%) perceived service needs were of a supportive nature for caregivers. Caregiver perceptions of the value and perceived need of services were consistent over time and into bereavement. Logistic regression analyses suggested that younger caregivers who were not employed, reported higher levels of burden and cared for someone with a diagnosis of cancer had greater perceived service needs.

CONCLUSIONS

The findings reported in this paper provide important insights into caregiver perceptions of valued services when caring for a terminally ill family member. These finding also highlight the stability of caregiver service perceptions over time and into bereavement.

Introducing an integrated care pathway for the last days of life

Integrated care pathways (ICPs) are multiprofessional documents designed to enable the implementation of evidence-based care and support the practical delivery of clinical governance. However, the implementation of care pathways is resource intensive and few evaluations have been conducted with respect to these areas or to the efficacy of care pathways to change practice and improve outcomes in care. This project sought to address these issues and the report outlines the approach taken by a palliative care team in South Wales, UK, to implement a care pathway for the dying throughout a district general hospital and six community hospitals. Dying can be a complex area of care and changing practice can be challenging, therefore a PRINCE Project management approach was taken and a full-time project nurse employed for the life of the project. This paper describes the strategies used to approach implementing a care pathway and provides a template for other teams who may embark on similar projects. At the end of the project, the care pathway was successfully implemented and provided demonstrable outcomes of care for those dying from cancer and nonmalignant diseases. Strikingly, a large number of patients dying from nonmalignant disease were cared for via the pathway, which was not expected.

Patients with advanced cancer and family caregivers' knowledge of health and community services: a longitudinal study

The present study examines the knowledge of health and community services reported by patients with advanced cancer and their family caregivers, and compares patient-stated use with their knowledge of availability. A longitudinal study of the quality of life of patients with advanced cancer was conducted out of the cancer services of The Canberra Hospital, a teaching service, in Canberra, Australian Capital Territory, Australia. Some 317 subjects were recruited sequentially, comprising patients (n = 181) and their nominated family caregivers (n = 136). Patients were more aware of the available health and community support services compared with their caregivers, and differences were significant for most allied professional services, as well as some key supportive care institutions and community programmes. Knowledge of community support services was variable and low for those specifically associated with terminal care. While congruence of knowledge for dyads was quite low in some areas, overall household knowledge was high. The identified sources were mainly non-medical. Nurses, social workers and alternative practitioners, as well as family, friends and commercial sources were the main categories which were identified. No statistically significant changes in knowledge or sources of information occurred over time. Further longitudinal research would assist healthcare teams to understand the role of health and community services in the advanced cancer setting. The identification of systemic and regional weaknesses in communication may assist in improving family knowledge and improve timely access to important supports in the advanced cancer setting.

Community hospitals: an under-recognized resource for palliative care

In the UK there are concerns that, in certain groups of dying patients such as the old, those with non-cancer diagnoses and those in rural areas, the quality of care is unacceptably variable. There has been no systematic survey of the extent to which community hospitals provide general palliative care for such patients. Therefore, by means of a structured questionnaire we asked senior nurses/managers at all 478 community hospitals in the UK for information on staff expertise, facilities and specialist equipment, liaison arrangements with specialist palliative care providers, priorities, practice and policy in end-of-life care. Of the 346 hospitals (72%) that responded, only 28 were in urban areas. 73% of hospitals employed at least one nurse with additional training in palliative care, 72% had access to 24-hour specialist palliative care advice and 51% had separate overnight accommodation for relatives, but only 22% had designated palliative care beds. Most hospitals did not have written policies or guidelines for patient assessment or symptom control. These findings add to evidence that community hospitals represent an important resource to improve access to palliative care for groups that are currently under-served.

Place of death: preferences among cancer patients and their carers

The place of death of cancer patients has become an important theme in UK cancer and palliative care policy. This paper examines the place of death preferences of 41 terminally ill cancer patients and 18 of their informal carers, living in the Morecambe Bay area of north-west England. We interviewed cancer patients referred to the research team by 13 specialist palliative care professionals; patients had an estimated 3 months of life remaining. The study design involved an in-depth qualitative interview with each patient soon after referral to the study, followed by an interview some 4 weeks later and subsequent tracking interviews by telephone at 2-4 week intervals until death occurred. Interviews were also conducted with main coresident carers soon after patient referral to the study and again in the post-bereavement period. Thirteen factors were identified as shaping the place of death preference of patients and carers. These are organised into four thematic domains: the informal care resource, management of the body, experience of services, and existential perspectives. In documenting these factors, this paper adds significantly to current knowledge on the factors that shape place of death preference, a field of enquiry acknowledged to be underdeveloped (J. Palliative Med. 3 (2000) 287). More importantly, it uncovers some of the reasons that underpin these preferences. Our research revealed a much stronger preference for deaths in a hospice than had been anticipated, leading us to take a qualified stance on the current policy drive in favour of home deaths by those charged with delivering UK cancer and palliative care services.

