Palliative care in oncology: making quality the endpoint

A Reliability and Validity Study of the McMaster Quality of Life Scale (MQLS) for a Palliative Population

The McMaster Quality of Life Scale (MQLS) was developed to measure the quality of life in a palliative patient population. This paper describes the tool and its psychometric properties. Palliative stage patients could assess their condition using this tool (r=0.84; 95% CI 0.76–0.94). Although ratings by different raters (patient, family, staff) were correlated, systematic differences were found by source of rating, which suggests that proxy rating (substituting family or staff ratings for a patient rating) should be avoided. The MQLS was sensitive to changes in the patient's quality of life. Neither age nor sex of patient influenced total score obtained. Persons close to death rated their quality of life as being poorer than those who were alive at the end of the data collection period. People who needed to have the MQLS read to them rated their quality of life somewhat lower than patients who could complete the task by themselves. Staff-rated MQLS scores correlated significantly with the staff-rated Spitzer Quality of Life Index. This study suggests the MQLS is a reliable and valid measure of quality of life during the palliative phase.

Measurement of quality of life in patients with end-stage cancer

BACKGROUND

Cancer is the leading cause of death in Korean adults. A good quality of life for patients at end life can control pain and symptoms and help maintain well-being.

OBJECTIVE

The aim of this study was to measure quality of life in end-stage cancer patients using the Korean version of the McMaster Quality of Life (K-MQOL).

METHODS

The K-MQOL was administered to adult end-stage cancer patients from 4 Korean university hospitals. We hypothesized quality-of-life differences between participants by daily activity level, number of symptoms, and participant status (alive or not) at end of study.

RESULTS

Participants' mean age was 49.2 years, and 74.5% were men. As hypothesized for discriminant validity, Pearson correlation coefficients among the K-MQOL were less than 0.4, with the exceptions of emotion (0.25-0.52) and cognition (0.33-0.51). A higher Eastern Cooperative Oncology Group Performance States Rating score was significantly associated with a lower quality of life (F = 2.840, P = 0.034). The mean score of those within 21 days of death was significantly lower than that of patients who were alive at the end of the study (t = -2.48, P = .04). Patients with a smaller number of symptoms other than pain had significantly higher quality-of-life scores than did those with more symptoms (F = 5.059, P = .004).

CONCLUSIONS

The K-MQOL provided reliable and valid scores of quality of life in end-stage cancer patients.

IMPLICATIONS FOR PRACTICE

Assessing end-stage cancer patients' quality of life helps to identify each patient's condition and aspects that could benefit from nursing care. We anticipate that the K-MQOL will be useful for patient assessment in clinical and community settings.

Enabling Communication and Enhancing Services for People with Motor Neurone Disease

Ignorance about the impact of motor neurone disease (MND) may be undermining services for people with the condition. Challenges around communication in the research setting suggest ways of addressing some potential barriers to quality in the community.

Instruments for assessing quality of life in palliative care settings

Quality of life is an outcome that is particularly important during palliative care. However, in order to measure this outcome, it is necessary to have a valid and reliable measure. The purpose of the article was to identify and describe quality of life measures that are appropriate for use in palliative care settings. Characteristics that are believed to be critical for quality of life instruments include the following. The instrument should: (1) be multidimensional; (2) provide self-report data; (3) be useful in the setting in which it is to be used; (4) be valid and reliable for use in palliative care settings. The five scales described measure a variety of dimensions including physical, psychological, social, spiritual, existential, support, symptoms and functional aspects of quality of life. All but one are self-report instruments. All have evidence of validity and reliability for use with palliative care populations.

The last 3 months of life of cancer patients: medical aspects and role of home-care services in southern Switzerland

The clinical data on terminal cancer patients who have died since the establishment of a program of collaboration between community services and the cancer center of Canton of Ticino, southern Switzerland, were retrospectively analyzed to describe the characteristics of patients seen and the effect on them of a home-care program coordinated by the cancer center. The home-care program is based on five geographically grouped community-based domiciliary services, with the addition of one nurse responsible for coordination and one physician from the oncology center. Selection criteria for participation in the home-care program are defined. The main outcome measures were: number of hospitalizations and median hospital stay during the last 3 months of life; reasons for and median length of last hospitalization; place of death of patients who had home care and those who did not. In the group of 993 patients analyzed, the median contact time with the cancer center was 9.5 months (10th percentile: 1 month, 90th percentile: 71 months); the most frequent neoplasm was lung cancer (22%) with the briefest contact time (7.5 months; 10th percentile: 1 month; 90th percentile: 21 months); 13.5% of patients were never hospitalized; half of the patients had a total hospital stay of 24 days or longer and 23% died at home. The sociodemographic and medical characteristics of home-care users were similar to those of the home-care non-users and to those of the overall group. In the group of home-care users (32% of the total) 22% were never hospitalized, half of the patients had a total hospital stay of 17 days or longer, and 43.5% of them died at home. These values were significantly different (P > 0.001) from those reported in the group of home-care non-users. Palliative care, provided at home through community-based domiciliary services, is associated with less frequent and shorter hospitalizations in the last 3 months of life. Medical oncology and palliative treatments should be mutually complementary to improve patients care. Cancer centers should be involved in the planning and coordination of supportive-care domiciliary services.

