Problems to discuss with cancer patients in palliative care: a comprehensive approach

What makes the palliative care initial encounter meaningful? A descriptive study with patients with cancer, family carers and palliative care professionals

BACKGROUND

The palliative care initial encounter can have a positive impact on the quality of life of patients and family carers if it proves to be a meaningful experience. A better understanding of what makes the encounter meaningful would reinforce the provision of person-centred, quality palliative care.

AIM

To explore the expectations that patients with cancer, family carers and palliative care professionals have of this initial encounter.

DESIGN

Qualitative descriptive study with content analysis of transcripts from 60 semi-structured interviews.

SETTING/PARTICIPANTS

Twenty patients with cancer, 20 family carers and 20 palliative care professionals from 10 institutions across Spain.

RESULTS

Four themes were developed from the analysis of interviews: (1) the initial encounter as an opportunity to understand what palliative care entails; (2) individualised care; (3) professional commitment to the patient and family carers: present and future; and (4) acknowledgement.

CONCLUSION

The initial encounter becomes meaningful when it facilitates a shared understanding of what palliative care entails and acknowledgement of the needs and/or roles of patients with cancer, family carers and professionals. Further studies are required to explore how a perception of acknowledgement may best be fostered in the initial encounter.

Dying in hospital is worse for non-cancer patients. A regional cross-sectional survey of bereaved relatives' views

OBJECTIVE

The aim of the study is to examine differences in hospital care between patients with cancer and non-cancer conditions in their dying phase, perceived by bereaved relatives.

METHODS

A retrospective cross-sectional post-bereavement survey, with the total population of 351 deceased, 91 cancer patients and 46 non-cancer patients, who spent their last 2 days of life in hospital. A validated German version of the VOICES-questionnaire ('VOICES-LYOL-Cologne') was used.

RESULTS

There were substantial differences between the two groups in the rating of sufficient practical care such as pain relief or support to eat or drink (p = 0.005) and sufficient emotional care needs (p = 0.006) and in the quality of communication with healthcare professionals (p < 0.001), with non-cancer patients scoring lowest in all these dimensions.

CONCLUSION

In all surveyed dimensions on the quality of care in the dying phase, non-cancer patients' relatives rated the provided care worse than those of cancer patients. To compensate any differences in care in the dying phase between diagnosis groups, hospital care should be provided as needs-oriented and non-indication-specific.

Health professionals' view on the role of hope and communication challenges with patients in palliative care: A systematic narrative review

OBJECTIVE

To identify health professionals' (HPs) perspectives on the role of hope and the main challenges faced when communicating with patients in palliative care (PC).

METHODS

Search on PubMed, Scopus, SocIndex, Cochrane, and Web of Science using: palliat*, palliative care, palliative medicine, hospice care, terminal care, long term care, supportive care, end of life (EOL) care and hope*, followed by a thematic narrative analysis.

RESULTS

Thirty-five studies were included. HPs' views were grouped in: Bringing out hope and Taking down hope. HPs believe that hope is elicited through a personal patient-provider bond and exhibited through medical treatment delivery. HPs face difficulties when delivering prognosis, referring to hospice, and providing palliation.

CONCLUSION

Hope is conveyed through verbal and non-verbal communication. HPs struggle to account for hope's shifting character, challenging the engagement in EOL discussions.

PRACTICAL IMPLICATIONS

Findings show a patient-provider clash of perspectives, suggesting a gap in acknowledging the shifting nature of hope. An important question emerges: Are the existing theories of hope that are solely explained from a patient experience relevant for HPs' own interpretation? Investigating the HPs' attitudes gathered in collective experiences in PC, might contribute to answering the question in the context of building more constructive communication approaches.

Talking control sessions in people with advanced cancer: a qualitative analysis of sessions

BACKGROUND

Talking control (TC) was developed to control for the common factors in therapy so that the specific effects of therapy can be tested. A TC was recently used in a pilot study of Acceptance and Commitment therapy for dysfunction in people with advanced cancer. This work explores the audio recording of the sessions in a TC to explore how they were utilised by people with advanced cancer.

METHODS

This is a qualitative study nested in larger feasibility randomised control trial. The trial participants were recruited from three London hospices. The study examined data for 5 participants who received weekly sessions of a TC. Fifteen sessions, three per participant, were transcribed and analysed using a thematic approach.

RESULTS

Individuals with advanced cancer used TC sessions as a safe place in which they could express their feelings-from smaller daily concerns to deeper-rooted difficulties. Many participants also engaged in emotional and cognitive avoidance regarding some topics, particularly those pertaining to their cancer. The TC sessions were also used as an opportunity to focus on the more positive aspects of their lives. Lastly, they served to reflect on ways to overcome difficulties.

CONCLUSIONS

This study suggests the TC can have beneficial, albeit varying uses for people with advanced cancer, that may even be considered therapeutic.

Breaking bad news to children with chronic kidney disease: A questionnaire-based study and literature review

Introduction

Breaking bad ne ws to caregivers of children with (CKD) [I can't comment in the box] Title says to breaking bad news to children but in here, breaking bad news to caregivers. Please clarify and edit accordingly. is an important role of nephrologists. In our practice there has been a thought about parental dissatisfaction from breaking bad news to CKD patients. Caregiver's preferences on how to be told the bad news in CKD children has not been studied adequately. Our objective was to identify how much is the emotional and knowledge satisfaction of CKD caregivers and the relation of their socioeconomic and educational levels with their preferences in breaking bad news.

Methods

A questionnaire based study was conducted for caregivers of CKD children, in the outpatient clinics, and peritoneal dialysis and hemodialysis units at the King Faisal Specialist Hospital and Research Centre for three months.

Results

83 questionnaires from caregivers of CKD patients age (1-14) years, mean age of 8.5 ± 3.9 years. (47.6%) were emotionally very satisfied, 29.5% were very satisfied about the knowledge they had.

Conclusion

Caregivers of CKD patients are satisfied emotionally more than the satisfaction about the amount of information they got. Different demographic data might affect their preferences in the way of receiving the bad news. The dissatisfaction suggesting that physicians' communication skills needs improvement.

What defines the comprehensive assessment of needs in palliative care? An integrative systematic review

BACKGROUND

The comprehensive assessment of needs in palliative care identifies where patients most want attention to guide clinical decisions that tailor care provision from their first encounters.

AIM

To define how and what needs are identified by the comprehensive assessment of needs in the original peer-reviewed articles in the field of palliative care.