Primary care continuity and location of death for those with cancer

BACKGROUND

Continuity of primary care is known to be associated with both improved processes and outcomes of care. Despite continuity being a desired attribute of end-of-life care and despite the desire by most patients with cancer to die at home, there has been no health services research examining this relationship.

AIM

To examine the association between family physician continuity of care and the location of death for patients with cancer.

DESIGN OF STUDY

A retrospective population-based study involving secondary data analysis of four linked administrative health databases spanning 6 years of information (1992-1997).

SETTING

Nova Scotia, Canada Participants: All those who died of cancer from 1992 to 1997 and had made at least three ambulatory visits to a family physician.

METHODS

The relationship of provider continuity of care and an out-of-hospital death was examined using logistic regression.

RESULTS

Out-of-hospital deaths accounted for 31.6% of the 9714 deaths in the study population. The mean provider continuity of care was 0.78 (standard deviation [SD] 0.22). Those who died out-of-hospital had a greater odds of having received high provider continuity (adjusted odds ratio [OR] = 1.54, 95% confidence interval [CI] = 1.22, 1.93) when compared to those who died in-hospital. There appears to be a modification of this effect by gender with a significant association found for males and not for females. The trends in the point estimates are, however, similar for both sexes.

CONCLUSIONS

This study demonstrates an association between family physician continuity of care and the location of death for those with advanced cancer. Such continuity should be fostered in the development of models of integrated service delivery for end-of-life care.

Xerostomia: clinical aspects and treatment

Xerostomia or dry mouth is a condition that is frequently encountered in dental practice. The most common cause is the use of certain systemic medications, which make the elderly at greater risk because they are usually more medicated. Other causes include high doses of radiation and certain diseases such as Sjogren's syndrome. Xerostomia is associated with difficulties in chewing, swallowing, tasting or speaking. This results in poor diet, malnutrition and decreased social interaction. Xerostomia can cause oral discomfort, especially for denture wearers. Patients are at increased risk of developing dental caries. A thorough intraoral and extra-oral clinical examination is important for diagnosis. Treatment may include the use of salivary substitutes (Biotene), salivary stimulants such as pilocarpine, ongoing dental care, caries prevention, a review of the current prescription drug regimen and possible elimination of drugs having anticholinergic effects. Because of the ageing population, and the concomitant increase in medicated individuals, dentists can expect to be presented with xerostomia in an increasing number of patients in the coming years and therefore should be familiar with its diagnosis and treatment. Therefore, the purpose of this review is to outline for clinicians the common aetiologies, clinical identification, and routine therapeutic modalities available for individuals with xerostomia.

Validation of a symptom measure suitable for use among palliative care patients in the community: CAMPAS-R

The purpose of the study was to investigate psychometric properties of CAMPAS-R, an instrument for prospectively monitoring patients' symptoms and needs during palliative care at home. CAMPAS-R was piloted for face and content validity and then administered alongside criterion measures to a home care sample. Cronbach's alpha was used to test internal consistency and criterion-related validity was tested by non-parametric correlation with Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS) and EORTC QLQ-C30. Predictive validity was assessed by relating CAMPAS-R scores to survival. One hundred and nine patients were recruited to the study. Good reliability and high correlations between CAMPAS-R and criterion measures were found. Predictive validity was demonstrated by significant differences in symptom scores between groups differing in length of survival. CAMPAS-R is acceptable to patients, families and primary care professionals and is a valid, reliable instrument, which has the benefit of being easy to score.

