ABC of palliative care. The carers

Evaluation of the effect of accompanying lymphedema on the quality of life and anxiety level of caregivers of patients with breast and genitourinary system cancers

Objectives

This study aims to determine the effect of accompanying lymphedema in patients with breast or genitourinary system cancer on the quality of life and anxiety levels of caregivers of these patients.

Patients and methods

Sixty-three caregivers (37 males, 26 females; mean age: 47.5±14.4 years; range, 20 to 80 years) of patients with breast or genitourinary system cancer and lymphedema, 40 caregivers (21 males, 19 females; mean age: 43.9±15.6 years; range, 18 to 75 years) of patients with breast or genitourinary system cancer without lymphedema, and 52 healthy volunteers (15 males, 37 females; mean age: 37.0±10.8 years; range, 23 to 68 years) as the control group were included in the cross-sectional study between May 10, 2022 and August 10, 2022. Sociodemographic information of the caregivers and information about the cancer diagnosis of the patients were recorded. The anxiety level of the caregivers was assessed with the Beck Anxiety Inventory (BAI), hopelessness level with the Beck Hopelessness Scale (BHS), and quality of life with the Caregiver Quality of Life Index-Cancer (CQOL-C).

Results

There was no statistically meaningful difference between the caregivers of patients with and without lymphedema and the control group regarding anxiety (p=0.818). The hopelessness level was higher in caregivers of patients with lymphedema compared to healthy controls (p=0.011). No statistically meaningful difference was found in CQOL-C burden, disruptiveness, positive adaptation, or financial concerns subscales in caregivers of patients with and without lymphedema (p=0.697, p=0.209, p=0.823, p=0.855, and p=0.257, respectively). Continuous caregiving was negatively associated with the total CQOL-C score in caregivers of patients with lymphedema (p=0.031). Complex decongestive therapy was negatively associated with high BAI and BHS scores (p=0.038 and p=0.034, respectively).

Conclusion

Lymphedema has a negative impact on hopelessness, while complex decongestive therapy has positive effects on anxiety and depression. Continuous caregiving may be considered a risk factor for high total CQOL-C scores.

Frequency and Prediction of Burnout Among Physicians Who Completed Palliative Care Fellowship Training - A 10 Year Survey

CONTEXT

Palliative Care (PC) physicians are vulnerable to burnout given the nature of practice. Reports suggest that burnout frequency is variable across different countries.

OBJECTIVE

The main objective of our study was to determine knowledge, attitudes and frequency of burnout among Hospice and Palliative Medicine (HPM) Fellowship graduates trained at a comprehensive cancer center.

METHODS

We conducted a survey to determine the knowledge, attitudes, and frequency of burnout in former fellows, consisting of the Maslach Burnout Inventory (MBI) and 41 custom questions. Palliative care fellows who trained at a Comprehensive Cancer Center from 2008 to 2018 were included in the survey.

RESULTS

Eighty-four percent of the 52 eligible physicians completed surveys. Median age was 38 years, with 68% females. Seventy-seven percent practiced PC more than 50% of time. Median practice duration was four years, and 84% were board certified. Most common disease types treated were cancer (89%), cardiac (43%) and pulmonary (43%). Burnout rate was high at 52% (n=20). The median scores for emotional exhaustion were 25.5, depersonalization 9, and personal accomplishment 48. Female gender (P=0.07) and having administration as a component in the job description (P=0.044) were associated with risk of burnout. Clinical care setting, work hours/week, frequency of weekend calls, and size of team were not significantly associated with burnout.

CONCLUSION

Burnout among former fellows trained in HPM between 2008 and 2018 is high. More research is needed to develop strategies to better prevent and manage burnout among HPM fellowship trained PC physicians.

Prevalence and Determinants of Burnout Among Palliative Care Clinicians in Saudi Arabia

Background

Palliative care is in dire necessity than ever before due to aging populations and the prevalence of cancer and other chronic diseases associated with aging.

Objective

To assess the prevalence and risk factors associated with burnout among palliative care clinicians in Saudi Arabia.

Methods

A cross-sectional study conducted in 2018 covering all palliative care centers of Saudi Arabia and included 44 palliative care physicians (26 males and 18 females). The level of burnout was measured using Maslach Burnout Inventory's (MBI) 22 point scale questionnaire which assesses emotional exhaustion, depersonalization, and reduced personal accomplishment, the three dimensions of burnout syndrome. Pearson correlation and binary logistic analysis were performed using SPSS to find out factors influencing burnout considering P-value of <0.05 as significant.

Results

Eight participants (18.2%) had experienced emotional exhaustion and 11 (25%) had experienced depersonalization and detachment, and reduced personal accomplishment, each. Job title and availability of some administrative departments, supporting health care staff, and pain relief medications have shown significant impact of level of burnout. However, the prevalence of the burnout dimensions did not differ significantly according to the palliative care physicians' other characteristics.

Conclusions

This is amongst the first survey to assess the prevalence of burnout among palliative care physicians in Saudi Arabia. Although, some variables have shown significantly high level in the burnout domains, yet, the overall prevalence of burnout is low among palliative care physicians in Saudi Arabia. The availability of hospitals services such as administrative departments, supporting health care staff, and pain relief drugs have shown significant impact on burnout.

Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis

Oxygen therapy is frequently prescribed for the palliation of breathlessness, despite lack of evidence for its effectiveness in people who are not hypoxaemic. This study aimed to compare and contrast patients', caregivers' and clinicians' experiences of palliative oxygen use for the relief of chronic breathlessness in people with advanced life-limiting illnesses, and how this shapes prescribing.A systematic review and meta-synthesis of qualitative data was conducted. MEDLINE, CINAHL and PsycINFO were searched for peer-reviewed studies in English (2000-April 2019) reporting perspectives on palliative oxygen use for reducing breathlessness in people with advanced illnesses in any healthcare setting. After data extraction, thematic synthesis used line-by-line coding of raw data (quotes) to generate descriptive and analytical themes.Of 457 articles identified, 22 met the inclusion criteria by reporting perspectives of patients (n=337), caregivers (n=91) or clinicians (n=616). Themes common to these perspectives were: 1) benefits and burdens of palliative oxygen use, 2) knowledge and perceptions of palliative oxygen use beyond the guidelines, and 3) longitudinal trajectories of palliative oxygen use.There are differing perceptions regarding the benefits and burdens of using palliative oxygen. Clinicians should be aware that oxygen use may generate differing goals of therapy for patients and caregivers. These perceptions should be taken into consideration when prescribing oxygen for the symptomatic relief of chronic breathlessness in patients who do not quality for long-term oxygen therapy.

Perceptions, knowledge and attitudes towards the concept and approach of palliative care amongst caregivers: a cross-sectional survey in Karachi, Pakistan

Background

Limited comprehension of the concept of palliative care and misconceptions about it are barriers to meaningful utilisation of palliative care programs. As caregivers play an integral role for patients with terminal illness, it is necessary to assess their perceptions and attitudes towards the palliative care approach.

Method

A cross-sectional survey was conducted. Data was collected from the Aga Khan Hospital in-patient and out-patient departments and home-based palliative care services. All adult caregivers who met the inclusion criteria and consented, completed a questionnaire till the sample size was reached. Univariate and multivariate multivariable analysis was done and results were reported as crude prevalence’s, crude and adjusted prevalence ratios with 95% confidence intervals using Cox-proportional hazard algorithm. Mean difference of knowledge and attitude scores by caregiver variables were assessed using one-way ANOVA. SPSS version 18 was used and a p-value of less than 5% was treated as significant.

Results

Out of 250 caregivers more than 60% were 40 years or less, majority were males and at least graduates. Approximately 70% of the respondents agreed with the statement that the person suffering from cancer should be informed about the diagnosis and disease progression. About 45% (95% C.I.: 39.03, 51.37%) of the study respondents had enhanced understanding about palliative care. Individuals under 40 years old, those with an education level of at least grade 10, children or relatives were found to have significantly more enhanced knowledge about palliative care. The majority believed that the patient should be informed about the diagnosis and should be facilitated to carry out routine activities and fulfill their wishes.

Conclusion

Nearly half of the caregivers had enhanced understanding of the palliative care approach. They showed consistent understanding of two foundational aspects indicating correct knowledge across age groups, gender, education level, and relationship with the patient. Firstly, that palliative care should be offered to everyone suffering from a terminal illness and, secondly, that this approach encompasses not just physical, but also psychological and social needs of the patient and the family. These findings will help inform the establishment of a palliative care program that fills the gaps in comprehension and knowledge of caregivers.

Team approaches in palliative care: a review of the literature

Background:

Interdisciplinary team involvement is commonplace in many palliative care settings across the world. Teamwork is perceived by many experts as an indispensable functionality of palliative care teams. Significantly different structural and functional attributes of these teams between regional and organisational contexts could potentially act both as strengths and weaknesses towards their overall productivity. The sustainability and resilience of the team also has an indirect bearing on the team functioning.

Aim:

This article describes international evidence on dynamic palliative care teams with a view of how and when they function efficiently or adversely. Emphasis is also placed on studies that suggest means to mitigate the conflicts and limitations of teamwork in palliative care and related healthcare settings.

Findings:

Evidence strongly suggests that palliative care is best delivered through a multidisciplinary team approach.

Conclusion:

The overall performance of a healthcare team is largely determined by the supportive work environment built through effective communication, leadership skills and mutual respect.

Depression in caregivers of patients with breast cancer: A cross-sectional study from a cancer research center in South India

CONTEXT

Existing literature suggests an alarming rate of depression in cancer caregivers, which is comparable to or even higher than in patients themselves. There are no studies on depression among caregivers of breast cancer from India.

AIMS

The aim is to study the prevalence and determinants of depression in caregivers of breast cancer.

SETTINGS AND DESIGN

This is a cross-sectional study of 384 patient-caregiver dyads at a cancer research center in South India.

MATERIALS AND METHODS

Based on the International Classification of Diseases, 10^th Revision Diagnostic Criteria for Research depression was diagnosed, and the severity of depression was assessed using the Hamilton rating scale for depression. A semi-structured pro forma was used to collect the clinical data under patient, caregivers, and care characteristics.

