Family Caregiving in Advanced Chronic Organ Failure

Self-Assessment Instruments for Supporting Family Caregivers: An Integrative Review

Family caregivers take on a variety of tasks when caring for relatives in need of care. Depending on the situation and the intensity of care, they may experience multidimensional burdens, such as physical, psychological, social, or financial stress. The aim of the present study was to identify and appraise self-assessment instruments (SAIs) that capture the dimensions of family caregivers' burdens and that support family caregivers in easily identifying their caregiving role, activities, burden, and needs. We performed an integrative review with a broad-based strategy. A literature search was conducted on PubMed, Google Scholar, Google, and mobile app stores in March 2020. After screening the records based on the eligibility criteria, we appraised the tools we found for their usefulness for family care and nursing practice. From a total of 2654 hits, 45 suitable SAIs from 274 records were identified and analyzed in this way. Finally, nine SAIs were identified and analyzed in detail based on further criteria such as their psychometric properties, advantages, and disadvantages. They are presented in multi-page vignettes with additional information for healthcare professionals. These SAIs have proven useful in assessing the dimensions of caregiver burden and can be recommended for application in family care and nursing practice.

What factors are associated with informal carers' psychological morbidity during end-of-life home care? A systematic review and thematic synthesis of observational quantitative studies

Background

Family carers are central in supporting patients nearing end of life. As a consequence, they often suffer detrimental impacts on their own mental health. Understanding what factors may affect carers' mental health is important in developing strategies to maintain their psychological well-being during caregiving.

Aim

To conduct a systematic review and thematic evidence synthesis of factors related to carers' mental health during end-of-life caregiving.

Method

Searches of MEDLINE, CINAHL, PsychINFO, Social Sciences Citation Index, EMBASE, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effects 1 January 2009-24 November 2019. We included observational quantitative studies focusing on adult informal/family carers for adult patients at end of life cared for at home considering any factor related to carer mental health (anxiety, depression, distress and quality of life) pre-bereavement. Newcastle-Ottawa Quality Assessment Scale was used. Thematic analysis with box score presentation, and meta-analysis were done where data permitted.

Results

Findings from 63 included studies underpinned seven emergent themes. Patient condition (31 studies): worse patient psychological symptoms and quality of life were generally associated with worse carer mental health. Patient depression was associated with higher depression in carers (standardised mean difference = 0.59, 95% confidence interval 0.32 to 0.87, I2 = 77%). Patients' other symptoms and functional impairment may relate to carer mental health, but findings were unclear. Impact of caring responsibilities (14 studies): impact on carers' lives, task difficulty and general burden had clear associations with worse carer mental health. Relationships (8 studies): family dynamics and the quality of the carer-patient relationship may be important for carer mental health and are worthy of further investigation. Finance (6 studies): insufficient resources may relate to carers' mental health and warrant further study. Carers' psychological processes (13 studies): self-efficacy and preparedness were related to better mental health. However, findings regarding coping strategies were mixed. Support (18 studies): informal support given by family and friends may relate to better carer mental health, but evidence on formal support is limited. Having unmet needs was related to worse mental health, while satisfaction with care was related to better mental health. Contextual factors (16 studies): older age was generally associated with better carer mental health and being female was associated with worse mental health.

Limitations

Studies were mainly cross-sectional (56) rather than longitudinal (7) which raises questions about the likely causal direction of relationships. One-third of studies had samples < 100, so many had limited statistical power to identify existing relationships.

Conclusions and future work

Future work must adopt a comprehensive approach to improving carers' mental health because factors relating to carer mental health cover a broad spectrum. The literature on this topic is diverse and difficult to summarise, and the field would benefit from a clearer direction of enquiry guided by explanatory models. Future research should (1) further investigate quality of relationships and finances; (2) better define factors under investigation; (3) establish, through quantitative causal analyses, why factors might relate to mental health; and (4) utilise longitudinal designs more to aid understanding of likely causal direction of associations.

Study registration

This study is registered as PROSPERO registration 2019 CRD42019130279 at https://www.crd.york.ac.uk/prospero/.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme HSDR 18/01/01 and is published in full in Health and Social Care Delivery Research. See the NIHR Funding and Awards website for further award information.