Fit to care? A comparison of informal caregivers of first-generation Black Caribbeans and White dependants with advanced progressive disease in the UK

The present survey aimed to describe and compare the main needs and problems experienced by informal caregivers of Black Caribbean and White native-born patients in their last year of life. Out of the 106 Black Caribbean and 110 White patients identified as dying during the survey period, 50 interviews per ethnic group were conducted, a response rate of 47% and 45%. Out of these, 31 respondents representing Black Caribbean and 28 representing White dependants said that they bore the brunt of caregiving. Compared with those who cared for White dependants, those who cared for Black Caribbean dependants were more likely to be women (84% versus 46%, chi2 = 9.21, 1 d.f., asymptotic P = 0.002) and younger than 55 years of age (73% versus 37%, chi2 = 7.60, 1 d.f., asymptotic P = 0.006). The personal-care tasks which caregivers assisted their dependants with were similar, as were the informal resources they drew on. Many caregivers reported restrictions in their daily lives; this was more pronounced for those who cared for Black Caribbean dependants (chi2 = 6.40, 2 d.f., asymptotic P = 0.041, exact P = 0.039). Research is required to provide a qualitative narrative of the meaning caregivers from different communities ascribe to caring, and the formal and informal resources which they need to support them.

Building bridges in palliative care: evaluating a GP Facilitator programme

The objective of this study was to evaluate the impact of the Macmillan GP Facilitator Programme in Palliative Care on the knowledge, attitudes and confidence in symptom control of general practitioners (GPs), communication with patients and out-of-hours practice. GP Facilitators work on average for two sessions a week with practices in their locality. The design included a before and after study, with geographical controls matched on type of area (inner city, urban and rural) and broadly on Jarman scores using postal questionnaires sent to GPs. Scores measured change in GP awareness, attitudes and practice over two years of the intervention, derived from Likert scale responses to the postal questionnaires. Although overall few significant results were found, we did identify an increase in the use of palliative care guidelines in Facilitator districts, together with an increase in awareness of day care. The programme was associated with increased positive attitudes towards specialist palliative care services and results suggested increased satisfaction with out-of-hours services for patients. No change was found for confidence in symptom control and communication over diagnosis with cancer patients was less than in control districts. The design also incorporated a qualitative component, and from this we found the Facilitator programme to be popular with local GPs who valued the support of a colleague who knew the demands and constraints of general practice. In conclusion, we have demonstrated an impact of the GP Facilitator programme on GP awareness of, use and increased positive attitudes towards specialist palliative care services. By improving communication between primary and specialist palliative care, the programme should contribute substantially to improved care of the dying at home.

Palliative care at home: general practitioners working with palliative care teams

Home care is the preferred option for most people with a terminal illness. Providing home care relies on good community-based services, and a general practice workforce competent in palliative care practice and willing to accommodate patients' needs. Structured palliative care training of general practitioners is needed at undergraduate and postgraduate level, with attention to barriers to teamwork and communication. Good palliative care can be delivered to patients at home by GPs (supported by specialist palliative care teams) and community nurses, with access to an inpatient facility when required. To optimise patient care, careful planning and good communication between all members of the healthcare team is crucial.

Difficulties encountered by nurses in the care of terminally ill cancer patients in general hospitals in Japan

The aim of this study was to investigate the difficulties encountered by nurses who have cared for terminally ill cancer patients at general hospitals. To collect data, a survey by questionnaire was self-administered. The respondents were 375 nurses and the response rate was 70.2%. Factor analysis was conducted on 80 items related to the difficulties encountered by nurses who have cared for terminally ill cancer patients to allow reasonable item reduction and to explore better domains. Two items were excluded and the results revealed eight underlying domains: 'Communication with patients and families', 'Knowledge and skill of nurses', 'Treatment and informed consent (IC)', 'Personal issues', 'Collaboration as a team including patients and families', 'Environment and system', 'Collaboration among nurses', and 'Near-death issues'. Cronbach's alpha coefficients for each domain ranged from 0.77 to 0.93. The results showed that nurses working at general hospitals have experienced a high degree of difficulty overall while caring for the dying, particularly with communication with patients and families. It was concluded that this study was useful in determining the specific areas where nursing education and research should be focused.

A comparison of pain and health-related quality of life between two groups of cancer patients with differing average levels of pain

A study was performed to describe and compare pain and Health-Related Quality of Life (HRQOL) in two groups of cancer patients in palliative care as well as to describe the correlation between pain and HRQOL. Forty-seven patients with mild average pain [Visual Analogue Scale (VAS) </= 3] and 28 patients with moderate to severe average pain (VAS > 3) were included. Medical Outcomes Study Short Form (SF-36) was used to evaluate HRQOL, pain intensity levels were measured with the VAS on Pain-O-Meter. Compared to patients with mild pain, patients with moderate to severe pain had statistically significant, higher pain intensity for the items 'pain at time of interview', 'worst pain in the past 24 hours' and 'pain interrupting sleep.' They also had the lowest scores of the SF-36 dimensions: physical functioning, role-physical, and bodily pain. Patients with moderate to severe pain had statistically significant, fewer months of survival. There were statistically significant positive correlations between pain items and negative correlation between pain and SF-36 dimensions. The conclusion is that pain has a negative impact on HRQOL, especially on physical health and that pain increases towards the final stages of life. Even if patients have to endure symptoms such as fatigue and anxiety during their short survival time, dealing with pain is an unnecessary burden, which can be prevented.