DESIGN

An integrative systematic review as outlined by Whittemore and Knafl. Quality appraisal performed using the Mixed Methods Appraisal Tool.

DATA SOURCES

PubMed, CINAHL, PsycINFO, Web of Science databases searched through May 2019 and updated in July 2020.

RESULTS

Forty-nine articles met inclusion criteria for original articles in English or Spanish reporting comprehensive assessment of needs of adult patients receiving palliative care. The majority (41/49) of studies were moderate to high quality. Two themes were identified: (1) How a comprehensive assessment of needs should be carried out in palliative care, which reflected a preference to develop structured tools for assessment; (2) What needs of patients should be assessed in the comprehensive assessment of needs in palliative care, which conveyed a trend to assess beyond core domains - physical, psychological, social, spiritual - with information and practical most prevalent, but with substantial variation in specifying and classifying needs into domains.

CONCLUSIONS

The assessment of needs in palliative care is comprehensive but lacks consensus on the needs and domains that should be assessed by the palliative care team. Future studies should better define what needs can be standardized into the assessment to improve process of care and patient satisfaction.

Impacts on employment, finances, and lifestyle for working age people facing an expected premature death: A systematic review

Objective:

The working ages (25–65 years) are a period when most people have significant work, financial, and family responsibilities. A small proportion of working age people will face an expected premature death from cancer or other life-limiting illness. Understanding the impact an expected premature death has on this population is important for informing support. The current study set out to summarize research describing the effects that facing an expected premature death has on employment, financial, and lifestyle of working age people and their families.

Method:

A systematic review using narrative synthesis approach. Four electronic databases were searched in July 2016 for peer-reviewed, English language studies focusing on the financial, employment, and lifestyle concerns of working age adults living with an advanced life-limiting illness and/or their carers and/or children.

Results:

Fifteen quantitative and 12 qualitative studies were included. Two-thirds (n = 18) were focused on cancer. All studies identified adverse effects on workforce participation, finances, and lifestyle. Many patients were forced to work less or give up work/retire early because of symptoms and reduced functioning. In addition to treatment costs, patients and families were also faced with child care, travel, and home/car modification costs. Being younger was associated with greater employment and financial burden, whereas having children was associated with lower functional well-being. Changes in family roles were identified as challenging regardless of diagnosis, whereas maintaining normalcy and creating stability was seen as a priority by parents with advanced cancer. This review is limited by the smaller number of studies focussing on the needs of working age people with nonmalignant disease.

Significance of results:

Working age people facing an expected premature death and their families have significant unmet financial, employment, and lifestyle needs. Comparing and contrasting their severity, timing, and priority for people with nonmalignant conditions is required to better understand their unique needs.

Validation of the OPportunity for Treatment In ONcology (OPTION) questionnaire measuring continuity of care

Increasing efforts are ongoing to deliver effective cancer care through integrated networks of services. Measuring patients' experience of care is essential to identify problematic areas that require organisational adjustments. The aim of the present study was to examine the validity of OPTION questionnaire, designed to measure patient's perceived continuity of care across different phases of their care pathway. The study was carried at the Institute for Cancer Treatment and Research, Meldola and the oncology departments of the Local Health Authority of Romagna, Italy. Principal component analysis (PCA) was performed to identify factors underlying patients' perception of continuity of care. Factor scores were compared between patients with or without a care coordinator using Mann-Whitney test. The study sample consisted of 214 patients with breast or colorectal cancer, with a mean age of 62.3 years. Most patients identified the oncologist as their care coordinator. Five factors were extracted using PCA: (1) "trustful relationship with health care staff," (2) "information on care pathway," (3) "information on changes related to the illness," (4) "feelings of abandonment" and (5) "collaboration among health care professionals." The scores of factors 2 and 3 were significantly higher among those with a care coordinator. The OPTION questionnaire is a reliable instrument that can help clinicians and administrative stakeholder target efforts and resources in the pursuit of quality of care.

Provider perspectives on patient-provider communication for adjuvant endocrine therapy symptom management

PURPOSE

Providers' communication skills play a key role in encouraging breast cancer survivors to report symptoms and adhere to long-term treatments such as adjuvant endocrine therapy (AET). The purpose of this study was to examine provider perspectives on patient-provider communication regarding AET symptom management and to explore whether provider perspectives vary across the multi-disciplinary team of providers involved in survivorship care.

METHODS

We conducted three one-hour focus groups with a multi-disciplinary group of health care providers including oncology specialists, primary care physicians, and non-physician providers experienced in caring for breast cancer survivors undergoing AET (n = 13). Themes were organized using Epstein and Street's (2007) Framework for Patient-Centered Communication in Cancer Care.

RESULTS

The findings of this study suggest providers' communication behaviors including managing survivors' uncertainty, responding to survivors' emotions, exchanging information, and enabling self-management influences the quality of patient-provider communication about AET symptoms. Additionally, lack of systematic symptom assessment tools for AET requires providers to use discretion in determining which symptoms to discuss with survivors resulting in approaches that vary based on providers' discipline.

CONCLUSION

There may be AET-specific provider communication skills and behaviors that promote effective patient-provider communication but additional research is needed to identify practices and policies that encourage these skills and behaviors among the many providers involved in survivorship care. Efforts are also needed to coordinate AET symptom assessment across providers, clarify providers' roles in symptom assessment, and determine best practices for AET symptom communication.

Clinical considerations for working with patients with advanced cancer

Advanced cancer is a life-limiting condition, but improvements in medical care are contributing to longer survival among some patients. As a result, it is likely that mental health professionals will be called upon to assist more patients with advanced cancer. The present paper reviews the psychological literature and from it draws clinical considerations for working with individuals affected by advanced cancer. It begins with a brief description of advanced cancer and the medical attributes of an advanced cancer diagnosis, and then catalogues salient medical, psychological, existential, and interpersonal challenges faced by this patient population. The review concludes with recommendations for treatment planning including an overview of some of the more recently tested and widely available interventions. It is hoped that this review will serve as a resource for professionals working with patients affected by advanced cancer.

Dealing with symptoms and issues of hospitalized patients with cancer in indonesia: the role of families, nurses, and physicians

OBJECTIVE

Patients with cancer often face physical, psychological, social, spiritual, and emotional symptoms. Our aim was to study symptoms and issues of hospitalized patients with cancer in Indonesia, a country with strong family ties, and how family members, nurses, and physicians deal with them.