Burden, depression and fatigue in caregivers of lung transplantation candidates

Objective: A great deal of social support is often provided by the caregiver of the patient. The purpose of this study is to evaluate the burden, fatigue and depression of the primary caregiver of patients with pulmonary transplantation candidates. Patients and Method: The primary caregivers of patients who were admitted to our hospital’s pulmonary transplant outpatient clinic with end-stage pulmonary disease and no definite contraindications for transplantation, were included in the study. Zarit Burden Scale, Beck Depression Inventory and Short-Form (SF)-36 – Vitality questionnaires were applied to participants. Results: Thirty-nine patients and their caregivers were evaluated. Caregivers experienced low levels of depression. Mean score for Beck Depression Inventory was 12.7±10.1. Caregivers generally experienced medium levels of burden. Mean score for Zarit Burden Scale was 26.9±14.2. Majority of caregivers experienced clinically significant fatigue. Mean score for SF-36 – Vitality was 61±16.7. Zarit Burden Scale scores and Beck Depression Inventory scores showed a statistically significant positive correlation (r:0.962 p

Feasibility of telepsychology support for patients with advanced cardiorespiratory diseases and their caregivers

Objective

The aim of this study was to test the feasibility of telepsychology support for patients with severe cardiorespiratory disease and their caregivers. A secondary objective was to explore pre-post relationships between patients' and caregivers' clinical measures.

Methods

A telehealth program incorporating telepsychology support, i.e., an “on-demand” phone service with a psychologist, was provided to consecutive cardiorespiratory patients at discharge from inpatient rehabilitation and to their caregivers. At the start and end of the 1-year program, participants were interviewed “face-to-face,” and their anxiety/depression level, patients' quality of life (MRF-28, SF-36, and MQOL), and caregivers' (n = 18) family strain (FSQ) and needs (CNA) were assessed: we analyzed the correlations and evaluated customer satisfaction.

Results

Of 80 eligible individuals, 40 took part in this study: 22 patients (FVC = 39 ± 14%; EF = 39 ± 13%) and 18 caregivers. Eleven (28%, 6 patients and 5 caregivers) requested tele-psychological support, resulting in 51 consultations focused on anxiety, difficulty in patient management, worry about the patient's emotional state, and need for emotional support; 3 participants underwent a tailored psychotherapy program. All participants expressed high satisfaction with the service. At enrolment, anxiety was less evident in patients (73% men) than in caregivers, while depressive symptoms were more evident (6.5 ± 3.1), and correlated with MRF-28 and MQOL. Caregivers' (94% women) FSQ showed a “strongly recommended” need for support; at enrolment, high levels of anxiety/depression were correlated with high FSQ (for both, p < 0.05); depressive symptoms correlated negatively with age (p = 0.025) and positively with emotional needs (p = 0.025); anxiety was positively correlated with education level (p = 0.048). At follow-up, patients' perception of support (n = 13/22) tended to increase (p = 0.089), while caregivers' strain (n = 10/18) tended to decline (to within the “range of attention”). At enrolment, caregivers' anxiety/depression and strain correlated with patients' quality of life (for both; p < 0.05). At follow-up, caregivers' strain correlated with patients' quality of life (p = 0.028) and cognitive performance (p = 0.048).

Conclusion

Telepsychology support associated with a telehealth service is feasible and satisfying for both participants and psychological management. A suitable support program can benefit both patients and caregivers, particularly those at higher risk of depressive symptoms (younger caregivers) and anxiety (all caregivers).

Instruments to assess the burden of care for family caregivers of adult palliative care patients

BACKGROUND

A primary caregiver shares the illness experience of the patient and undertakes vital care work, alongside managing the patient's emotions, and is actively involved in care process without being paid. When faced with the palliative care patient's needs, caregivers are affected on multiple levels (physical, psychological and socio-economic), thereby experiencing a moderate or severe burden of care.

AIM

To identify assessment instruments for the burden of care for family caregivers that are suitable to be used in clinical practice.

METHOD

A narrative review was conducted using an electronic search in Pubmed, PsychINFO, CINAHL of articles published in English between 2009-2019, using the search terms: 'caregiver/family, caregiver/carer and burden and palliative care/hospice/end of life'. An assessment grid was developed to appraise the clinical use of identified instruments.

RESULTS

Of the 568 articles identified, 40 quantitative studies were selected using 31 instruments to measure the caregiver burden of cancer, noncancer and terminally ill patients. Most instruments 23 (74.11%) evaluate the psycho-emotional and, 22 (70.96%) the social domain, 12 instruments (38.7%) focused on the physical domain, three (9.67%) on the spiritual field and six instruments (19.35%) on economic aspects. For the multidimensional instruments, the assessment grid scored highest for the Burden Scale for Family Caregiver (BSFC).

CONCLUSION

The BSFC is the tool that seems to meet the most requirements, being potentially the most useful tool in clinical practice.

The Role of Palliative Care in COPD

Chronic obstructive pulmonary disease is a highly symptomatic disease that may lead to significant morbidity. Even with optimal therapy, the patient's quality of life can be severely affected. These symptoms include dyspnea, anxiety, depression, and malnourishment. Palliative care is a branch of medicine that specializes in the care of patients with a terminal illness no matter what stage of the disease they are in. It implements a family-centered approach to help patients deal with their symptoms. It also helps with shared decision-making and advanced care planning.