Organizing palliative care for rural populations: a systematic review of the evidence

BACKGROUND

Palliative care services have developed mostly in urban areas. Rural areas typically are characterized by the lack of well-organized services, with primary care professionals, specifically GPs and community nurses, having to undertake most of the palliative care. Little is known, however, either of their views or of how best to organize palliative care in rural areas.

OBJECTIVE

The aim of this study was to conduct a systematic literature review of studies that have examined the organization of rural palliative care and the views of professionals in rural areas.

METHOD

Six electronic databases were searched for published studies between 1991 and 2001. Articles had to match against (i). MeSH or keyword terms relating to palliative, terminal or end of life care; and (ii). MeSH or keyword terms relating to rural. A data extraction framework was designed and used systematically by two reviewers to consider research question and method, sample characteristics, selection and size, study quality, summary results and implications.

RESULTS

Twenty-six studies were identified. These were mostly questionnaire surveys and reports, and three qualitative studies. No randomized controlled studies or cohort studies were identified. Education and strategic issues were dominant research questions. Both the sample numbers and response rates in the surveys were variable. The qualitative studies had methodological strengths and elicited important views from nurses, carers and families. GPs were, however, unrepresented. Whilst the role of primary care emerged as an important theme, primary care professionals reported difficulties in obtaining education and training. There were also reported problems in symptom control and in the management of emotional issues such as bereavement counselling. Difficulties were also described in accessing specialist services such as hospices, and families were reported as having problems in accessing information. Developments in information technology such as telemedicine were seen as possible solutions to some of the problems.

CONCLUSIONS

There is little published work on this topic. Most of the work identifies problems in the delivery of palliative care in rural areas. Whilst primary care professionals are seen as having a key role, there is a need to discover both their views and their needs in this field.

The bereavement experience following home-based family caregiving for persons with advanced cancer

The purpose of this qualitative interpretive study was to explore the experience of bereavement following home-based family caregiving for persons with advanced cancer. The research question addressed by this research was: How do family caregivers of patients with advanced cancer perceive the effects of home-based caregiving on their bereavement? Fifteen caregivers were retrospectively interviewed twice after the death of their family member. Caregivers reported both positive (e.g., feelings of accomplishment, improved family relationships) and negative (e.g., haunting images, feelings of failure) outcomes that they attributed to having cared for their family member. Overall positive outcomes predominated and bereaved family members reported satisfaction with having provided care for their loved one who had died.

Changes in Attitudes and Practice toward Dying People after Completion of a U.K.-Based Distance Learning Death and Dying Course

K260 is an Open University distance learning course in death and dying that incorporates historical, anthropological, sociological, and psychological approaches to death and dying. The course deals with principles and practices of palliative care, communication with dying people and their families, bereavement and grief, and moral, ethical, and legal issues involved in death and dying. Through a qualitative analysis of respondent written comments regarding how they would respond to a dying person, this study sought to determine how students felt their attitudes and practice had changed as a result of studying this course in terms of how they would respond to a dying person. Six themes emerged that individually and in combination highlight important ways in which respondents perceived their response toward a dying person had altered as a result of completing K260. These themes are awareness, understanding, and insight; individualized care and patient autonomy; self-awareness; ability to communicate emotionally; ability to communicate practically; and practical knowledge and resources developed.

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

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

Caring for the dying: how well prepared are general practitioners? A questionnaire study in Wales

CONTEXT

General practitioners (GPs) and generalist hospital doctors provide the majority of palliative and terminal care in the UK. Studies have revealed problems with symptom control and communication in these settings and inadequate training for clinical students and junior doctors.

OBJECTIVES

To investigate the training of GPs in Wales in palliative medicine throughout their careers, with a focus on the Welsh Valleys, an area of social deprivation and high levels of chronic ill health. To compare these data with those previously obtained from a survey of GPs in East Anglia. To develop regression models that enable the prediction of less well trained medical students and GPs.

METHODS

A postal questionnaire survey of a random sample of GPs, stratified by practice location (Valleys or elsewhere in Wales). Responders were invited to recall their training in five topics of palliative care (pain control, other symptom control, use of syringe drivers, communication skills and bereavement care) during four career stages (clinical students, junior doctors, GP registrars and GP principals).