Recent clinical trials of pain control: impact on quality of life

The understanding and treatment of pain is one of the oldest challenges for physicians, scientists and philosophers. Much of our present rationale of pain control is based on the Cartesian idea that pain mostly originates from external or internal noxious stimuli, which are transmitted to and interpreted in the brain. Consequently, removal (blocking) of the stimuli and modification of cerebral awareness have been the prime targets of analgesic interventions. Only recently has the relationship between pain and other physical, psychological and social aspects of illness been considered in the overall management plan. Most of the literature on pain control reveals the physical bias of measurement. Apart from simple but reliable tools such as visual analogue scales and Likert-type verbal scales, more sophisticated measures such as multidimensional pain inventories have also been used when it is necessary to characterise pain more specifically. In clinical studies, it is usual to ask the patient to report on his own pain, although proxy measures such as mobility, performance status and analgesic consumption are also often used. The hospice concept of "total pain", in which the psychological, social, spiritual and other aspects are emphasised, has been influential in our new approach to pain measurement. Particularly when it is chronic and related to advancing disease as in metastatic cancer, pain can interact significantly with many facets of daily living. A holistic model of quality of life in such patients should, therefore, include a multidimensional or modular assessment of these areas. Medical interventions themselves can affect quality of life in both positive and negative ways. Some side-effects may be so common as to be accepted as "normal", e.g. constipation or sedation with opioids: it is only by their careful evaluation, when comparing opioids with essentially similar analgesic potentials, that differential toxicities may be revealed. Simple recording of physical side-effects of drugs is really not sufficient, because analgesics as well as other therapies may be associated with mood changes and broader consequences for quality of life. Only in the past few years has quality of life been seriously addressed in palliation research. For example, standardised quality of life scales are now included almost routinely in oncological studies involving radiotherapy or chemotherapy by the Medical Research Council (MRC) of Great Britain. Trials of the new biphosphonates, which can reduce bone pain in metastatic cancer, have been enhanced by incorporating quality of life measures. Based on the experience from earlier efficacy/safety studies with the new transdermal route of drug delivery for the opioid fentanyl, important areas of life such as sleep and cognitive function have been addressed. Randomised controlled trials of analgesics which include quality of life endpoints are still rare, but should be encouraged as these represent the most rigorous way of evaluating new therapies. The current preoccupation with quality assurance in healthcare is directed, ultimately, to the delivery of a better quality of care, which should also be more cost-effective, for large populations. An important intermediate step towards that ideal is the collection of data on pain and other symptoms, but also validated quality of life parameters on well-defined groups. Only by widening the scope of analgesic studies to include these dimensions can we hope to define appropriate strategies for more rational healthcare.

Quality of life assessment in palliative care

Palliative care aims to improve the quality of life of patients through attention to physical, psychological, social and spiritual distress. Assessment of quality of life, expressed as a global score, is difficult because patients are too ill for long interviews, but relatives and professionals are poor proxy respondents for patients. Quality of life assessment tools must be multidimensional, considering both physical and psychosocial issues, must be quick and easy to administer and score and must be sufficiently sensitive to detect changes with time. Quality of life assessment has audit and routine clinical uses; it is an essential consideration in any research involving the patient with advanced cancer. The different types of questionnaire assessment tool are discussed in detail.

A therapy impact questionnaire for quality-of-life assessment in advanced cancer research

The first part of the validation procedure used for a Therapy Impact Questionnaire (TIQ) on quality-of-life assessment in advanced cancer patients is described. The TIQ is composed of 36 items which assess both disease and therapy impact according to four dimensions that operationally define quality of life: physical symptoms (24 items), functional status (3 items), concomitant emotional and cognitive factors (6 items) and social interaction (2 items). A global judgement expressed as "have you been feeling ill" further completes the TIQ. Patients answered each question using a 4-point verbal Likert scale: not at all, slight, a lot and very much. The TIQ was given to 1,000 consecutive patients who were no longer responsive to cancer treatment and presented symptoms due to disease progression. The compliance rate was quite high (87%). Results of confirmatory factor analysis were consistent with the operational dimensions identified during questionnaire construction. In particular, the dichotomized answers to 3 functional status items could be used as a Guttman scale. In a sub-sample of 50 patients, the reproducibility of functional status items was assessed using a 7-item parallel form. The intraclass correlation coefficient obtained indicated a reasonably high reproducibility. On the basis of the analyses conducted, the TIQ appears to be a reliable and concise instrument for studies aimed to assess the effectiveness of therapies in advanced cancer patients.