Family members' experiences and expectations of self-management counseling while caring for a person with chronic obstructive pulmonary disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to identify and synthesize existing evidence on the experiences and expectations of self-management counseling of adult family members who are informal caregivers of a person with chronic obstructive pulmonary disease (COPD) in the context of inpatient or outpatient care.

INTRODUCTION

Chronic obstructive pulmonary disease is the fourth leading cause of mortality and morbidity worldwide. It is a progressive, lifelong and unpredictable disease. As the disease progresses, both the people with COPD and their family members require information and practical skills to manage the disease. The role of family members is particularly important at the advanced stage of COPD. This systematic review examined family members' experiences and expectations of self-management counseling.

INCLUSION CRITERIA

This review considered qualitative studies that investigated adult (older than18 years) family members' experiences or expectations of COPD self-management counseling in the context of inpatient or outpatient care. "Family member" refers to a person who is an informal caregiver because of his or her relationship to the person with COPD.

METHODS

A three-step search strategy was utilized in this review. The search strategy aimed to find published and unpublished studies in English and Finnish. The databases MEDLINE, CINAHL, PsycINFO, Scopus and the Finnish medical bibliographic database, Medic, were searched. The search was conducted in December 2015 and updated in September 2018. Titles and abstracts were screened by two independent reviewers for the review's inclusion criteria. Eligible studies were then critically appraised by two independent reviewers for methodological quality. The findings and illustrations of the findings were extracted and assigned a level of credibility. The qualitative research findings were pooled using the JBI method of meta-aggregation.

RESULTS

Ten papers were selected for inclusion in this review. These studies were published from 2002 to 2017. The quality of all included studies was at least moderate. Each study had a total score between 7 and 10 on the JBI Critical Appraisal Checklist for Qualitative Research. The following four synthesized findings were aggregated from nine categories and 39 study findings: i) Family members' experiences with unresponsive behavior from health professionals, ii) Family members' experiences of unmet needs in self-management counseling, iii) Family members' information needs concerning COPD management, and iv) Family members' information needs concerning coping strategies.

CONCLUSIONS

The synthesized findings indicate that family members are frustrated by the shortcomings of self-management counseling. They also feel unprepared for and uncertain about their caring role. They need more information about COPD and coping strategies for COPD. Counseling is essential to high-quality care and should be offered to family members caring for a loved one at any stage of COPD.

Emotional Burden and Perceived Social Support in Male Partners of Women with Cancer

Background: The aim of this study was to describe the correlations between the psychosocial burden on male caregivers and their perception of social support, as well as distress, anxiety, and depression among their partners in the first six months after a cancer diagnosis. Methods: A cross-sectional, longitudinal and observational study was conducted on a group of 61 couples, with the use of Zarit Burden Interview (ZBI), Caregiver Burden Scale (CBS), Berlín Social Support Scales (BSSS), Hospital Anxiety and Depression Scale (HADS) and Distress Thermometer (DT). Statistical analysis was performed using Statistica v.13. Results: A strong positive correlation between the ZBI and CBS, as well as between support-seeking and the emotional involvement of male partners, was documented. The negative correlation between the lack of instrumental support and a much greater burden on caregivers, in emotional, social, and family life was documented. The level of distress, anxiety, and depression, as well as family problems reported by female patients, were positively correlated with the male caregiver′s burden. A demographic analysis showed significant relationships between the number of offspring and the negative health indicators of patients and their partners. Implications: The obtained results encourage deeper reflection on the need to improve the availability of instrumental support for male caregivers and support for families with an oncological ill parent in caring for minor children, and to maintain the social activity of the caregiver.

Describing the psychosocial profile and unmet support needs of parents caring for a child with a life-limiting condition: A cross-sectional study of caregiver-reported outcomes

BACKGROUND

There is a lack of studies examining the prevalence and severity of psychosocial distress in parents caring for a child with life-limiting condition. More research is also needed to better understand the experience, support needs and quality-of-life of this population.

AIM

To describe the experience and support needs of caring for children with life-limiting conditions and examine the level of distress and quality-of-life experienced by parents.

DESIGN

Cross-sectional, prospective, quantitative study guided by an advisory group. Participants completed a survey that included demographics and self-report outcome measures of unmet support needs, appraisal of caregiving, psychological distress and quality-of-life. Bivariate correlation analyses were performed to examine for associations between measures.

SETTING/PARTICIPANTS

Parents currently caring for one or more children (⩽18 years) with a life-limiting condition and registered with a paediatric palliative care service (Australia).

RESULTS

In total, 143 parents (88% female) completed the questionnaire (36% RR). Compared with population norms, participants reported low quality-of-life, high carer burden and high psychological distress. Almost half (47%) of the sample met the criteria for one or more diagnoses of clinically elevated stress, anxiety or depression. There were significant associations between the psychosocial outcome variables; carer strain and depression had the strongest correlations with quality-of-life (r = -.63, p < .001, for both). Participants also reported multiple unmet needs related to emotional and practical support.

