End of life issues in older patients

Symptoms of depression, sadness and sense of coherence (coping) among cognitively intact older people with cancer living in nursing homes-a mixed-methods study

BACKGROUND

Symptoms of depression are often reported among patients with a cancer diagnosis. Strong sense of coherence (SOC) is shown to be associated with less depression in the general older population and among nursing homes (NH) residents in particular. Knowledge about mixed-methods perspectives that examine symptoms of depression and SOC among cognitively intact NH residents with cancer is scarce.

AIM

To investigate symptoms of depression and SOC among NH residents who are cognitively intact and have cancer.

METHODS

We used a quantitatively driven mixed-methods design with sequential supplementary qualitative components. We facilitated the collection of quantitative survey data of 60 NH residents (≥ 65 years) with cancer using the Geriatric Depression Scale (GDS) and SOC scale. The supplementary psychosocial component comprised qualitative research interviews about experiences related to depression with nine respondents from the same cohort.

RESULTS

In fully adjusted multiple regression analysis of the sociodemographic variables, the GDS was significantly correlated with SOC (P < 0.001). The experience of sadness was identified by the following theme: sadness. Coping with the experience of symptoms of depression was dominated by coping with sadness.

CONCLUSION

More than half the NH residents reported symptoms of depression, and the SOC was associated with reduced symptoms. A mixed-methods design contributed to nuanced and detailed information about the meaning of depression, and the supplementary component informs and supports the core component. To improve the situation of NH residents with cancer, more attention should be paid to the residents' experience of symptoms of depression and their SOC.

Cancer-related pain and symptoms among nursing home residents: a systematic review

CONTEXT

Many older nursing home (NH) residents with cancer experience pain and distressing symptoms. Although some develop cancer during their time in the institution, an increasing number are admitted during their final stages of their lives. Numerous studies have evaluated various treatment approaches, but how pain and symptoms are assessed and managed in people with cancer with and without dementia is unclear.

OBJECTIVES

The objective of this review was to summarize the evidence on cancer-related symptoms among NH residents with and without dementia.

METHODS

We systematically searched the PubMed (1946-2012), Embase (1974-2012), CINAHL (1981-2012), AgeLine, and Cochrane Library (1998-2012) databases using the search terms neoplasms, cancer, tumor, and nursing home. The inclusion criteria were studies including NH residents with a diagnosis of cancer and outcome measures including pain and cancer-related symptoms.

RESULTS

We identified 11 studies (cross-sectional, longitudinal, clinical trial, and qualitative studies). Ten studies investigated the prevalence and treatment of cancer-related symptoms such as vomiting, nausea, urinary tract infections, and depression. Studies clearly report a high prevalence of pain and reduced prescribing and treatment, regardless of the cognitive status. Only one small study included people with cancer and a diagnosis of dementia. Studies of new cancer diagnoses in NHs could not be identified.

CONCLUSION

This review clearly reports a high prevalence of pain and reduced drug prescribing and treatment among NH residents with cancer. This issue appears to be most critical among people with severe dementia, emphasizing the need for better guidance and evidence on pain assessment for these individuals.

The lack of standard definitions in the supportive and palliative oncology literature

CONTEXT

Multiple organizations have raised concerns about the lack of standard definitions for terminology in the supportive and palliative oncology literature.

OBJECTIVES

We aimed to determine 1) the frequency of 10 commonly used terms in the supportive and palliative oncology literature, 2) the proportion of articles that provided definitions for each term, and 3) how each term was defined.

METHODS

We systematically searched MEDLINE, PubMed, PsycINFO, the Cochrane Library, Embase, ISI Web of Science, and Cumulative Index to Nursing and Allied Health Literature for original studies, review articles, and systematic reviews related to palliative care and cancer in the first six months of 2004 and 2009. We counted the number of occurrences for "palliative care," "supportive care," "best supportive care," "hospice care," "terminal care," "end-of-life," "terminally ill," "goals of care," "actively dying," and "transition of care" in each article, reviewed them for the presence of definitions, and documented the journal characteristics.