METHODS

In 2011, 150 hospitalized cancer patients in 3 general hospitals in Indonesia were invited to fill in a questionnaire, which was based on the validated Problems and Needs of Palliative Care (short version) questionnaire. Descriptive statistics were performed.

RESULTS

Of 119 patients (79%) who completed the questionnaire, 85% stated that their symptoms and issues were addressed. According to these patients, financial (56%), autonomy (36%), and psychosocial (34%) issues were most often addressed by the family alone. Physical symptoms (52%) and spiritual issues (33%) were addressed mainly by a combination of family, nurses, and physicians.

CONCLUSIONS

Hospitalized patients with cancer in Indonesia felt that most of their symptoms and issues had been addressed, and the family was highly involved. The strong family ties in Indonesian culture may have contributed to this family role. More research is needed to clarify how this influences patient outcome, quality of care, and quality of life of both the patients and their families, along with the degree of partnership between families and professionals. This information might help answer the question what advantages and disadvantages the family role in caring for a hospitalized patient with cancer generates for the patient, the family, and professional caregivers.

Comparison of problems and unmet needs of patients with advanced cancer in a European country and an Asian country

BACKGROUND

Patients with advanced cancer experience problems and unmet needs. However, we assume that patients with advanced cancer will have more problems and unmet needs in a country with a lower economic status than in an economically stronger country. We studied whether patients with advanced cancer in Indonesia have more problems and unmet needs than a similar group of patients in the Netherlands.

METHODS

We performed a cross-sectional survey. We compared the data for 180 Indonesian and 94 Dutch patients relating to 24 items of the Problems and Needs in Palliative Care-short version questionnaire. We performed descriptive and χ(2) analysis with Bonferroni correction.

RESULTS

The prevalence of most physical problems, including pain, was similar in the 2 groups. In Indonesia, financial problems were the most common: 70 to 80% vs. 30 to 42% in the Netherlands. In Indonesia, 25 to 50% of the patients reported psychological and autonomy problems versus 55 to 86% in the Netherlands. The Indonesian group had many more unmet needs for each problem (> 54%) than the Dutch group (< 35%).

CONCLUSION

Apparently, economic and cultural differences hardly influence physical problems. Nonetheless, fewer Indonesian patients reported psychological and autonomy problems than Dutch patients. This difference contradicts our hypothesis. However, we found more unmet needs for professional attention in Indonesia than in the Netherlands, which is compatible with our hypothesis. These simple comparative data provide interesting insights into problems and unmet needs and give rise to our new hypothesis about cultural influences. This hypothesis should be studied in more depth.

Effects of an educational intervention for managing fatigue in women with early stage breast cancer

PURPOSE

This randomized controlled trial of outpatients with breast cancer (stage I or II) evaluated the effects of a 3-week educational intervention on patient levels of fatigue.

METHODS

Norwegian outpatients were randomized into an intervention group (n = 79) and a control group (n = 81). Women with fatigue (>2.5 on a 0-10 numeric rating scale, NRS) completed the Fatigue Questionnaire (FQ) and the Lee Fatigue Scale (LFS) at baseline (after treatment) (T1), immediately after intervention (T2) and 3 months after intervention (T3).

RESULTS

The mean fatigue score (NRS) at study entry was 6.1 (SD 1.7) and 36% (n = 57) had a score ≥7. There were no statistically significant differences between the fatigue measures of women in the intervention and control group at T2 or T3 in the overall sample after the intervention. Using an NRS cut-off of 5, there was a borderline difference for women who scored <5 for chronic fatigue on FQ (p = 0.062) and a significant difference for energy on LFS (p = 0.042) where the women in the intervention group had less fatigue. Using an NRS cut-off score of 6, there was a borderline difference for women who scored <6 for fatigue on FQ (p = 0.062) and a significant difference for energy on LFS (p = 0.021) where women in the intervention group had more energy than those in the control group.

CONCLUSIONS

Further research is needed to identify psycho-educational interventions to reduce levels of fatigue and to tailor an intervention based on the level of fatigue. Fatigue measurements should be chosen more carefully.

Experienced continuity of care when patients see multiple clinicians: a qualitative metasummary

PURPOSE

Continuity of care among different clinicians refers to consistent and coherent care management and good measures are needed. We conducted a metasummary of qualitative studies of patients' experience with care to identify measurable elements that recur over a variety of contexts and health conditions as the basis for a generic measure of management continuity.

METHODS

From an initial list of 514 potential studies (1997-2007), 33 met our criteria of using qualitative methods and exploring patients' experiences of health care from various clinicians over time. They were coded independently. Consensus meetings minimized conceptual overlap between codes.

RESULTS

For patients, continuity of care is experienced as security and confidence rather than seamlessness. Coordination and information transfer between professionals are assumed until proven otherwise. Care plans help clinician coordination but are rarely discerned as such by patients. Knowing what to expect and having contingency plans provides security. Information transfer includes information given to the patient, especially to support an active role in giving and receiving information, monitoring, and self-management. Having a single trusted clinician who helps navigate the system and sees the patient as a partner undergirds the experience of continuity between clinicians.

CONCLUSION

Some dimensions of continuity, such as coordination and communication among clinicians, are perceived and best assessed indirectly by patients through failures and gaps (discontinuity). Patients experience continuity directly through receiving information, having confidence and security on the care pathway, and having a relationship with a trusted clinician who anchors continuity.

First assessments by specialist cancer nurses in the community: an ethnography

PURPOSE

The aim of the study is to explore how specialist cancer nurses carry out first assessments of patients in the community, their use of the Symptoms and Concerns Checklist (SCC) and their views on first assessments.

METHODS & SAMPLE

An ethnographic approach was taken. The data were collected by use of non-participant observation of specialist nurses carrying out a first assessment of patients with cancer, followed by semi-structured interviews with six specialist nurses. Data were analysed using iterative thematic analysis.

KEY RESULTS

All the specialist nurses recognised the value of facilitating the patients' narrative. Use of the SCC was seen to jar with the overall theme of building relationships during the first assessment visit. It was recognised by the specialist nurses that the SCC was beneficial in prompting the patients to discuss psycho-social concerns.

CONCLUSIONS

This study gives insight into the conflict and ambiguity for specialist nurses when using the SCC during the first assessment visit. It confirms the SCC as beneficial in cueing some patients to identify specific concerns and for these concerns to be recognised by the specialist nurses.