CONCLUSIONS

This study contributes to the growing body of evidence on paediatric palliative care, specifically that parents caring for a child with a life-limiting condition report high levels of distress and burden, low quality-of-life and need more emotional and practical support targeted at their unmet needs. Paediatric palliative care services should routinely assess parent mental health and provide appropriate support.

"I Don't Feel Like I Have Any Control of My Life at All . . . Everything Overwhelms Me. Everything": Analyzing Caregiver Uncertainty and Control Through Stance Marking

Informal caregivers immersed in the daily care of loved ones at end-of-life stages face such challenges as medical and household issues, worries, doubts, and uncertainties. Using a macro-mezzo-micro approach to discourse, we analyzed parent study interview data involving 46 caregivers facing end-of-life realities. At the mezzo level, we examined caregivers' expressed perceptions of control. We then more finely analyzed discursive expressions of affective stances pertaining to caregivers' emotions and feelings, and epistemic stances pertaining to their knowledge and belief states. Theories of uncertainty and control inextricably interweave areas of cognition, affect, and behavior regarding how caregivers perceive their realities and how they engage in or disengage from coping mechanisms in the process. The findings in this three-tiered approach make salient specific discursive patterns gleaned from systematic and fastidious attention to caregivers' own ways of using language that methodically afford deeper entry into the emotional, physical, and cognitive challenges in their everyday lived experiences.

Suspended Life Pattern: A Qualitative Study on Personal Life Among Family Caregivers of Hemodialysis Patients in Iran

Purpose To determine the personal life of family caregivers of patients undergoing hemodialysis. Methodology In this qualitative study, individual semistructured interviews were carried out with 19 caregivers of hemodialysis patients. All interviews were recorded, typed, and imported into the Open Code Software. The Graneheim and Lundman's content analysis approach was used for the analysis. Findings The theme of this study was suspended life pattern that was extracted from two categories of "Imbalance between caregiving and life" and "ambiguity in life status." The category of "Imbalance between caregiving and life" included some subcategories including compulsive compliance, suspension, and deferral of roles, conflicts between leisure time and caregiving and caregivers' time limits. Moreover, the category "ambiguity in life" was extracted from two subcategories of fear and hope and life satisfaction depending on care recipients' condition. Conclusion Caring for hemodialysis patients leads to instability and ambiguity in a caregiver's personal life. Therefore, authorities, policymakers, and health-care providers should pay more attention to support these people.

Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease

People with advanced chronic obstructive pulmonary disease (COPD) have distressing physical and psychological symptoms, often have limited understanding of their disease, and infrequently discuss end-of-life issues in routine clinical care. These are strong indicators for expert multidisciplinary palliative care, which incorporates assessment and management of symptoms and concerns, patient and caregiver education, and sensitive communication to elicit preferences for care towards the end of life. The unpredictable course of COPD and the difficulty of predicting survival are barriers to timely referral and receipt of palliative care. Early integration of palliative care with respiratory, primary care, and rehabilitation services, with referral on the basis of the complexity of symptoms and concerns, rather than prognosis, can improve patient and caregiver outcomes. Models of integrated working in COPD could include: services triggered by troublesome symptoms such as refractory breathlessness; short-term palliative care; and, in settings with limited access to palliative care, consultation only in specific circumstances or for the most complex patients.

Impacts of COPD on family carers and supportive interventions: a narrative review

Caring for a relative with chronic disease influences multiple dimensions of family carers' lives. This study aimed to provide an overview of the impacts of chronic obstructive pulmonary disease (COPD) on family carers and identify interventions aimed at supporting them. A narrative review was conducted. Searches were performed in electronic databases using a combination of keywords. Articles were screened for relevance and selected articles were analysed in two groups considering the study aims. Eighteen articles were selected. Fifteen studies evaluated the impacts of COPD on family carers and three studies presented interventions aimed at supporting them. Carers reported negative impacts of caring on physical health, emotional, social, relational and financial/employment life dimensions. Positive aspects of care-giving were reported in four studies and were related to carers' personal growth and satisfaction in being able to do something useful for their relatives. The existing interventions were directed at both patients and carers; however, studies provided limited information on how carers were involved, hindering the interpretation of findings. In conclusion, COPD poses several unique challenges to family carers related to the specificities of the disease. Further research with appropriate intervention studies is needed to promote carers' healthy adjustment to the disease.

Palliative care outcome measures in COPD patients: a conceptual review

In chronic obstructive pulmonary disease (COPD), palliative care is appropriate in very advanced stages based on recognition of its need when conventional therapy is no longer able to control symptoms, disease morbidity, or to improve/maintain an acceptable quality of life. Palliative care aims to improve quality of life, or, if applied specifically at the end-of-life, to ensure comfortable care. In COPD palliative care effectiveness of interventions should be quantified with outcome measures able to better capture the holistic nature of approaches and not only the specific features of disease. These should include: physical outcomes, psychological outcomes, social outcomes, spiritual outcomes. Such measures are discussed in this review along with arguments supporting their use.