RESULTS

Among the 1213 articles found, 678 (56%) were from 2009. "Palliative care" and "end-of-life" were the most frequently used terms. "Palliative care," "end-of-life," and "terminally ill" appeared more frequently in palliative care journals, whereas "supportive care" and "best supportive care" were used more often in oncology journals (P<0.001). Among 35 of 601 (6%) articles with a definition for "palliative care," there were 16 different variations (21 of 35 articles used the World Health Organization definition). "Hospice care" had 13 definitions among 13 of 151 (9%) articles. "Supportive care" and other terms were rarely defined (less than 5% of articles that used the term).

CONCLUSION

Our findings highlight the lack of definitional clarity for many important terms in the supportive and palliative oncology literature. Standard definitions are needed to improve administrative, clinical, and research operations.

Needs of older cancer survivors in a community cancer care setting

This study describes the unique supportive care needs and associated distress among older adults receiving cancer survivorship care in a community cancer center. The psychological and social changes that accompany aging may influence the impact of cancer, so documenting the distinctive experiences of older survivors is critical to the development of evidence-based practice guidelines. A secondary analysis of data was conducted using results from a survey of adult cancer survivors. Data were available from a convenience sample of 307 survivors receiving care in a community cancer care setting who volunteered to complete a Survey of Needs. Fatigue, fear of recurrence, sleep disturbance, balance/walking/mobility difficulties, long-term effects of treatment, and body changes were most frequently reported. Results suggest assessment of older adult cancer survivors' experiences related to physical symptoms, symptom management, and interest in education targeting physical effects common to survivorship.

Comparison of End-of-Life Preferences Between Japanese Elders in the United States and Japan

Significant attention is being paid to end-of-life preferences and their cultural variations. This study compares end-of-life preferences between older Japanese residing in Japan and the United States. A self-administered questionnaire was provided to elders affiliated with senior centers and clubs. Japanese Americans preferred to make decisions themselves about withholding life-sustaining treatments, whereas Japanese in Japan preferred to rely on physicians and family members. The U.S. sample showed more positive attitudes toward and higher completion rates of advance directives than the Japanese sample. Results suggest that end-of-life preferences differ between Japanese elders in the two countries and that preferences are influenced by contextual factors in one's country of residence. Practitioners need to be aware of both within-group and across-group diversity in end-of-life preferences, taking into account acculturation changes.

Role of a medical social worker in improving quality of life for patients with advanced cancer with a structured multidisciplinary intervention

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BACKGROUND

</i> Patients with advanced cancer face multiple challenges to their quality of life (QOL). The goal of this study was to investigate the impact of participation in a multidisciplinary intervention, including a social service component, on improving the QOL of patients with advanced cancer undergoing radiation therapy. <i>

DESIGN

</i> A total of 115 participants with newly diagnosed advanced stage cancer, who were receiving radiation therapy, were randomly assigned to either participate in an 8-session structured multidisciplinary intervention or to receive standard care. Each 90-minute session was led by either a psychologist or psychiatrist and co-led with a nurse, physical therapist, chaplain, and/or social worker. The sessions were designed to address the domains that impact QOL: emotional, spiritual, physical, and social domains (support, community resources, financial and legal issues, and advance directives). QOL was assessed, at baseline, 4 (end of treatment), 8 and 27 weeks. The primary endpoint was overall QOL assessed on a 0-100 scale at Week 4. <i>

RESULTS

</i> A total of 115 patients were enrolled from October 2, 2000 to October 28, 2002. Overall QOL at Week 4 averaged 10 points higher in the intervention group than in the control group (80 vs. 70 points, p = 0.047) which was an increase of 3% from baseline in the intervention group versus a decrease of 9% in the control group (p = 0.009). Of the subscores reflecting patient's opinion regarding their QOL, there was improvement in all social domains which contributed to the overall improvement in QOL. Significant changes from baseline to Week 4 scores were seen in the areas of financial concerns (p = 0.025) and legal issues (p = 0.048). <i>