RESULTS

The prevalence of depression in caregivers was 52.5%. Among them, 35% had mild depression, 16% had moderate depression, and 2% had severe depression. Spousal caregivers, those who resided with the patient, those providing financial support and those with noncaring domestic responsibilities appeared as vulnerable determinants in univariate analysis. However, multivariate analysis did not support the same.

CONCLUSION

Depression is common among caregivers of patients with breast cancer. There is a need for focused interventions for this group, which may improve the outcome of the patient as well.

The Role of Support Staff in Pediatric Palliative Care: Their Perceptions, Training, and Available Resources

Pediatric palliative care requires the orchestrated efforts of a multidisciplinary care team of medical staff, nursing, psychosocial staff, and other healthcare professionals. Augmenting this team are support staff including financial counsellors, volunteers, secretaries, and others not involved in the direct administration of medical services. Prior research in palliative care has studied the perceptions, training, and professional resources of medical staff and social workers, but neglected to investigate such factors in support staff. Our study examined the effect of involvement in end-of-life pediatric care on support staff. We found this community to consist of a heterogeneous population of hospital employees, who develop numerous, substantial, direct interactions with dying children and their families. They indicated that such experiences had caused some adverse outcomes in their lives, and that few felt they had sufficient knowledge or training in palliative care. Our respondents voiced noteworthy opinions on symptom control, cultural issues, and spirituality pertinent to pediatric palliative care. Support staff play a key role in the palliative care team; research and resources need to be directed to educating, training, and supporting them.

Staff Stress, Work Satisfaction, and Death Attitudes on an Oncology Palliative Care Unit, and on a Medical and Radiation Oncology Inpatient Unit

Professional caregivers for cancer patients are at high risk for work-related stress, but it is not clear how this relates to exposure to death and dying, and to professional satisfaction. This study compares work-related stress and staff satisfaction on an academic acute palliative care unit (PCU) with that on a medical and radiation oncology inpatient unit (OIU) at the same cancer centre. PCU staff tended to report less work stress-particularly related to terminal care—than those on the OIU, and higher work satisfaction and team support. PCU staff were more likely to perceive their work experience as having “positively altered their attitude to death” (p=0.007). These results show that a supportive team environment can exist on an academic PCU and suggest that support currently offered to PCU staff in terms of caring for terminally ill patients should also be extended to those working in general oncology settings.

Professional Competence and Palliative Care: An Ethical Perspective

The aim of this article is to explore an ethical view of professional competence by examining the professional competence of physicians in the context of palliative care. A discussion of the four dimensions of professional competence—knowledge, technical skills, relationships, and affective and moral attitude—leads us to the conclusion that “habits of mind” are important in every aspect of professional competence. This observation is then considered in the context of virtue ethics and ethics of care. Virtue ethics focuses on personal qualities and moral attitudes, while the ethics of care concentrates on the way these qualities are lived out in specific care relationships. Our conclusion points up the importance of education in ethics in the development of professional competence, and argues that because palliative care involves intense human interactions, integrating palliative care into the medical curriculum may improve the ethical culture of health care as a whole.

Educational Needs of Palliative Care Nurses in Quebec

Education appears to be a useful strategy for improving quality of care and work-related stress management. The present study assesses the educational needs of palliative care nurses working in acute care hospitals (n=88) and CLSCs (Centre Local de Services Communautaires, home-based, n=109) of the larger Quebec City area. It also describes relationships between educational needs, psychological distress, and self-efficacy. Nurses were surveyed and compared on training needs, preferred learning format, as well as barriers and factors facilitating attendance to workshops. Similar educational needs were observed in both work settings. Crisis, stress, and emotion management were rated as the most useful topics, followed by nonpharmacological ways to manage pain. Preferred educational formats were lectures and group discussions. Attending free training sessions during work hours was described as the best way to promote participation. Educational needs were positively related to psychological distress, and negatively related to perceived self-efficacy in providing good palliative care.

Feasibility and Acceptability of Distress Screening for Family Caregivers at a Cancer Surgery Center

OBJECTIVES

To determine the feasibility and acceptability of a validated electronic distress screening program for cancer caregivers.

SAMPLE & SETTING

17 informal caregivers presenting with a patient with cancer to an ambulatory cancer surgery center.

METHODS & VARIABLES

Caregivers completed the CancerSupportSource®-Caregiver screening and a brief semistructured interview concerning the screening.

RESULTS

Caregivers described the screening as straightforward and comprehensive. They endorsed concerns about their self-care needs but were most likely to request information or a referral for patient-focused concerns. Referrals generated from the program are likely viably addressed with existing supportive care resources.

IMPLICATIONS FOR NURSING

Brief, caregiver-focused distress screening is perceived positively by caregivers. Caregivers indicated that they felt it validated the importance of their role and highlighted the hospital's efforts to continually improve care. This screening program may be particularly beneficial in ambulatory surgical centers to efficiently identify caregivers with concerns and provide a point of entry to remediate these concerns.

Mind the gap: is the Canadian long-term care workforce ready for a palliative care mandate?