Psychometric properties of carer-reported outcome measures in palliative care: A systematic review

BACKGROUND

Informal carers face many challenges in caring for patients with palliative care needs. Selecting suitable valid and reliable outcome measures to determine the impact of caring and carers' outcomes is a common problem.

AIM

To identify outcome measures used for informal carers looking after patients with palliative care needs, and to evaluate the measures' psychometric properties.

DESIGN

A systematic review was conducted. The studies identified were evaluated by independent reviewers (C.T.J.M., M.B., M.P.). Data regarding study characteristics and psychometric properties of the measures were extracted and evaluated. Good psychometric properties indicate a high-quality measure.

DATA SOURCES

The search was conducted, unrestricted to publication year, in the following electronic databases: Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, EMBASE, PubMed, PsycINFO, Social Sciences Citation Index and Sociological Abstracts.

RESULTS

Our systematic search revealed 4505 potential relevant studies, of which 112 studies met the inclusion criteria using 38 carer measures for informal carers of patients with palliative care needs. Psychometric properties were reported in only 46% (n = 52) of the studies, in relation to 24 measures. Where psychometric data were reported, the focus was mainly on internal consistency (n = 45, 87%), construct validity (n = 27, 52%) and/or reliability (n = 14, 27%). Of these, 24 measures, only four (17%) had been formally validated in informal carers in palliative care.

CONCLUSION

A broad range of outcome measures have been used for informal carers of patients with palliative care needs. Little formal psychometric testing has been undertaken. Furthermore, development and refinement of measures in this field is required.

Enhanced Psychosocial Support for Caregiver Burden for Patients With Chronic Kidney Failure Choosing Not to Be Treated by Dialysis or Transplantation: A Pilot Randomized Controlled Trial

BACKGROUND

Family caregivers of patients with chronic kidney failure have increased burden, as reflected by their high frequency of physical and mental disturbances. The impact of enhanced psychosocial support to caregivers of patients with chronic kidney failure remains unclear.

STUDY DESIGN

Open-label randomized controlled trial.

SETTING & PARTICIPANTS

All new patients referred to the renal palliative clinic were screened. Caregivers of patients who met the following criteria were recruited: (1) chronic kidney failure as defined by creatinine clearance < 15 mL/min, (2) opted for conservative management by nephrology team or patient, (3) never treated with dialysis or transplantation, and (4) able to provide informed consent.

INTERVENTIONS

Random assignment to treatment with enhanced psychosocial support or standard renal care (control). Enhanced psychosocial support included counseling and psychosocial interventions by an on-site palliative care nurse and designated social worker. Each caregiver was followed up at 2- to 4-week intervals for up to 6 months.

OUTCOMES

Zarit Burden Inventory (ZBI) and Hospital Anxiety and Depression Scale (HADS) in caregivers and McGill Quality of Life scores in patients of both groups were compared.

RESULTS

29 pairs of family caregivers/patients with chronic kidney failure were randomly assigned (intervention, n=14; control, n=15). Mean ages of patients and caregivers were 81.6 ± 5.1 and 59.8 ± 14.2 (SD) years, respectively. The intervention group showed significantly lower ZBI scores than the control group at 1 and 3 months (22.0 ± 5.3 vs 31.6 ± 9.5 and 21.3 ± 6.6 vs 33.4 ± 7.2; P=0.006 and P=0.009, respectively). HADS anxiety scores of caregivers who received the intervention were significantly lower than those of controls at 1 and 3 months (7.1 ± 3.2 vs 10.1 ± 2.2 and 6.5 ± 4.5 vs 11.0 ± 3.1; P=0.01 and P=0.03, respectively). Insignificant reductions in ZBI and HADS scores were found at 6 months. 19 patients died (intervention, n=10; control, n=9) during the study period.

LIMITATIONS

The study is limited by a relatively small sample size and short duration.

CONCLUSIONS

Enhanced psychosocial support program in patients with chronic kidney failure and caregivers resulted in an early significant reduction in caregiver burden and anxiety.

Informal caregivers of patients with COPD: Home Sweet Home?

The burden of chronic obstructive pulmonary disease (COPD) on society is increasing. Healthcare systems should support patients with COPD in achieving an optimal quality of life, while limiting the costs of care. As a consequence, a shift from hospital care to home care seems inevitable. Therefore, patients will have to rely to a greater extent on informal caregivers. Patients with COPD as well as their informal caregivers are confronted with multiple limitations in activities of daily living. The presence of an informal caregiver is important to provide practical help and emotional support. However, caregivers can be overprotective, which can make patients more dependent. Informal caregiving may lead to symptoms of anxiety, depression, social isolation and a changed relationship with the patient. The caregivers' subjective burden is a major determinant of the impact of caregiving. Therefore, the caregiver's perception of the patient's health is an important factor. This article reviews the current knowledge about these informal caregivers of patients with COPD, the impact of COPD on their lives and their perception of the patient's health status.