A Qualitative Review of Occupational Therapists' Listening Behaviors and Experiences When Caring for Patients in Palliative or Hospice Care

Listening behaviors and experiences of occupational therapists working with patients in palliative or hospice care were investigated. Because the U.S. Government's Healthy People 2020 mandates better listening in health care, this research is timely. A qualitative design using semi-structured interviews and member checks provided researchers with rich text that revealed patterns and themes associated with listening behaviors, listening experiences, and listening training of occupational therapists working in palliative and hospice care. Participants were selected using typical case and snowball sampling. Six participants from two distinct geographic regions of the United States agreed to be interviewed. Interviews revealed four themes: working within the OT Practice Framework, key listening behaviors used in this context, listening barriers and challenges, and clinical competence and training needed prior to working with this population. This small sample size represents only a fraction of the occupational therapists working in palliative or hospice care, yet provides a foundation for further research and underscores the importance of listening behaviors.

The ACA training programme to improve communication between general practitioners and their palliative care patients: development and applicability

We describe the development of a new training programme on GP-patient communication in palliative care, and the applicability to GPs and GP Trainees. This ‘ACA training programme’ focuses on  A vailability of the GP for the patient,  C urrent issues that should be raised by the GP, and  A nticipating various scenarios. Evaluation results indicate the ACA training programme to be applicable to GPs and GP Trainees. The ACA checklist was appreciated by GPs as useful both in practice and as a learning tool, whereas GP Trainees mainly appreciated the list for use in practice.

What can we learn about the spiritual needs of palliative care patients from the research literature?

CONTEXT

Spirituality is a distinctive subject within palliative care practice and literature, but research to date is relatively undeveloped in this field and studies often throw more light on conceptual and methodological issues than producing reliable data for clinical practice.

OBJECTIVES

To determine what is known about the spiritual needs of palliative care patients from the evidence presented in published research.

METHODS

Specialist online databases were interrogated for primary empirical studies of patients with a chronic disease unresponsive to curative treatment. Studies that only used a proxy for the patient or reported expert opinion were excluded. Each study was critically appraised for quality and the strength of its evidence to determine if any data could be pooled.

RESULTS

Thirty-five studies were identified, equating to a total of 1374 patients. Study populations were typically people with advanced-stage cancer, older than 60 years, who were English speaking, and with a Christian or Jewish religious affiliation, reflecting the predominance of Anglo-American studies. Studies fell into two groups: those that investigated the nature of spiritual experience and those that examined the relationship of spirituality with other phenomena. The evidence was insufficiently homogeneous to pool.

CONCLUSION

Relevant accounts of what spirituality means for palliative care patients and evidence of how it operates in the lives of people with life-limiting disease can be derived from research. Studies to date are limited by reductive representations of spirituality and the conduct of research by health professionals within health care communities demarcated from disciplines and interpretive traditions of spirituality.

Culture and end of life care: a scoping exercise in seven European countries

AIM

Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries.

METHODS

We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes.

RESULTS

A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities.

CONCLUSION

This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.

Perceived barriers and facilitators for general practitioner-patient communication in palliative care: a systematic review

While effective general practitioner (GP)-patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP-patient communication in palliative care. In a systematic review seven computerized databases were searched to find empirical studies on GP-patient communication in palliative care. Fifteen qualitative studies and seven quantitative questionnaire studies were included. The main perceived barriers were GPs' lack of availability, and patients' and GPs' ambivalence to discuss 'bad prognosis'. Main perceived facilitators were GPs being available, initiating discussion about several end-of-life issues and anticipating various scenarios. Lack of availability and failure to discuss former mistakes appear to be blind spots of GPs. GPs should be more forthcoming to initiate discussions with palliative care patients about prognosis and end-of-life issues. Empirical studies are needed to investigate the effectiveness of the perceived barriers and facilitators.

Development and initial validation of the Three-Levels-of-Needs Questionnaire for self-assessment of palliative needs in patients with cancer

CONTEXT

To improve palliative care, it is important that questionnaires accurately assess the needs of the patients. No questionnaire existed that combined three different and important approaches to needs assessment. We developed such a questionnaire, called the Three-Levels-of-Needs Questionnaire (3LNQ), based on literature searches. The 3LNQ measures 12 important needs with three different approaches when used as a supplement to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30): problem intensity, problem burden, and felt need.

OBJECTIVES

To investigate the initial validity of the 3LNQ.

METHODS

We used a relatively new method that investigates whether the questionnaire has the same meaning for the patients as for the researchers. To do this, 74 patients with advanced cancer filled out the questionnaire and participated in an open-ended interview. The patients' responses to the questionnaire before the interview were compared against the researchers' responses based on the interviews. Items showing substantial agreement were accepted as valid without further analysis. For the remaining items, reasons for disagreements were analyzed qualitatively.

RESULTS

All items on problem intensity, eight of 12 items on problem burden, and three of 12 items on felt need were accepted as valid because of high agreement. Analysis of the qualitative data concerning the remaining items showed that most disagreements did not indicate problems with the patients' self-assessment. Instead, different causes for disagreements were elucidated, but these did not interfere with validity.

CONCLUSION

The 3LNQ appears to measure palliative needs comprehensively, and this initial validation showed satisfactory results. The analysis gave important insights into the patients' perceptions of their own situations, into their expectations of the health care system, and into the complexity of needs assessment.

Facilitators and barriers for GP-patient communication in palliative care: a qualitative study among GPs, patients, and end-of-life consultants

BACKGROUND

Effective communication is considered to be essential for the delivery of high-quality care. Communication in palliative care may be particularly difficult, and there is still no accepted set of communication skills for GPs in providing palliative care.

AIM

To obtain detailed information on facilitators and barriers for GP-patient communication in palliative care, with the aim to develop training programmes that enable GPs to improve their palliative care communication skills.

DESIGN OF STUDY

Qualitative study with focus groups, interviews, and questionnaires.

SETTING

GPs with patients receiving palliative care at home, and end-of-life consultants in the Netherlands.

METHOD

GP (n = 20) focus groups discussing facilitators and barriers, palliative care patient (n = 6) interviews regarding facilitators, and end-of-life consultant (n = 22) questionnaires concerning barriers.