The average expected lifespan in Canadian long-term care (LTC) homes is now less than two years post-admission, making LTC a palliative care setting. As little is known about the readiness of LTC staff in Canada to embrace a palliative care mandate, the main objective of this study was to assess qualities relevant to palliative care, including personal emotional wellbeing, palliative care self-efficacy and person-centred practices (e.g. knowing the person, comfort care). A convenience sample of 228 professional and non-professional staff (e.g. nurses and nursing assistants) across four Canadian LTC homes participated in a survey. Burnout, secondary traumatic stress and poor job satisfaction were well below accepted thresholds, e.g. burnout: mean = 20.49 (standard deviation (SD) = 5.39) for professionals; mean = 22.09 (SD = 4.98) for non-professionals; cut score = 42. Furthermore, only 0–1 per cent of each group showed a score above cut-off for any of these variables. Reported self-efficacy was moderate, e.g. efficacy in delivery: mean = 18.63 (SD = 6.29) for professionals; mean = 15.33 (SD = 7.52) for non-professionals; maximum = 32. The same was true of self-reported person-centred care, e.g. knowing the person; mean = 22.05 (SD = 6.55) for professionals; mean = 22.91 (SD = 6.16) for non-professionals; maximum = 35. t-Tests showed that non-professional staff reported relatively higher levels of burnout, while professional staff reported greater job satisfaction and self-efficacy (p < 0.05). There was no difference in secondary traumatic stress or person-centred care (p > 0.05). Overall, these results suggest that the emotional wellbeing of the Canadian LTC workforce is unlikely to impede effective palliative care. However, palliative care self-efficacy and person-centred care can be further cultivated in this context.

Sleeping with One Eye Open: The Sleep experience of Family Members Providing Palliative Care at Home

Purpose: To empirically describe the sleep experience of family caregivers (n=13) of advanced cancer patients. Method: Mixed methodology using: family interviews; Epworth Sleepiness Scale (ESS); Pittsburgh Sleep Quality Index (PSQI); and actigraphy measurement. Qualitative data analysis utilized constant comparative content techniques. Actiware for the actigraphy data and the Statistical Package for the Social Sciences-15 (SPSS-15) generated descriptive and correlation statistics. Findings: The over arching theme “sleeping with one eye open” captures the vigilant nature of caregivers’ sleep experiences. Caregiver narratives were validated by quantitative findings: 5 of the family caregivers (38.5 percent) had an ESS score ≥ 11 indicative of excessive daytime sleepiness, all caregivers had a PSQI global score > 5 indicative of moderate to severe sleep problems, and actigraphy scores — including total sleep time, sleep efficiency, and time awake after sleep onset — fell beyond normal values documented in the literature. Conclusion: Impeccable assessment of the patient's and family's sleep status, sleep education, intervention strategies, and high-quality respite services are critical in community-based palliative care.

Insomnia among Cancer Caregivers: A Proposal for Tailored Cognitive Behavioral Therapy

Caregivers are relatives, friends, or partners who have a significant relationship with and provide assistance (i.e., physical, emotional) to a patient with often life-threatening, serious illnesses. Between 40 and 76 percent of caregivers for people with cancer experience sleep disturbance. This is thought to be due, in part, to the unique responsibilities, stressors, and compensatory behaviors endemic to caregiving that serve as precipitating and perpetuating factors of insomnia. Sleep disturbances are associated with significant alterations in one's mental and physical health. Once chronic, insomnia does not remit naturally. Cognitive-behavioral therapy for insomnia (CBT-I) is well-suited to address the multifaceted contributing factors unique to caregivers' sleep disturbance, yet only one intervention has tested a CBT-I informed intervention among cancer caregivers. Toward the goal of developing effective, tailored treatments for insomnia in caregivers, we address the distinct presentation of insomnia among cancer caregivers and describe key modifications to standard CBT-I that address these specific needs and enhance sensitivity and feasibility, modeled in a demonstrative case vignette. Future research must seek to provide a wide range of effective treatment options for this population, including internet-based, dyadic, and alternative integrative medicine treatments. Applicability of key modifications for caregivers of patients with other chronic illnesses is discussed. Establishing empirically-supported interventions for insomnia among cancer caregivers has the potential to enhance their quality of life and care provided, lead to improved bereavement outcomes, and attenuate the notable mental and physical health disparities present in this vulnerable population.

Predictors of depression and anxiety among caregivers of hospitalised advanced cancer patients

INTRODUCTION

Cancer is a chronic disease that requires long-term treatment and care. Caregivers of cancer patients are at greater risk of developing depression than the general population. The effect of caregivers' cognitive flexibility on depression and anxiety has not been well studied. We aimed to investigate the social characteristics, burden levels and cognitive flexibility of caregivers of advanced cancer patients, and determine the relationship between these factors and depression and anxiety. We hypothesised that factors such as cognitive flexibility and caregiver burden level significantly predict anxiety and depression.

METHODS

The study included 69 primary informal caregivers of patients with Stage 4 cancer. Methods utilised included diagnostic semi-structured interviews, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Zarit Caregiver Burden Inventory and cognitive flexibility inventory.

RESULTS

BDI scores were found to be significantly higher in caregivers who cared for men compared to those who cared for women (20.44 ± 2.06 vs. 13.29 ± 1.81; t = 2.60; p = 0.01). BDI mean scores were statistically lower in caregivers who received help with caregiving compared to those who did not (t = 2.62; p = 0.01). Cognitive flexibility level, burden level and lack of social support were found to be predictors of caregiver depression.