Patient-Clinician Communication About End-of-Life Care in Patients With Advanced Chronic Organ Failure During One Year

CONTEXT

Patient-clinician communication is an important prerequisite to delivering high-quality end-of-life care. However, discussions about end-of-life care are uncommon in patients with advanced chronic organ failure.

OBJECTIVES

The aim was to examine the quality of end-of-life care communication during one year follow-up of patients with advanced chronic organ failure. In addition, we aimed to explore whether and to what extent quality of communication about end-of-life care changes toward the end of life and whether end-of-life care communication is related to patient-perceived quality of medical care.

METHODS

Clinically stable outpatients (n = 265) with advanced chronic obstructive pulmonary disease, chronic heart failure, or chronic renal failure were visited at home at baseline and four, eight, and 12 months after baseline to assess quality of end-of-life care communication (Quality of Communication questionnaire). Two years after baseline, survival status was assessed, and if patients died during the study period, a bereavement interview was done with the closest relative.

RESULTS

One year follow-up was completed by 77.7% of the patients. Quality of end-of-life care communication was rated low at baseline and did not change over one year. Quality of end-of-life care communication was comparable for patients who completed two year follow-up and patients who died during the study. The correlation between quality of end-of-life care communication and satisfaction with medical treatment was weak.

CONCLUSION

End-of-life care communication is poor in patients with chronic organ failure and does not change toward the end of life. Future studies should develop an intervention aiming at initiating high-quality end-of-life care communication between patients with advanced chronic organ failure and their clinicians.

An observational, longitudinal study on the home environment of people with chronic obstructive pulmonary disease: the research protocol of the Home Sweet Home study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) represents an important public health challenge. Patients are confronted with limitations during activities of daily living (ADLs). Resident loved ones of patients with COPD may be uniquely positioned to witness these limitations. COPD may have an impact on not only the patients' life, but also on the lives of the resident loved ones. Furthermore, COPD exacerbation-related hospital admissions often occur in patients with COPD. However, whether and to what extent these admissions influence resident loved ones' burden and health status remains currently unknown. Therefore, the primary objectives of this study are to investigate the differences between patients with COPD and resident loved ones' perceptions of patients' health status and problematic ADLs and to study prospectively the effects of a COPD exacerbation on resident loved ones' perceptions of patients' health status and problematic ADLs.

METHODS AND ANALYSIS

An observational, longitudinal study will be performed in 192 patients with COPD and their 192 resident loved ones. Primary outcomes are daily functioning, ADL, disease-specific health status, generic health status and dyspnoea. These will be assessed during home visits at baseline and after 12 months. Additional home visits will be performed when a COPD exacerbation-related hospital admission occurs during the 12-month follow-up period.

ETHICS AND DISSEMINATION

This protocol was approved by the Medical Ethics Committee of the Catharina Hospital Eindhoven, the Netherlands (NL42721.060.12/M12-1280) and is registered in the Dutch Trial Register (NTR3941).

Caring for relatives with chronic obstructive pulmonary disease: how does the disease severity impact on family carers?

OBJECTIVES

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of disability, morbidity and mortality in old age, representing a significant burden for families. However, information on the impacts of caring for relatives with COPD on carers' psychological health is limited. This study aimed to analyse the subjective burden of family carers of people with early and advanced COPD and its predictor variables.

METHODS

A cross-sectional study was conducted. A structured questionnaire was used to collect socio-demographics and care-giving characteristics. Self-rated physical and mental health were measured by two items from the International Classification of Functioning, Disability and Health checklist. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression. Subjective burden was assessed with the Carers' Assessment of Difficulties Index (CADI). Descriptive and inferential analyses were performed.

RESULTS

A total of 167 family carers participated: 113 were caring for people with early and 54 with advanced COPD. Both groups presented anxiety/depression symptoms. Those caring for people with advanced COPD reported higher subjective burden, more depression symptoms and poorer self-rated mental health than those caring for early COPD. Advanced COPD (coefficient 6.7), depression (coefficient 6.3), anxiety (coefficient 5.6), care-giving hours per week (coefficient 3.2) and self-rated mental health (coefficient 2.8) were significant predictors of carers' subjective burden.

CONCLUSION

The findings suggest that the gradual course of COPD imposes an increasing physical and emotional burden on carers, with negative impacts on their psychological health. The study highlights the relevance of early interventions in the context of COPD to prevent carers' burden.