RESULTS

Facilitators reported by both GPs and patients were accessibility, taking time, commitment, and listening carefully. GPs emphasise respect, while patients want GPs to behave in a friendly way, and to take the initiative to discuss end-of-life issues. Barriers reported by both GPs and end-of-life consultants were: difficulty in dealing with former doctors' delay and strong demands from patients' relatives. GPs report difficulty in dealing with strong emotions and troublesome doctor-patient relationships, while consultants report insufficient clarification of patients' problems, promises that could not be kept, helplessness, too close involvement, and insufficient anticipation of various scenarios.

CONCLUSION

The study findings suggest that the quality of GP-patient communication in palliative care in the Netherlands can be improved. It is recommended that specific communication training programmes for GPs should be developed and evaluated.

Measuring patient-centered communication in cancer care: a literature review and the development of a systematic approach

Patient-centered communication (PCC) is a critical element of patient-centered care, which the Institute of Medicine (Committee on Quality of Health Care in America, 2001) promulgates as essential to improving healthcare delivery. Consequently, the US National Cancer Institute's Strategic Plan for Leading the Nation (2006) calls for assessing the delivery of PCC in cancer care. However, no comprehensive measure of PCC exists, and stakeholders continue to embrace different conceptualizations and assumptions about how to measure it. Our approach was grounded in the PCC conceptual framework presented in a recent US National Cancer Institute monograph (Epstein & Street, 2007). In this study, we developed a comprehensive inventory of domains and subdomains for PCC by reviewing relevant literature and theories, interviewing a limited number of cancer patients, and consulting experts. The resulting measurement domains are organized under the six core functions specified in the PCC conceptual framework: exchanging information, fostering healing relationships, recognizing and responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. These domains represent a promising platform for operationalizing the complicated PCC construct. Although this study focused specifically on cancer care, the PCC measurements are relevant to other clinical contexts and illnesses, given that patient-centered care is a goal across all healthcare. Finally, we discuss considerations for developing PCC measures for research, quality assessment, and surveillance purposes. United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute (2006). The NCI Strategic Plan for Leading the Nation: To Eliminate the Suffering and Death Due to Cancer. NIH Publication No. 06-5773.

Telephone consultations on palliative sedation therapy and euthanasia in general practice in The Netherlands in 2003: a report from inside

BACKGROUND

GPs with a special interest and with specific training in palliative medicine (GP advisors) supported professional carers (mostly GPs) through a telephone advisory service. Each telephone call was formally documented on paper and subsequently evaluated.

OBJECTIVE

Data from 2003 were analysed independently to reveal how often and in what way palliative sedation and euthanasia were discussed.

METHODS

The telephone documentation forms and corresponding evaluation forms of two GP advisors were systematically analysed for problems relating to the role of sedation and/or euthanasia both quantitatively and qualitatively.

RESULTS

In 87 (21%) of 415 analysed consultations, sedation and/or euthanasia were discussed either as the presenting question (sedation 26 times, euthanasia 37 times and both 10 times) or arising during discussion (sedation 11 times and euthanasia three times). Qualitative analysis revealed that GPs telephoned to explore therapeutic options and/or wanted specific information. Pressure on the GP (either internal or external) to relieve suffering (including shortening life by euthanasia) had often precipitated the call. On evaluation, 100% of the GPs reported that the advice received was of value in the patient's care.

CONCLUSION

GPs caring for patients dying at home encountered complex clinical dilemmas in end-of-life care (including palliative sedation therapy and euthanasia). They valued practical advice from, and open discussion with, GP advisors. The advice often helped the GP find solutions to the patient's problems that did not require deliberately foreshortening life.

Presence, communication and treatment of fatigue and pain complaints in incurable cancer patients

OBJECTIVE

This study describes the experiences of fatigue and pain in incurable cancer patients and the treatment they receive.

METHODS

Patients were recruited via medical specialists from hospitals in the South and Southwest of the Netherlands. Hundred and twenty-five incurable cancer patients filled out a written questionnaire and were also interviewed at home.

RESULTS

Ninety percent reported to suffer from fatigue and 48% had pain. Forty-five percent had discussed fatigue with a healthcare professional and 55% had discussed pain. Fifteen percent reported to receive medical treatment for their fatigue and 29% received pain treatment. Treatment for fatigue and pain treatment had been recently adjusted in 4% of the patients with fatigue complaints and 21% of the patients with pain complaints.

CONCLUSION

Although fatigue is a more common problem than pain in patients with incurable cancer, less attention in the care is paid to fatigue and its treatment than to pain.

PRACTICE IMPLICATIONS

Fatigue deserves more attention in the care policy for incurable cancer patients and more research should be focused on interventions to address fatigue in this group of cancer patients.

Evaluating the impact of a cancer supportive care project in the community: patient and professional configurations of need

Advances in cancer care and treatment have created a new and somewhat anomalous category of patients with a diagnosis of non-curative disease who still have a considerable period of life remaining. During much of this time they may remain relatively well, without manifest need for clinical care. The responses of patients to this challenging situation are largely unknown. However, it has been assumed that because they confront a difficult experience they will need, or can benefit from, professional intervention. The implementation of pre-emptive support measures is anticipated to improve patients' resilience in coping with their illness and approaching death. This study aimed to investigate the impact of the keyworker role in a 3-year cancer supportive community care project to identify and provide for the needs of patients with a diagnosis of non-curative cancer. It was a qualitative study incorporating face-to-face interviews and focus groups with 19 healthcare professionals and 25 patients and carers from an urban East Midlands locality and a thematic analysis of qualitative interview and focus group transcripts. The project was positively evaluated by patients, carers and professionals. However, the findings raised questions about the different configuration of 'need' within the lay and professional perspectives and how this should most appropriately be addressed. In contrast to widespread professional assumptions about patients' need for counselling, many patients preferred to turn to their friends and families for support, and to adopt a stance of emotional and personal self-reliance as a strategy for coping with their predicament. The study highlights the continuing orientation of services around professional, rather than patient, agendas and the momentum towards increasing specialisation of professional roles and the medicalisation of everyday life that flows from this.

A practical instrument to explore patients' needs in palliative care: the Problems and Needs in Palliative Care questionnaire short version

OBJECTIVE

Short and convenient checklists are necessary tools to support and structure needs assessments in daily palliative practice. This study aims to develop a short version of the Problems and Needs in Palliative Care questionnaire (PNPC-sv); a self-report questionnaire for patients covering all dimensions of palliative care, to investigate their problems and (unmet) needs.