CONCLUSION

The study showed that individuals with low cognitive flexibility levels are more likely to have depressive and anxiety symptoms. Based on our findings, we opine that evaluations of caregivers' cognitive strategies and social support are needed to determine the risk of depression in caregivers of cancer patients.

Supporting the provision of palliative care in the home environment: a proof-of-concept single-arm trial of a PalliativE Carers Education Package (PrECEPt)

INTRODUCTION

Practical educational interventions for palliative carers are needed. Current supports frequently rely on carers travelling to a central venue to receive education. A substantial gap therefore exists around determining how high-quality relevant information can be delivered nationally, with limited cost implications, using educational methods that are acceptable to carers in palliative care. This study seeks to design and assess feasibility and acceptability of a distance-learning approach to educating carers.

METHODS

This is an embedded mixed-method feasibility and acceptability study. It embeds an unblinded 1-arm pilot test, with subsequent qualitative interviews which will be used to inform the assessment of the intervention's acceptability and feasibility. The theoretical framework is self-efficacy theory, whereby we seek to impact carers' beliefs in their ability to carry out and succeed in caring tasks and situations. The educational materials focused on pain and nutrition/hydration will be developed in phase 1 with former carers (n=8) providing input into the content and style of materials. The educational package privileges adult-learning styles, recognising and responding to the learner's context including their learning needs, prior knowledge and motivations for engaging in education. The materials will be tested with up to 24 current carers.

ANALYSIS

Analysis will focus on determining recruitment processes for a full-scale study, data collection procedures/completion rates, queries directed to the hospice from carers involved in the feasibility work, mode of delivery and content of the materials. The primary outcome measure is self-efficacy, with other measures focused on caregiver preparedness and caregiving tasks, consequences and needs questionnaire. Adherence to educational components will also be collected and reported.

ETHICS AND DISSEMINATION

Ethical approval has been provided by the participating site, Calvary Healthcare, Canberra, reference 02-2016, and the Australian Catholic University. Results will be published in peer-reviewed journals, presented at conferences and a lay summary sent to participants.

TRIAL REGISTRATION NUMBER

ACTRN12616000601437; Pre-results.

The importance of measuring customer satisfaction in palliative care

In the last decades, palliative care has been more and more focused on the evaluation of patients' and families' satisfaction with care. However, the evaluation of customer satisfaction in palliative care presents a number of issues such as the presence of both patients and their families, the frail condition of the patients and the complexity of their needs, and the lack of standard quality indicators and appropriate measurement tools. In this manuscript, we critically review existing evidence and literature on the evaluation of satisfaction in the palliative care context. Moreover, we provide - as a practical example - the preliminary results of our experience in this setting with the development of a dedicated tool for the measurement of satisfaction.

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

BACKGROUND

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

AIM

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

DESIGN

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

DATA SOURCES

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

RESULTS

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

CONCLUSION

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

Uncovering an invisible network of direct caregivers at the end of life: a population study

BACKGROUND

Most palliative care research about caregivers relies on reports from spouses or adult children. Some recent clinical reports have noted the assistance provided by other family members and friends.

AIM

This population study aims to define the people who actually provide care at the end of life.

SETTING/PARTICIPANTS

A South Australian study conducted an annual randomized health population survey (n=23,706) over a 7 year period. A sample was obtained of self-identifying people who had someone close to them die and 'expected' death in the last 5 years (n=7915). Data were standardised to population norms for gender, 10-year age group, socioeconomic status, and region of residence.

RESULTS

People of all ages indicated they provided 'hands on' care at the end of life. Extended family members (not first degree relatives) and friends accounted for more than half (n=1133/2028; 55.9%) of identified hands-on caregivers. These people came from the entire age range of the adult community. The period of time for which care was provided was shorter for this group of caregivers. People with extended family or friends providing care, were much more likely to be supported to die at home compared to having a spousal carer.

CONCLUSION

This substantial network of caregivers who are mainly invisible to the health team provide the majority of care. Hospice and palliative care services need to create specific ways of identifying and engaging this cohort in order to ensure they are receiving adequate support in the role. Relying on 'next-of-kin' status in research will not identify them.

Admission to the intensive care unit and well-being in patients with advanced chronic illness

PURPOSE

To describe the association of intensive care with trajectories of functional, emotional, social, and physical well-being in patients with 3 common advanced illnesses.

METHODS

Cross-sectional cohort study of 42 patients admitted to the intensive care unit selected from 210 patients with stage IV breast, prostate, or colon cancer or stage IIIb or IV lung cancer; New York Heart Association class III or IV congestive heart failure; and chronic obstructive pulmonary disease with hypercapnea (Pco2 > 46 mm Hg). Scores on subscales of the Functional Assessment of Chronic Illness Therapy-General survey were measured monthly for 6 months before and after admission to the intensive care unit and were analyzed by using the unit admission date as a point of discontinuous change to illustrate trajectories before and after the admission.

RESULTS

Overall, trajectories of well-being declined sharply after admission to the intensive care unit. Declines in physical, functional, and emotional well-being were statistically significant. During the 6 months after admission, physical, functional, and emotional well-being scores trended back up to baseline while social well-being scores continued to decline.