RESULTS

The response rate was 67.6%. Available data enabled evaluation of generalizability and response bias. Contrary to an initial hypothesis, no significant differences were found between Valleys and non-Valleys responders' reported training, although the study was adequately powered. As medical students, 27% reported receiving no training in any topic, 75% no training in bereavement care and 50% no training in communication skills. Training varied across medical schools and was more common for more recent graduates. As junior doctors, 25% reported no training in any topic, 75% no training in bereavement care and 77% no training in communication skills. The GP registrar year provided significantly more coverage of communication, bereavement and syringe drivers than the combined preceding 6 years of general professional training. As GP principals, a high level of training is reported in all topics. The training experience of GPs in Wales is very similar to that previously reported by GPs in East Anglia: this lends support to the generalizability of these data. Logistic regression analysis indicated that the only predictor of less common training as medical students was having qualified less recently. The main predictors of less common training as GP principals was having become a GP more recently and not being a GP trainer.

CONCLUSIONS

There is still some way to go in ensuring that medical students, junior hospital doctors and GPs are all adequately trained for their important role in caring for dying patients.

Correlates of health status for family caregivers in bereavement

The purpose of this retrospective cohort study was to identify aspects of caregiving associated with health status among family caregivers in bereavement. Study participants included 151 family caregivers of terminally ill patients who had died, on average, 294 days prior to the study telephone interview. The interview covered two main areas: patient characteristics and caregiver characteristics. Multivariate linear regressions revealed that as the age of the care recipient (regression coefficient [b] = -0.32; 95% confidence interval [CI] -0.48,-0.15) and caregiver (b = -0.14; 95% CI = -0.25, -0.02) increased, caregivers experienced a decline in their physical health during bereavement. Furthermore, caregivers who reported that caregiving interrupted their usual activities (b = -5.97; 95% CI = -9.79, -2.15) had a decline in physical health during bereavement. A poorer mental health status during bereavement was seen in caregivers who reported poor physical health during caregiving (b = -4.31; 95% CI = -8.17, -0.45); and that they received insufficient family support in caregiving (b = -6.01; 95% CI = -9.75, -2.27). It was also revealed that a home death was associated with higher mental health of the caregiver (b = 3.55; 95% CI = 0.26, 6.84). The practice implications of these findings are discussed in this paper.

A systematic review of the use of opioids in the management of dyspnoea

BACKGROUND

Opioids are commonly used to treat dyspnoea in palliative medicine but there has been no formal evaluation of the evidence for their effectiveness in the treatment of dyspnoea. A systematic review was therefore carried out to examine this.

METHODS

The criteria for inclusion required that studies were double blind, randomised, placebo controlled trials of opioids for the treatment of dyspnoea secondary to any cause. The methods used to identify suitable studies included electronic searching of the literature, hand searching of the literature, and personal contact with relevant individuals and organisations. Random effects meta-analyses were performed on all included studies and on various subgroups (studies involving nebulised opioids or patients with chronic obstructive pulmonary disease (COPD)). Subgroups were compared using meta-regression. Some studies included in the systematic review could not be included in the meta-analysis because insufficient data were presented.

RESULTS

Eighteen studies fulfilled the criteria for the review. The meta-analysis showed a statistically significant positive effect of opioids on the sensation of breathlessness (p=0.0008). Meta-regression indicated a greater effect for studies using oral or parenteral opioids than for studies using nebulised opioids (p=0.02). The subgroup analysis failed to show a positive effect of nebulised opioids on the sensation of breathlessness. The results of the subgroup analysis of the COPD studies were essentially similar to the results of the main analysis.

CONCLUSION

This review supports the continued use of oral and parenteral opioids to treat dyspnoea in patients with advanced disease. There are insufficient data from the meta-analysis to conclude whether nebulised opioids are effective, but the results from included studies that did not contribute to the meta-analysis suggest that they are no better than nebulised normal saline.