METHODS

The original Problems and Needs in Palliative Care questionnaire (PNPC) instrument is a comprehensive checklist of problems and needs for palliative care, and has shown validity and reliability. With its 90 items, however, it is not always practical. Thus it was abridged to a short version with 33 items. The validity and reliability are established with its item response, its internal consistency, and with its correlations with the original PNPC and with European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 and COOP/WONCA quality-of-life measures. A secondary analysis was done with data from 94 patients with metastatic cancer who had completed the long version.

RESULTS

Each item in the PNPC represents a problem relevant to 25% of the patients or more. High correlations of PNPC-sv and PNPC domains demonstrate construct validity. The dimension reliability was satisfactory (Cronbach's alpha > 0.70), while two problem-aspect domains were less coherent. The PNPC-sv domains show convergent validity with corresponding health-related quality-of-life domains.

CONCLUSION

The PNPC-sv is a concise, patient-centred tool that helps to identify the problems affecting the patient's quality of life and needs for care. It identifies prevalent needs for care and appears reliable. Further research should study the clinical effects of integrating the questionnaire into daily palliative-care practice.

Dying at home or in an institution: perspectives of Dutch physicians and bereaved relatives

INTRODUCTION

Previous studies have shown that most people prefer to die at their own home. We investigated whether physicians or bereaved relatives in retrospect differently appreciate the dying of patients in an institution or at home.

MATERIALS AND METHODS

Of 128 patients with incurable cancer who were followed in the last phase of their lives, 103 passed away during follow-up. After death, physicians filled out a written questionnaire for 102 of these patients, and 63 bereaved relatives were personally interviewed.

RESULTS

Of 103 patients, 49 died in an institution (mostly a hospital), and 54 died at home (or in two cases in a home-like situation). Patients who had been living with a partner relatively often died at home. Bereaved relatives knew of the patient's wish to die at home in 25 out of 63 cases; 20 of these patients actually died at home. Thirty-one patients had no known preference concerning their place of dying. Most symptoms and the care provided to address them were equally prevalent in patients dying in an institution and patients dying at home. Bereaved relatives were in general quite satisfied about the provision of medical and nursing care in both settings.

CONCLUSION

We conclude that most patients' preferences concerning the place of dying can be met. In about half of all cases, patients do not seem to have a clear preference concerning their place of dying, which is apparently not a major concern for many people. We found no indication that dying in an institution or at home involves major differences in the process and quality of dying.

Patient evaluation of end-of-life care

The Dutch health care system is characterized by a strong emphasis on primary care. To get insight into the strengths and gaps in end-of-life care in the Netherlands, data are needed about use and patient evaluation of end-of-life care. We assessed the experiences of patients with end-of-life care during the last months of life. We followed 128 patients with incurable lung, breast, ovarian, colorectal or prostate cancer. At inclusion they were interviewed personally at home. During follow-up, every 6 months, we asked them to fill out a questionnaire on the end-of-life care they had received. One-hundred of them died during the research period. Eighty-seven of the deceased patients were able to fill out a questionnaire in the last 6 months of their lives. They reported that, on average, 4.2 disciplines were involved in their care. Most patients indicated to be satisfied with the care offered by their caregivers. Problems in end-of-life care concerned communication, difficulties in coordination, accessibility of end-of-life care and responding quickly to acute problems. We conclude that comprehensive and interdisciplinary end-of-life care may address patients' needs, but that it simultaneously is a challenge to optimal communication among disciplines and between caregivers and the patient.

The last 3 days of life in three different care settings in The Netherlands

INTRODUCTION

Little is known about the characteristics of dying in different care settings, such as the hospital, the nursing home, or the home-care setting.

MATERIALS AND METHODS

We measured the burden of symptoms, medical and nursing interventions, and aspects of communication during the last 3 days of life within each of these settings. We included 239 of 321 patients (74%) who died in one of these settings in the southwest of The Netherlands, between November 2003 and February 2005. After the patient's death, a nurse filled in a questionnaire.

RESULTS

Pain and shortness of breath were more severe in hospital patients as compared to nursing home and home-care patients, whereas incontinence was less severe in hospital patients. Several medical interventions, such as a syringe driver, vena punctures or lab tests, radiology or ECG, antibiotics, and drainage of body fluids were more often applied during the last 3 days of life to hospital patients than to nursing home and home-care patients. This also holds for the measurement of body temperature and blood pressure. In the hospital setting, the patient and the family were more often informed about the imminence of death of the patient than elsewhere. The general practitioner and other professional caregivers were less often informed about the imminence of death of hospital patients than of other patients.

DISCUSSION

We conclude that pain and shortness of breath were more severe among hospital patients, whereas incontinence was more severe among nursing home and home-care patients. Hospital patients relatively often receive medical interventions and standard controls during the last 3 days of life. In hospital, communication about impending death seems to take place more often shortly before death.

Patients' needs assessment in cancer care: a review of assessment tools

BACKGROUND

The assessment of patients' needs for care is a critical step in achieving patient-centred cancer care. Tools can be used to assess needs and inform care planning. This review discusses the importance of systematic assessment of needs in routine care and the contribution tools can make to this process.

METHOD

A rapid appraisal was undertaken to identify currently available tools for patient assessment in cancer care through searches conducted with Medline and CINHAL databases. It focused on tools for the systematic assessment of individual patients' needs for help, care or support, to be used for clinical purposes-not for research or other purposes. Tools that focused on a single domain of care such as psychosocial needs were excluded, as were studies of patient satisfaction. A wide list of search terms was used, with references stored and managed using bibliographic software.

RESULTS

In all, 1,803 papers were identified from the initial search, with 91 papers found to be relevant; although 36 tools were identified, only 15 tools were found to fit our criteria. These were appraised for their validity, reliability, responsiveness to change and feasibility, including acceptability to patients. The process of their development and psychometric properties were reasonably well documented, but data on how feasible they were to use in practice was scarce. Each tool met some but not all the widely accepted criteria for validity, reliability, responsiveness and burden. None were found to be complete for all dimensions of needs assessment. Most have not been sufficiently well tested for use in routine care.

CONCLUSION

There is a need to continue to develop and test tools that have the attributes necessary for effective practice and to research their effects on the quality of supportive cancer care.