CONCLUSIONS

Well-being trajectories declined sharply after admission to the intensive care unit, with recovery in the subsequent 6 months, and may be characterized by common patterns. These results help to better describe intensive care as a marker for advancing illness in patients with advanced chronic illness.

Finding common ground to achieve a "good death": family physicians working with substitute decision-makers of dying patients. A qualitative grounded theory study

BACKGROUND

Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a "bad death" experience for the patient and family. We aim to describe Canadian family physicians' experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients.

METHODS

Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged.

RESULTS

Eleven family physicians with a range of 3 to 40 years in clinical practice participated.The family physicians expressed a desire to achieve a "good death" and described their role in positively influencing the experience of death.Finding Common Ground to Achieve a "Good Death" for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is described.

CONCLUSIONS

A novel framework for developing Common Ground to manage conflicts during end-of-life decision-making discussions may assist in achieving a "good death". These results could aid in educating physicians, learners, and the public on how to achieve productive collaborative relationships during end-of-life decision-making for dying patients, and ultimately improve their deaths.

The Experiences of Suffering of Palliative Care Informal Caregivers in Malaysia

A qualitative study was conducted with semi-structured interviews to explore the experiences of suffering in 15 palliative care informal caregivers in University Malaya Medical Centre. The data were thematically analyzed. Seven basic themes were generated (1) empathic suffering, (2) anticipatory grief, (3) obsessive–compulsive suffering, (4) helpless–powerless suffering, (5) obligatory suffering, (6) impedimental suffering, and (7) repercussion suffering. A model of compassion suffering was conceptualized from the analysis. This model may serve as a guide in the assessment and management of suffering in palliative care informal caregivers.

What does the informal caregiver of a terminally ill cancer patient need? A study from a cancer centre

Aims:

To assess the needs of informal caregivers of terminally ill cancer patients.

Materials and Methods:

Fifty four informal caregivers of patients registered in our palliative care service were interviewed 3–6 months after the death of the patient with the help of a semistructured questionnaire covering the physical, medical, psychological, social, and information domains.

Results:

Most of the caregivers were middle aged and had no prior experience of care giving. The caregivers were satisfied by the information and medical support provided to them by their treatment team. Most had an “emergency plan”. Caregivers had unmet needs including homecare, psychological support, and financial help.

Conclusions:

informal caregivers provide most of the nursing and psychological support to the patient. However, palliative care services need to recognize that the caregiver too may need psychological and technical support.

PalliPA: How can general practices support caregivers of patients at their end of life in a home-care setting? A study protocol

BACKGROUND

The care of patients with a life-threatening, progressive and far advanced illness in a home-care setting requires appropriate individual care and requires the active support of family caregivers. General practice teams are usually the primary care givers and first contact and are best placed to offer support to family caregivers and to recognise and respond to the burden of care giving on family members. The aim of this project is to develop a best practice model for engaging with and supporting family caregivers.

FINDINGS

The project is framed as an exploratory trial for a subsequent implementation study, covering phases 0, I and II of the MRC (Medical Research Council) framework for development, design and evaluation of complex interventions. The project is a multi-method procedure and has two phases. In the first phase, which has already been completed, we used a reflective practice procedure where general practice teams were asked about how they currently deal with family caregivers. In the second phase, a participatory action research approach aims to improve identification and response to when support is necessary for family caregivers. Ten participating general practice teams each enrol 40 eligible patients and their family caregiver, to identify structures and tools feasible for use in their practice. Standardised self-reported questionnaires (Burden Scale for Family Caregivers and Quality of Life Questionnaire Core 15 Palliative) are being applied at study inclusion (prior to or during the implementation period) and after 6 and 12 months to explore implementation effects. Qualitative assessment of general practice teams' experiences will be triangulated with the quantitative evaluation of the implementation.

DISCUSSION

This two-step approach, which is appropriate to primary palliative care in the German health care context, will enable general practice teams to develop feasible, acceptable and successful strategies for the implementation of best practice to successfully support family caregivers of patients at the end of life.

Predictors of caregiver distress among palliative home care clients in Ontario: Evidence based on the interRAI Palliative Care

Objective:

This study examines predictors of caregiver distress among community-based palliative care clients. Analyses are based upon interRAI Palliative Care (interRAI PC) assessment data from palliative home care programs in three regions in Ontario, Canada.

Method:

The study sample involved all community-based palliative care clients in Ontario who were assessed with the interRAI PC as part of normal clinical practice during pilot implementation of the instrument between 2007 and 2009 (N = 3,929). The assessments were performed by trained case managers and were used as the basis for determining service needs to be addressed through services contracted from provider agencies. The main study outcome of interest was the presence of one or more indicators of caregiver distress: helper(s) unable to continue caring activities; primary informal helper expresses feelings of distress, anger, or depression; family or close friends report feeling overwhelmed by person's illness.

Results:

Caregiver distress was evident among about 22% of palliative home care clients. Multivariate analyses identified included clinical instability (Changes in Health, End Stage disease, Signs and Symptoms [CHESS] scale), depressive symptoms, cognitive impairment, and positive outlook as significant client-level predictors. Significant caregiver characteristics included hours of informal care. Three service use/provider variables were significant predictors of caregiver distress: the specific home care agency, hospitalizations in the last 90 days, and nursing visits.