CONCLUSIONS

</i> A social work component within a structured multidisciplinary intervention results in significant advantages in the social domain of QOL, and contributes to clinically meaningful improvements in the overall QOL for patients with advanced cancer undergoing active medical treatment. Numerous studies have documented the financial burdens and social changes that may occur with the diagnosis of cancer. However, previous research has not examined the role of a social worker in providing financial, social, and legal education, in a structured multidisciplinary intervention, and its direct impact on QOL. Outlined in this paper is the role of the medical social worker in a clinical trial, how education was provided and strategies for future interventions. doi:10.1300/J077v25n04_07.

Ethical problems in end-of-life decisions for elderly Norwegians

Norwegian health professionals, elderly people and family members experience ethical problems involving end-of-life decision making for elders in the context of the values of Norwegian society. This study used ethical inquiry and qualitative methodology to conduct and analyze interviews carried out with 25 health professionals, six elderly people and five family members about the ethical problems they encountered in end-of-life decision making in Norway. All three participant groups experienced ethical problems involving the adequacy of health care for elderly Norwegians. Older people were concerned about being a burden to their families at the end of their life. However, health professionals wished to protect families from the burden of difficult decisions regarding health care for elderly parents at the end of life. Strategies are suggested for dialogue about end-of-life decisions and the integration of palliative care approaches into health care services for frail elderly people.

End-of-life care for nursing home residents dying from cancer in Nova Scotia, Canada, 2000-2003

INTRODUCTION

With our population aging, an increasing proportion of cancer deaths will occur in nursing homes, yet little is known about their end-of-life care. This paper identifies associations between residing in a nursing home and end-of-life palliative cancer care, controlling for demographic factors.

METHODS

For this population-based study, a data file was created by linking individual-level data from the Nova Scotia Cancer Centre Oncology Patient Information System, Vital Statistics, and the Halifax and Cape Breton Palliative Care Programs for all persons 65 years and over dying of cancer from 2000 to 2003. Multivariate logistic regression was used to compare nursing home residents to nonresidents.

RESULTS

Among the 7,587 subjects, 1,008 (13.3%) were nursing home residents. Nursing home residents were more likely to be female [adjusted odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2-1.7], older (for > or = 90 vs 65-69 years OR 5.4, CI 4.1-7.0), rural (OR 1.5, CI 1.2-1.8), have only a death certificate cancer diagnosis (OR 4.2, CI 2.8-6.3), and die out of hospital (OR 8.5, CI 7.2-10.0). Nursing home residents were less likely to receive palliative radiation (OR 0.6, CI 0.4-0.7), medical oncology consultation (OR 0.2, CI 0.1-0.4), and palliative care program enrollment (Halifax OR 0.2, CI 0.2-0.3; Cape Breton OR 0.4, CI 0.3-0.7).

CONCLUSION

Demographic characteristics and end-of-life services differ between those residing and those not residing in nursing homes. These inequalities may or may not reflect inequities in access to quality end-of-life care.

The social, professional, and legal framework for the problem of pain management in emergency medicine

The problem of harmful, unnecessary and neglected pain has been studied extensively in many health care settings over the past decade. Research has documented the incidence of untreated pain, and scholars and advocates have given the problem several names: “public health crisis,” “oligoanalgesia, and “moral failing,” among them. Articles have identified a litany of now familiar “obstacles” or “barriers” to effective pain relief. Each of these individual obstacles or barriers has been the subject of targeted remedial action in at least some context.

The checklist approach to improving care for patients in pain, however, is likely to have only limited effect. What really appears to be operating is a complex ecosystem that supports ambivalence, denial, and even suspicion of the circumstance of patients in pain and efforts to treat them. Pain relief in emergency medicine, a relatively new setting for the study of challenges to treating pain, provides a revealing context for viewing discrete obstacles to effective pain management in medicine as part of an integrated environment into which patients with pain enter for treatment.