Problems experienced by the informal caregivers of cancer patients and their needs for support

Informal caregivers experience problems of their own for which they need support, but despite the efforts of the World Health Organization to include the well-being of family members and caregivers in the concept of palliative care, their needs are rarely assessed systematically. This report explores caregivers' problems and their needs for professional support. Seventy-six caregivers of cancer patients with advanced disease completed a comprehensive needs assessment questionnaire, the Problems and Needs in Palliative Care questionnaire-caregiver form, listing 67 potential problems in their quality of life and their role of caregiver and 9 items concerning informational needs. The results of this study reveal that the "Top 20" list of the problems and needs reported by caregivers includes fears and emotional burdens; for the most part, caregivers did not need any more professional attention than they were already receiving. Many, however, needed support for managing patients' symptoms and wanted professional attention for the availability and coordination of services. Despite communalities, there was diversity in caregivers' individual needs. Personal needs could be identified with the Problems and Needs in Palliative Care questionnaire-caregiver form checklist. Although only a few caregivers were affected by some issues, such as financial problems, help for them was often needed. In conclusion, most caregivers would like more professional attention for 4 or 5 specific issues, often related to their competence as caregivers for their patients. Using structured needs assessments with the Problems and Needs in Palliative Care questionnaire-caregiver form seems a feasible method to identify the needs of individual caregivers in palliative care.

Spiritual issues in palliative care consultations in the Netherlands

INTRODUCTION

In the Netherlands, healthcare professionals are able to consult Palliative Care Consultation (PCC) teams about individual patients, for information, support and advice. This study aims to understand which spiritual issues are discussed in these consultations and to determine which factors influence whether they are raised or not.

METHODS

The national register of the consultations of the PCC teams was analysed for a two-year period.

RESULTS

Spiritual issues played a role in 8.4% of palliative care consultations, of which 4.1% were by phone and 18.3% were bedside consultations. Often spiritual issues were raised by the consultant during the exploration of the request from the caregiver; the discipline of the consultant rather than the discipline of the requesting professional or the patient characteristics determined whether or not such issues were raised. The main support given by the consultant was in coaching the professional caregiver on how to address these issues.

DISCUSSION

This study demonstrates the important role of PCC team consultants in exploring and identifying the spiritual needs of patients about whom they are consulted. Although continued education in spiritual care for palliative care professionals is essential, PCC team consultants will play an important role in drawing the attention of healthcare professionals to the need to recognize and address the spiritual needs of their patients.

Living With Incurable Cancer at the End of Life-Patients' Perceptions on Quality of Life

This study describes incurably ill cancer patients' perceptions of the quality of life at the end of life. Purposeful sampling was used to get as comprehensive descriptions as possible about quality of life. Five patients participated in repeated focus groups. Content analysis showed that the patients emphasized what they could perform and enjoy in daily life, not their shortcomings. Five themes were developed: "valuing ordinariness in life," "maintaining a positive life," "alleviated suffering," "significant relations," and "managing life when ill." The themes describe that the patients could participate in daily and social life despite cancer. Relation with family and palliative team deepened during the progress of illness in such that a resonance developed in communication. Other important findings were that patients' memories helped them to maintain a positive life and that the patients used individual strategies to relieve pain by emotional and physical distractions. For the patients, managing life as ill meant taking actions with creative thinking in solving problems as a way to cope and achieve quality of life. These positive findings from the focus groups have led to continued research regarding how patients with incurable cancer perceive quality of life.

Randomized controlled trial of an educational intervention for managing fatigue in women receiving adjuvant chemotherapy for early-stage breast cancer

PURPOSE

To evaluate the efficacy of a psychoeducational intervention in improving cancer-related fatigue.

PATIENTS AND METHODS

This randomized controlled trial involved 109 women commencing adjuvant chemotherapy for stage I or II breast cancer in five chemotherapy treatment centers. Intervention group patients received an individualized fatigue education and support program delivered in the clinic and by phone over three 10- to 20-minute sessions 1 week apart. Instruments included a numeric rating scale assessing confidence with managing fatigue; 11-point numeric rating scales measuring fatigue at worst, average, and best; the Functional Assessment of Cancer Therapy-Fatigue and Piper Fatigue Scales; the Cancer Self-Efficacy Scale; the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30; and the Hospital Anxiety and Depression Scale. For each outcome, separate analyses of covariance of change scores between baseline (T1) and the three follow-up time points (T2, T3, and T4) were conducted, controlling for the variable's corresponding baseline value.

RESULTS

Compared with the intervention group, mean difference scores between the baseline (T1) and immediate after the test (T2) assessments increased significantly more for the control group for worst and average fatigue, Functional Assessment of Cancer Therapy-Fatigue, and Piper fatigue severity and interference measures. These differences were not observed between baseline and T3 and T4 assessments. No significant differences were identified for any pre- or post-test change scores for confidence with managing fatigue, cancer self-efficacy, anxiety, depression, or quality of life.

CONCLUSION

Preparatory education and support has the potential to assist women to cope with cancer-related fatigue in the short term. However, further research is needed to identify ways to improve the potency and sustainability of psychoeducational interventions for managing cancer-related fatigue.

Patient autonomy problems in palliative care: systematic development and evaluation of a questionnaire

No instrument to assess autonomy problems in palliative care is currently available. The purpose of this study was to develop a comprehensive and concise questionnaire to measure autonomy problems in palliative cancer patients and to study its validity and reliability. We systematically developed a questionnaire through: a) a literature review of the concepts and elements of autonomy; b) qualitative analysis of interviews with patients and professional carers; c) the construction of questionnaires; and d) testing validity and reliability. The basic conceptual elements were: dependency, losing control, and limitation of activities. Patients with disseminated cancer in the palliative stage of the disease (n = 64) participated in the study. A 9-item Patient Autonomy Questionnaire (PAQ) was developed (Cronbach's alpha 0.86), followed by a concise 4-item version (PAQs) (Cronbach's alpha 0.71). Autonomy problems were more prevalent than pain problems. The development of the PAQ may help draw attention to autonomy problems.

Positive and negative affect after diagnosis of advanced cancer

Anxiety and depression are studied thoroughly in patients with advanced cancer. However, little is known about the nature of mood disorders in this stage of the disease. We studied positive and negative affect in patients who have had a diagnosis of advanced cancer, and examined how these are related to anxiety and depression, and to other patient and care factors. One hundred and five patients filled out a written questionnaire and were interviewed personally. The PANAS positive affect scores were lower than those in the general population, but the negative affect scores were fairly similar. We found a rather low prevalence of depression (13%) and anxiety (8%) as measured by the HADS. The emotional problems patients mentioned most frequently were anxiety about metastases (26%), the unpredictability of the future (18%) and anxiety about physical suffering (15%). Both positive and negative affect were most strongly related to patient's sense of meaning and peace. We conclude that distinguishing positive and negative affect enhances the understanding of psychological distress of patients with advanced cancer, that seems to be mainly caused by low levels of positive affect. Several theories are discussed to explain this finding, that may contribute to efforts to improve care for these patients.