Significance of results:

Caregiver distress affects approximately one in five palliative care clients in the community. This may lead to a number of adverse outcomes for the caregiver and client. The experience of distress is affected by client, caregiver, and agency characteristics that are readily identified by the interRAI PC assessment instrument. The present results point to the need for a care planning protocol that may be used on a targeted basis for clients experiencing or at elevated risk of caregiver distress.

How can informal caregivers in cancer and palliative care be supported? An updated systematic literature review of interventions and their effectiveness

INTRODUCTION

Informal caregivers needs in cancer/advanced disease are largely unmet. The science of carer intervention evaluation is methodologically challenging, and the evidence historically weak.

OBJECTIVE

This systematic review updates an earlier effectiveness review to determine both the effectiveness of subsequently published intervention studies, and the current state of science.

METHOD

The evidence was identified and appraised using a comprehensive search strategy. Articles were searched from 2001 to 2010 using the following electronic databases: Medline, PsychINFO and CINAHL. Inclusion criteria were studies reporting intervention data for informal adult caregivers of a patient with a diagnosis of cancer or receiving palliative care. The design and evidence rigour were assessed using the Jadad Rating Scale, and the Quality Rating Scale.

RESULTS

33 studies met inclusion criteria. From the original review, an encouraging increase was identified in the number of evaluations (from 8 to 33), in carer-specific interventions (from 6 to 17) and in the robustness of the study design (an increase from 2 to 12 studies with before/after measures, comparison groups and prospective data).

CONCLUSIONS

The evidence suggests a rapid increase in the number of robust intervention studies. However, the range of models remains narrow in relation to caregivers' needs and preferences.

Study protocol: optimization of complex palliative care at home via telemedicine. A cluster randomized controlled trial

BACKGROUND

Due to the growing number of elderly with advanced chronic conditions, healthcare services will come under increasing pressure. Teleconsultation is an innovative approach to deliver quality of care for palliative patients at home. Quantitative studies assessing the effect of teleconsultation on clinical outcomes are scarce. The aim of this present study is to investigate the effectiveness of teleconsultation in complex palliative homecare.

METHODS/DESIGN

During a 2-year recruitment period, GPs are invited to participate in this cluster randomized controlled trial. When a GP refers an eligible patient for the study, the GP is randomized to the intervention group or the control group. Patients in the intervention group have a weekly teleconsultation with a nurse practitioner and/or a physician of the palliative consultation team. The nurse practitioner, in cooperation with the palliative care specialist of the palliative consultation team, advises the GP on treatment policy of the patient. The primary outcome of patient symptom burden is assessed at baseline and weekly using the Edmonton Symptom Assessment Scale (ESAS) and at baseline and every four weeks using the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes are self-perceived burden from informal care (EDIZ), patient experienced continuity of medical care (NCQ), patient and caregiver satisfaction with the teleconsultation (PSQ), the experienced problems and needs in palliative care (PNPC-sv) and the number of hospital admissions.

DISCUSSION

This is one of the first randomized controlled trials in palliative telecare. Our data will verify whether telemedicine positively affects palliative homecare.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR2817.

[How many patient deaths can a team cope with? : a nationwide survey of palliative care units in Germany]

BACKGROUND

How many patient deaths the teams at palliative care units can cope with, the supporting factors in coping and the future prospects of the teams have not yet been subject to research in Germany. The aim of the study was to assess burden factors, burden symptoms and protective factors, the critical number and distribution of patient deaths as well as the prospects of the teams.

SAMPLE AND METHODS

A total of 873 members of palliative care teams from 95 (60% of n=158) German palliative care units took part in this explorative evaluation. Basic factors could be identified using factor analysis. Differences between professional groups were checked with analysis of variance.

RESULTS

Results showed that not having reached the objectives of palliative care was the central burden factor. In the majority of cases a team reacted by being loquacious. The team itself was ranked as the most important protective factor. The mean critical number of deaths was 4.4 per week. Consecutive patient deaths were rated as being significantly more stressful than evenly spread deaths. Ratings for the future prospects of the team were significantly lower in teams where not meeting the objectives of palliative care was considered a high burden factor.

CONCLUSION

A clearer definition of the objectives of palliative care and support of team communication are desirable.

Utilization of acute and long-term care in the last year of life: comparison with survivors in a population-based study

BACKGROUND

It is well-known that the use of care services is most intensive in the last phase of life. However, so far only a few determinants of end-of-life care utilization are known. The aims of this study were to describe the utilization of acute and long-term care among older adults in their last year of life as compared to those not in their last year of life, and to examine which of a broad range of determinants can account for observed differences in care utilization.

METHODS

Data were used from the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified population-based cohort of 3107 persons aged 55 - 85 years at baseline and representative of the Netherlands, follow-up cycles took place at 3, 6 and 9 years. Those who died within one year directly after a cycle were defined as the "end-of-life group" (n = 262), and those who survived at least three years after a cycle were defined as the "survivors". Utilization of acute and long-term care services, including professional and informal care, were recorded at each cycle, as well as a broad range of health-related and psychosocial variables.