How well do general practitioners deliver palliative care? A systematic review

General practitioners (GPs) deliver the majority of palliative care to patients in the last year of life. This article seeks to examine the nature of GP care, perceptions of the GPs themselves and others of that care, the adequacy of palliative care training, issues relating to accessibility of GPs to palliative care patients, and strategies that may be of use in encouraging more effective delivery of palliative care by GPs. Medline and PubMed databases from 1966 to 2000 were searched, and 135 references identified. Sixty-six of these described studies relevant to GP palliative care. GPs value this part of their work. Most of the time, patients appreciate the contribution the GP makes to palliative care particularly if the GP is accessible, takes time to listen, allows patient and carer to ventilate their feelings, and is seen to be making efforts made regarding symptom relief. However, reports from bereaved relatives suggest that palliative care is performed less well in the community than in other settings. GPs express discomfort about their competence to perform palliative care adequately. They tend to miss symptoms which are not treatable by them, or which are less common. However, with appropriate specialist support and facilities, GPs have been shown to deliver sound and effective care. GP comfort working with specialist teams increases with exposure to this form of patient management, as does the understanding of the potential other team members have in contributing to the care of the patient. Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes, patient satisfaction, improve effective use of resources and improve effective physician behaviour in other areas of medicine. Efforts by specialist services to develop formal involvement of GPs in the care of individual patients, may be an effective method of improving GP palliative care skills and appreciation of the roles specialist services can play.

Differences in assessment of symptoms and quality of life between patients with advanced cancer and their specialist palliative care nurses in a home care setting

This study examined differences in the assessment of symptoms and quality of life (QoL) between patients with advanced cancer living at home and their specialist palliative care nurses. Nurses introduced a recently validated outcome measure, the Palliative Care Outcome Scale (POS), to patients referred to their hospice at their first or second home visit. The POS has two components: a patient questionnaire mirrored almost exactly by a staff questionnaire, which are both completed independently. The POS contains 10 core questions examining aspects of symptom control and QoL. Of the 338 patients referred during the study period, 174 (51%) were eligible for inclusion in the study. Of these, 55 (32%) pairs of patient and nurse questionnaires were returned and suitable for assessment. Not all questionnaires were returned by nurse and patient to form a matched pair. There was good agreement and correlation between patients and nurses in the assessment of pain and symptom control. However, important differences were found in other areas explored including anxiety levels of patients and their families, personal thoughts, practical matters and information received. The study confirms the importance of evaluating the needs, feelings and concerns of patients with advanced cancer cared for at home and highlights both the significance and necessity of the patient's contribution to any such assessment.

Loss of weight and loss of appetite in advanced cancer: a problem for the patient, the carer, or the health professional?

This paper aims to examine the loss of weight and loss of appetite as 'problems' experienced by patients with advanced cancer and those that care for them. It reports the results of a systematic search of the literature and presents the findings as a narrative review. Research to date has focused upon charting the prevalence and incidence of these symptoms, but little empirical work has been conducted to investigate how patients and carers experience these problems. There is some evidence to suggest that anorexia may be more distressing for those caring for the patient than the person suffering from the symptom itself. Understanding the reason for this anguish requires an appreciation of the meaning of food refusal and constitutes the first step towards informing the development of effective interventions. Such exploratory work is mandatory if health professionals wish to move beyond speculation and deliver interventions that provide meaningful benefits for the cancer patient and their family.

Research design in end-of-life research: state of science

PURPOSE

The volume of research on end-of-life care, death, and dying has exploded during the past decade. This article reviews the conceptual and methodological adequacy of end-of-life research to date, focusing on limitations of research to date and ways of improving future research.

DESIGN AND METHODS

A systematic search was conducted to identify the base of end-of-life research. Approximately 400 empirical articles were identified and are the basis of this review.

RESULTS

Although much has been learned from research to date, limitations in the knowledge base are substantial. The most fundamental problems identified are conceptual and include failure to define dying; neglect of the distinctions among quality of life, quality of death, and quality of end-of-life care. Methodologically, the single greatest problem is the lack of longitudinal studies that cover more than the time period immediately before death.

IMPLICATIONS

Gaps in the research base include insufficient attention to psychological and spiritual issues, the prevalence of psychiatric disorder and the effectiveness of the treatment of such disorders among dying persons, provider and health system variables, social and cultural diversity, and the effects of comorbidity on trajectories of dying.

The imPaCT study: a randomised controlled trial to evaluate a hospital palliative care team

A randomised controlled trial was undertaken to assess the effectiveness of a hospital Palliative Care Team (PCT) on physical symptoms and health-related quality of life (HRQoL); patient, family carer and primary care professional reported satisfaction with care; and health service resource use. The full package of advice and support provided by a multidisciplinary specialist PCT ('full-PCT') was compared with limited telephone advice ('telephone-PCT', the control group) in the setting of a teaching hospital trust in the SW of England. The trial recruited 261 out of 684 new inpatient referrals; 175 were allocated to 'full-PCT', 86 to 'telephone-PCT' (2 : 1 randomisation); with 191 (73%) being assessed at 1 week. There were highly significant improvements in symptoms, HRQoL, mood and 'emotional bother' in 'full-PCT' at 1 week, maintained over the 4-week follow-up. A smaller effect was seen in 'telephone-PCT'; there were no significant differences between the groups. Satisfaction with care in both groups was high and there was no significant difference between them. These data reflect a high standard of care of patients dying of cancer and other chronic diseases in an acute hospital environment, but do not demonstrate a difference between the two models of service delivery of specialist palliative care.