Self-management in patients with COPD: theoretical context, content, outcomes, and integration into clinical care

In this narrative review, we put self-management in the context of a 50-year history of research about how patients with COPD respond to their illness. We review a definition of self-management, and emphasize that self-management should be combined with disease management and the chronic care model in order to be effective. Reviewing the empirical status of self-management in COPD, we conclude that self-management is part and parcel of modern, patient-oriented biopsychosocial care. In pulmonary rehabilitation programs, self-management is instrumental in improving patients' functional status and quality of life. We conclude by emphasizing how studying the way persons with COPD make sense of their illness helps in refining self-management, and thereby patient-reported outcomes in COPD.

Quality of Life in Chronic Obstructive Pulmonary Disease: An Evolutionary Concept Analysis

AIM

To explore the concept of quality of life (QoL) of people with chronic obstructive pulmonary disease (COPD) in the nursing context.

BACKGROUND

The issue of QoL takes on a leading role in the COPD field because it is an incurable pathology. Despite its relevance, this concept is quite ambiguous, and there is no consensus of opinion in the literature regarding its definition.

DESIGN AND METHODS

Rodgers' method of evolutionary concept analysis was employed to delineate and clarify the concept of QoL in COPD. An electronic review was made on scientific databases from 2008 to 2013. The 75 selected articles were analyzed in order to highlight the main themes related to QoL concept.

RESULTS

The QoL appears as a dynamic and multidimensional concept that evolves with the progression of the pathology and the impairment of health status. It has both subjective and objective characteristics, intrinsic and extrinsic elements.

CONCLUSIONS

This analysis provides an overview of the QoL concept related to COPD patients that is useful as a guide to research into nursing care and for clinical practice.

Determinants of 1-year changes in disease-specific health status in patients with advanced chronic obstructive pulmonary disease: A 1-year observational study

We aimed to identify baseline and longitudinal determinants of change in disease-specific health status in patients with advanced chronic obstructive pulmonary disease (COPD). Demographic and clinical characteristics as well as disease-specific health status (St George's Respiratory Questionnaire, SGRQ) were assessed in 105 outpatients with advanced COPD at baseline and at 4, 8 and 12 months. Eighty-five patients (81.0%) had complete SGRQ data at baseline and 12 months and were included in analyses. Stepwise multiple regression analysis revealed that lower SGRQ total score, higher depression scores and longer time needed to complete the Timed Up and Go (TUG) test at baseline, as well as increase in time needed to complete the TUG test and increase in dyspnoea during the 1-year follow-up period, were predictors of deterioration in disease-specific health status. The current study reinforces the stimulation of physical mobility and the targeting of dyspnoea as components for treatment programs to optimize disease-specific health status in patients with advanced COPD.

Within-day test-retest reliability of the Timed Up & Go test in patients with advanced chronic organ failure

OBJECTIVE

To investigate the within-day test-retest reliability of the Timed Up & Go (TUG) test in patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and chronic renal failure (CRF).

DESIGN

Cross-sectional.

SETTING

Patients' home environment.

PARTICIPANTS

Subjects (N=235, 64% men; median age, 70y [interquartile range, 61-77y]; median body mass index, 25.6kg/m(2) [interquartile range, 22.8-29.4kg/m(2)]) with advanced COPD (n=95), CHF (n=68), or CRF (n=72).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Time to complete the TUG test. Three trials were performed on the same day and by the same assessors. The intraclass correlation coefficient (ICC), kappa coefficient, standard error of measurement, and absolute and relative minimal detectable change (MDC) values were calculated.

RESULTS

Good agreement was observed, in general, for both the total sample and subgroups (COPD, CHF, CRF), with ICC values ranging from .85 to .98, and kappa coefficients from .49 to 1.00. However, statistical improvement occurred in the total sample from the first to the second trial with large limits of agreement (mean difference, -.97s; 95% confidence interval, 3.00 to -4.94s; P<.01). The third trial added little or no information to the first 2 trials. For the total sample, a standard error of measurement value of approximately 1.6 seconds, an absolute value of MDC at the 95% confidence level (MDC95%) of approximately 4.5 seconds, and a relative value of MDC at the 95% confidence level (MDC95%%) of approximately 35% were found between the first 2 trials, with similar values found for the subgroups.

CONCLUSIONS

The TUG test is reliable in patients with advanced COPD, CHF, or CRF after 2 trials. Values of standard error of measurement and MDC may be used in daily clinical practice with these populations to define what is expected and what represents true change in repeated measures.

Insight into advance care planning for patients on dialysis

CONTEXT

Advance care planning is not included in regular clinical care for patients on dialysis. Insight into life-sustaining treatment preferences and communication about end-of-life care is necessary to develop interventions to improve advance care planning for patients on dialysis.

OBJECTIVES

This cross-sectional observational study aimed to understand the preferences for life-sustaining treatments of outpatients on dialysis and to study the quality of patient-physician communication about end-of-life care and barriers and facilitators to this communication.