Health needs assessment tools: Progress and potential

Objectives:Health needs has attracted the interest of policy-makers, health economists, and health professionals as modern health services try to satisfy individual and population health needs to optimize resource utilization. Health needs can be assessed by administering various types of survey or interview-based instruments. If health needs are to be satisfied in changing health agendas in developed and developing countries, it is essential to employ valid and reliable tools. Despite the importance of needs assessment, no comprehensive review of tools is currently available. We carried out a literature search to define and categorize existing health needs assessment tools.

Methods:We reviewed medical and social search engines for items containing specific health needs–related words to identify needs tools across a range of specialties. Papers were reviewed in terms of design, subject matter, psychometric features, and method of administration method.

Results:Thirty-one employed in 52 studies including cancer, mental health, palliative care, multiple sclerosis, and cardiovascular disease tools were identified.

Conclusions:This report summarizes available health needs instruments in a range of diseases to assist researchers in accessing health needs resources more easily and to encourage further research in this field.

Information needs of patients with incurable cancer

GOALS

The aims of this study were to describe to what extent cancer patients with incurable cancer report to have been informed about disease-related topics and how they evaluate the quality of the information giving.

PATIENTS AND METHODS

One hundred and twenty-eight patients participated in our study within 2 months after having had a diagnosis of incurable cancer. They filled out a questionnaire and were interviewed personally. We assessed the level of information, information needs and demographic factors, and we registered the type and duration of the cancer, cancer therapy, other types of received care and contacts with health care professionals. Furthermore, we assessed patients' appreciation of the information giving by their health care professionals.

MAIN RESULTS

The majority of the patients said to have been informed about treatment options, side effects of their treatment, physical symptoms, where to get help, helpful devices, and diet, whereas less than half of the patients were informed about psychosocial care, euthanasia, and complementary care. Of all patients, 39% felt a need for additional information about topics such as physical symptoms, diet, euthanasia, and alternative or complementary care, whereas 19% would have appreciated extra written information. Most patients (78-88%) were satisfied with the information giving by the clinical specialist, oncology nurses, and non-specialised nurses, but only 63% evaluated the information giving by general practitioners as good.

CONCLUSION

We conclude that most patients feel sufficiently informed about important disease-specific issues and are satisfied with the information giving by health care professionals. Nevertheless, a considerable number of patients appreciate additional information.

General practitioners (GPs) and palliative care: perceived tasks and barriers in daily practice

BACKGROUND

General practitioners (GPs) play a crucial part in palliative care. The quality of care can be improved by investigating and addressing barriers perceived by GPs in daily practice. The aim of this study was to investigate GPs' task perception and barriers involved in palliative care.

METHODS

Qualitative focus group study. We gathered together a group of GPs representing a broad range of experience in palliative care. Content analysis was performed to derive a comprehensive view of tasks and barriers in daily palliative care.

RESULTS

GPs described their palliative care tasks as satisfactory and varied, but burdensome. Palliative care tasks included somatic and psychosocial care. Opinions differed with respect to whether the coordination of care belonged to the primary GP tasks. Barriers were classified according to three levels: (1) personal: barriers related to knowledge, skills, emotions; (2) relational: barriers concerning communication and collaboration; (3) organizational: barriers related to the organization of care and compartmentalization in healthcare.

CONCLUSIONS

This study revealed a complex web of tasks and barriers. It may be possible to trace back a problem (lack of knowledge, for example) on the personal level to an isolated knowledge gap, but the problem may well have originated from communication or compartmentalization problems. To maintain GPs' feeling of being at ease with palliative care requires helping them acquire the appropriate balance between technical and organizational interventions and a compassionate orientation to their terminally ill patients.

The problems experienced by patients with cancer and their needs for palliative care

OBJECTIVES

To investigate the problems that patients experience and their met- and unmet needs for professional help. This information is necessary to tailor palliative care to patient needs.

PATIENTS AND METHODS

Patients (n=94) with disseminated cancer completed a validated checklist with 90 potential problems and needs for palliative care (PNPC questionnaire).

MAIN RESULTS

On average, patients experienced 37 problems (range 0-68) and required more professional attention for eight problems (range 0-71). The five most prevalent problems were: fatigue, heavy housework, coping with the unpredictability of the future, fear of metastases, and frustrations because I can do less than before. The five issues most in need of extra attention were: informational needs, coping with the unpredictability of the future, fear of metastases, fear of physical suffering, and difficulties remembering what was told (during consultations). Younger patients experienced more social, psychological, and financial problems. Some 10% of patients expressed a multitude of problems and needs.

CONCLUSIONS

While patients with metastasized cancer experienced a wide variety of problems, they asked for more support for only a few specific problems. Evidently, "problems" are not synonymous with unmet needs. Therefore, not only problems but also needs for care should be assessed. A structural need for support to cope with fears of suffering and loss of autonomy was found. Ten percent of patients expressed a multitude of problems and needs and might benefit either from psychological counseling or better palliative care.

Towards a new clinical tool for needs assessment in the palliative care of cancer patients: the PNPC instrument

This study describes a new clinical tool for needs assessment in palliative care: the Problems and Needs in Palliative Care questionnaire (PNPC). It was developed to support the provision of care tailored to the specific demands of patients, which only can be provided when their needs are clearly identified. To test validity and reliability, 64 patients with metastatic cancer living at home completed the PNPC. Of 140 initial items, 2 were deleted because of low response. No important topics were missing. Dimensions were proposed to organize the problems and needs in a logical and practical array for use in individual patients, and to enable statistical analysis of patient-groups. Reliability analysis supported the proposed dimensions, with Cronbach's alpha coefficient >0.70 for dimensions with > or = 5 items, and alpha >0.65 for the 3- and 4-item dimensions. However, the dimensions 'physical symptoms' and 'social issues' lacked coherency with some low item-total correlations. The PNPC demonstrated convergent validity with the European Organization for Research and Treatment of Cancer (EORTC) and COOP-WONCA quality-of-life measures. These data are a first step in validating the PNPC, although the 'social issues' dimension needs reconsideration. Further studies are needed to evaluate clinical use.