Successful Pain Management for the Recovering Addicted Patient

Successful pain management in the recovering addict provides primary care physicians with unique challenges. Pain control can be achieved in these individuals if physicians follow basic guidelines such as those put forward by the Joint Commission on Accreditation of Healthcare Organizations in their standards for pain management as well as by the World Health Organization in their stepladder approach to pain treatment. Legal concerns with using pain medications in addicted patients can be dealt with by clear documentation of indication for the medication, dose, dosing interval, and amount provided. Terms physicians need to be familiar with include physical dependence, tolerance, substance abuse, and active versus recovering addiction. Treatment is unique for 3 different types of pain: acute, chronic, and end of life. Acute pain is treated in a similar fashion for all patients regardless of addiction history. However, follow-up is important to prevent relapse. The goal of chronic pain treatment in addicted patients is the same as individuals without addictive disorders-to maximize functional level while providing pain relief. However, to minimize abuse potential, it is important to have 1 physician provide all pain medication prescriptions as well as reduce the opioid dose to a minimum effective dose, be aware of tolerance potential, wean periodically to reassess pain control, and use nonpsychotropic pain medications when possible. Patients who are at the end of their life need to receive aggressive management of pain regardless of addiction history. This management includes developing a therapeutic relationship with patients and their families so that pain medications can be used without abuse concerns. By following these strategies, physicians can successfully provide adequate pain control for individuals with histories of addiction.

Family satisfaction with end-of-life care for cancer patients in a cluster randomized trial

The main aim of this study was to examine similarities and differences in satisfaction with care between 112 family members who were close to patients who had participated in an intervention with a comprehensive palliative care program and the 68 family members in a conventional care program (controls). The FAMCARE Scale measured satisfaction with care at one month after the time of death. The majority of respondents reported high satisfaction with care. The respondents related to the patients in the intervention group reported significantly higher satisfaction with care than the respondents related to the patients in the control group. This difference remained unchanged after controlling for a range of other relevant factors: relationship to the deceased, sex and age of the respondent, sex and age of the patient, time since inclusion in the study, and place of death.

Community specialist palliative care: experiences of patients and carers

Specialist palliative care provides a range of services for patients and their carers who have complex needs. There is a need to identify what patients and carers gain from contact with the specialist palliative care nurse (SPCN) and what aspects of that care have a positive impact on their quality of life (QoL). The aims of the study were to gain insightful and credible accounts of participants' experiences of the SPCN; to consider those dimensions of care which impact on satisfaction; to discover whether the SPCN provides improvements in QoL and to explore whether experiences match expectations. A qualitative approach focused on the experience and individual meaning; it is the individual narratives produced by each participant that are the rich and interesting outcomes of this study. Both patients and carers reported satisfaction at being given time and being listened to, with the interviewees using words and phrases such as 'confidence', 'trust', knowledge', 'listens to' and 'a sense of being there'. The study shows the patient and carers' lack of knowledge about specialist palliative care while confirming the positive influence of the SPCN.

The unrecognised cost of cancer patients' unrelieved symptoms:a nationwide follow-up of their surviving partners

We investigated if a cancer patient's unrelieved symptoms during the last 3 months of life increase the risk of long-term psychological morbidity of the surviving partner. All women (n=506) living in Sweden under 80 years of age, who lost their husband/partner owing to cancer of the prostate in 1996 or of the urinary bladder in 1995 or 1996 were asked to answer an anonymous postal questionnaire, 2-4 years after their loss. The widows' psychological morbidity was associated with the patient's unrelieved mental symptoms. When the patient was perceived to have been very anxious during last three months of life (compared to no observed symptoms) the relative risks for the widows' psychological morbidity were: 2.5 (1.4-4.3) for depression and 3.4 (1.4-8.2) for anxiety. When comparing reports of the patient's pain (much vs no), the relative risks were 0.8 (0.5-1.2) for widowhood depression, and 0.8 (0.4-1.7) for widowhood anxiety. The patients were found to have had adequate access to physical pain control but poor access to psychological symptom control. Efficiency in diagnosing and treating psychological complications of terminally ill cancer patients may not only improve their quality of life but possibly also prevent long-term psychological morbidity of their surviving partners.