METHODS

The following outcomes were assessed in 80 clinically stable dialysis patients: demographics, clinical characteristics, life-sustaining treatment preferences (cardiopulmonary resuscitation and mechanical ventilation, and Willingness to Accept Life-Sustaining Treatment instrument), preference for site of death, quality of communication (Quality of Communication Questionnaire), and barriers and facilitators to communication about end-of-life care (Barriers and Facilitators Questionnaire).

RESULTS

Patients were able to indicate their preferences for life-sustaining treatments and site of death. Preferences for life-sustaining treatments depend on the specific treatment, the expected outcome of treatment, and likelihood of an adverse outcome. Life-sustaining preferences were discussed with the nephrologist by 30.3% of the patients. Quality of the patient-physician communication about end-of-life care was rated poor. This study identified several barriers and facilitators to end-of-life care communication.

CONCLUSION

Patients should receive information about treatment burden, expected outcome, and the likelihood of an adverse outcome when discussing life-sustaining treatments. Quality of patient-physician communication about end-of-life care needs to improve. Barriers and facilitators to communication about end-of-life care provide direction for future interventions to facilitate advance care planning for patients on dialysis.

Correlations between disease-specific and generic health status questionnaires in patients with advanced COPD: a one-year observational study

Background

Longitudinal studies analyzing the correlations between disease-specific and generic health status questionnaires at different time points in patients with advanced COPD are lacking. The aim of this study was to determine whether and to what extent a disease-specific health status questionnaire (Saint George’s Respiratory Questionnaire, SGRQ) correlates with generic health status questionnaires (EuroQol-5-Dimensions, EQ-5D; Assessment of Quality of Life instrument, AQoL; Medical Outcomes Study 36-Item Short-Form Health Survey, SF-36) at four different time points in patients with advanced COPD; and to determine the correlation between the changes in these questionnaires during one-year follow-up.

Methods

Demographic and clinical characteristics were assessed in 105 outpatients with advanced COPD at baseline. Disease-specific health status (SGRQ) and generic health status (EQ-5D, AQoL, SF-36) were assessed at baseline, four, eight, and 12 months. Correlations were determined between SGRQ and EQ-5D, AQoL, and SF-36 scores and changes in these scores. Agreement in direction of change was assessed.

Results

Eighty-four patients (80%) completed one-year follow-up and were included for analysis. SGRQ total score and EQ-5D index score, AQoL total score and SF-36 Physical Component Summary measure (SF-36 PCS) score were moderately to strongly correlated. The correlation of the changes between the SGRQ total score and EQ-5D index score, AQoL total score, SF-36 PCS, and SF-36 Mental Component Summary measure (SF-36 MCS) score were weak or absent. The direction of changes in SGRQ total scores agreed slightly with the direction of changes in EQ-5D index score, AQoL total score, and SF-36 PCS score.

Conclusions

At four, eight and 12 months after baseline, SGRQ total scores and EQ-5D index scores, AQoL total scores and SF-36 PCS scores were moderately to strongly correlated, while SGRQ total scores were weakly correlated with SF-36 MCS scores. The correlations between changes over time were weak or even absent. Disease-specific health status questionnaires and generic health status questionnaires should be used together to gain complete insight in health status and changes in health status over time in patients with advanced COPD.

Symptom distress in advanced chronic organ failure: disagreement among patients and family caregivers

BACKGROUND

Proxy reporting is frequently used to assess symptom distress of patients with advanced chronic organ failure. The aim of the present cross-sectional study was to examine agreement in severity of symptom distress, presence of symptom-related interventions, and satisfaction with medical treatment among patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) and chronic renal failure (CRF) and their family caregivers.

METHODS

Outpatients with advanced COPD (n=73), CHF (n=45) and CRF (n=41) and their family caregivers rated severity of physical and psychological symptoms experienced by the patient using Visual Analogue Scales (VAS). The presence of symptom-related interventions was recorded by patients and family caregivers. Finally, patients and family caregivers rated satisfaction with medical treatment of the patient using VAS. Agreement was determined using intraclass correlation coefficients (ICC) for continuous variables and Cohen's kappa for categorical variables.

RESULTS

Family caregivers reported a higher number of symptoms than patients (mean [standard deviation; SD]: 8.2 [3.5] versus 7.3 [3.6], respectively [p<0.0005]). For most symptoms, agreement about severity between patients and family caregivers was moderate (ICC: 0.41-0.60). Agreement about satisfaction with medical treatment was fair (ICC [95% confidence interval; CI]: 0.21 [0.05-0.35]). Agreement was poor to moderate for presence of symptom-related interventions (kappa: -0.03-0.54).

CONCLUSIONS

Studies using proxy reporting reflect the views of proxies and do not accurately represent the patients' experience. For clinical care, it's important to pay attention to the perception from the patient as well as the perception from the family caregiver of symptom distress, presence of symptom-related interventions, and satisfaction with treatment.