Controlling cancer pain in primary care: the prescribing habits and knowledge base of general practitioners

During recent years, the national policy of the United Kingdom has increasingly recognized the central place of general practitioners (GPs) in the care of cancer patients, from screening and early diagnosis through to palliative care and bereavement. There are, however, continuing reports of poor control of pain and other symptoms in the community. To investigate general practitioners' prescribing habits and knowledge of some key pain control issues in advanced cancer, a postal questionnaire surveyed a random sample of 450 East Anglian GPs. The response rate was 73.3%. Most respondents were familiar with the modern management of cancer pain, including the World Health Organization approach, the use of oral opioids, and the management of bone pain. There was less awareness of the drug options available for more uncommon situations, especially the dose conversion of oral morphine to subcutaneous diamorphine and drugs that may be used in syringe drivers. GPs in the UK are familiar with the management of the more common pain control problems. However, it is not appropriate to expect GPs to know the details of management of more unusual cancer pain problems. Specialist clinicians need to make themselves readily available to advise their generalist colleagues. The educational implications for GPs are discussed.

Developing an integrated care pathway to manage cancer pain across primary, secondary and tertiary care

Throughout the palliative care journey, the patient encounters many different health professionals in a variety of settings so good channels of communication between these professionals is a prerequisite for successful continuity of care (Scottish Partnership Agency for Palliative and Cancer Care (SPA), 1994). Pain control has also long been documented as being ineffective and it has been indicated that pain affects up to 88% of cancer patients in the last year of their life (Addington-Hall and McCarthy, 1995). In order to attempt to resolve these important issues, a joint project was established between primary, secondary and tertiary care in the south sector of Glasgow to establish an integrated care pathway (ICP) for the management of chronic cancer pain. This article discusses how the joint project was successfully established, was instrumental in breaking down existing barriers across the traditional boundaries and developed a uniform system of assessing and managing chronic cancer pain with ICP documentation held in a patient-held record.

The Cavendish Centre for integrated cancer care: assessment of patients' needs and responses

The use of complementary therapies in combination with conventional medicine is increasing. In cancer care, as at the Cavendish Centre for Cancer Care in Sheffield, the range of therapies offered can include aromatherapy, massage, reflexology, shiatsu, acupuncture, homeopathy, counselling, visualization, hypnotherapy, relaxation, healing and art therapy. Before offering any therapy careful assessment of patients' needs is important as patients seeking complementary therapies may present with unrealistic hopes and expectations of benefit. There are wide variations in provision of services offering complementary cancer care throughout the United Kingdom but few offer a comprehensive assessment which is used as a baseline for both planning treatment and evaluating its outcome and which is conducted by a trained and objective practitioner who has no investment in any specific therapy. We describe the model of care developed at the Cavendish Centre with particular emphasis on the assessment process. Our model of assessment provides an opportunity for patients to tell their story, make sense of the illness experience, construct meaning from it and set realistic expectations for the chosen intervention. It also offers patients involvement and choice in decisions about their care. In addition we present evaluative data from a case series of 157 patients, 138 of whom (88%) reported improvement in their main concern on MYMOP (Measure Your Medical Outcome Profile).

Nurses' attitudes to palliative care in nursing homes in Western Australia

Nursing homes are one of the care settings in Western Australia where older people may spend their final years. Residents should be able to receive palliative care where appropriate, but this type of care is not always available at some nursing homes in the state. This study investigated nurses' attitudes to palliative care in nursing homes by examining their cognitive, affective and behavioural information. A sample of 228 nurses working in nursing homes completed a questionnaire, using a free response methodology. Results showed that participants had either a positive or negative attitude to palliative care. Cognitive and affective information significantly and independently predicted the attitudes of nurse, whereas knowledge of palliative care did not contribute significantly to these attitudes. Nurses currently working in palliative care were more positively disposed towards such care, but this disappeared when they ceased working in the area. There is an emphasis on education in the literature which does not take into account the beliefs and emotions of the nurse. Therefore, there is a need to consider these in undergraduate and postgraduate training for nurses. Current experience is also important in palliative care education. The results obtained from nurses in this study should be incorporated into policy for introducing palliative care into nursing homes and used to provide support and assistance to nurses working in this field.