RESULTS

The end-of-life group used more care than the survivors. In the younger-old this difference was most pronounced for acute care, and in the older-old, for long-term care. Use of both acute and long-term home care in the last year of life was fully accounted for by health problems. Use of institutional care at the end of life was partly accounted for by health problems, but was not fully explained by the determinants included.

CONCLUSION

This study shows that severity of health problems are decisive in the explanation of the increase in use of care services towards the end-of-life. This information is essential for an appropriate allocation of professional health care to the benefit of older persons themselves and their informal caregivers.

Supporting lay carers in end of life care: current gaps and future priorities

Informal carers are central to the achievement of end of life care and death at home and to policy aims of enabling patient choice towards end of life. They provide a substantial, yet hidden contribution to our economy. This entails considerable personal cost to carers, and it is recognised that their needs should be assessed and addressed. However, we lack good research evidence on how best to do this. The present position paper gives an overview of the current state of carer research, its gaps and weaknesses, and outlines future priorities. It draws on a comprehensive review of the carer literature and a consensus meeting by experts in the field. Carers' needs and adverse effects of caregiving have been extensively researched. In contrast, we lack both empirical longitudinal research and conceptual models to establish how adverse effects may be prevented through appropriate support. A reactive, "repair" approach predominates. Evaluations of existing interventions provide limited information, due to limited rigour in design and the wide variety in types of intervention evaluated. Further research is required into the particular challenges that the dual role of carers as both clients and providers pose for intervention design, suggesting a need for future emphasis on positive aspects of caregiving and empowerment. We require more longitudinal research and user involvement to aid development of interventions and more experimental and quasi-experimental research to evaluate them, with better utilisation of the natural experiments afforded by intra- and international differences in service provision.

Development of the palliative care needs assessment tool (PC-NAT) for use by multi-disciplinary health professionals

Needs assessment strategies can facilitate prioritisation of resources. To develop a needs assessment tool for use with advanced cancer patients and caregivers, to prompt early intervation. A convenience sample of 103 health professionals viewed three videotaped consultations involving a simulated patient, his/her caregiver and a health professional, completed the Palliative Care Needs Assessment Tool (PC-NAT) and provided feedback on clarity, content and acceptability of the PC-NAT. Face and content validity, acceptability and feasibility of the PC-NAT were confirmed. Kappa scores indicated adequate inter-rater reliability for the majority of domains; the patient spirituality domain and the caregiver physical and family and relationship domains had low reliability. The PC-NAT can be used by health professionals with a range of clinical expertise to identify individuals' needs, thereby enabling early intervention. Further psychometric testing and an evaluation to assess the impact of the systematic use of the PC-NAT on quality of life, unmet needs and service utilisation of patients and caregivers are underway.

Haemato-oncology and burnout: an Italian survey

This cross-sectional survey aimed to evaluate the prevalence of burnout and estimated psychiatric disorders among haemato-oncology healthcare professionals in Italy. The aspects of work that respondents perceive as stressful and satisfying have also been examined. The assessments were made using the Maslach Burnout Inventory (MBI), General Health Questionnaire and a study-specific questionnaire. Logistic regression models were applied to show associations between different sources of work-related stress and burnout. Three hundred and eighty-seven out of 440 (87.95%) returned their questionnaires. The scores on MBI subscales indicate a high level of emotional exhaustion in 32.2% of the physicians and 31.9% of the nurses; a high level of Depersonalisation in 29.8 and 23.6%, respectively; and a low level of personal accomplishment in 12.4 and 15.3% respectively. The estimated prevalence of psychiatric disorders was 36.4% in physicians and 28.8% in nurses. Statistical analysis confirmed age, sex, personal dissatisfaction, physical tiredness and working with demanding patients to be associated with burnout. In conclusion, haemato-oncology healthcare professionals report a level of burnout and estimated psychiatric morbidity comparable to other oncological areas. Knowledge of the mechanisms of burnout and preventing and dealing with them is therefore a fundamental requirement for the improvement of quality in health services and job satisfaction.

Financial stress and strain associated with terminal cancer--a review of the evidence

Financial circumstances are a significant influence on the quality of life for older people and may be important to health and wellbeing at the end of life. The aim of this study is to review the evidence for the existence and consequences of financial stress and strain at the end of life for people dying with cancer. We conducted a systematic search of four electronic databases for studies, providing data on illness-related financial burden (stress), or perception of financial hardship (strain), from patients with terminal cancer or their caregivers. Twenty-four papers were identified from 21 studies published in English between 1980 and 2006, the majority (14) of cross-sectional design. Financial stress was reported in all 13 studies from the USA (median 33%, range 10-66%), but only four sought measures of financial strain. In the USA, specific social consequences, such as moving house or change in employment to cope with caregiving, were reported in four of these studies; one of these also noted changes in treatment choices and avoidance of care for other family members. In studies from outside the USA, there is a dearth of data on financial stresses and the consequences of this for the household, despite widespread reporting of financial strain. To fill a gap in our understanding and improve holistic palliative care, researchers need to ask the questions about the consequences of financial stresses and strain for the health and wellbeing of the household.

Bridging the gap: can a link nurse initiative influence palliative care in an acute hospital?

With 90% of people needing some inpatient hospital care in the final year of life, it is evident that the provision and awareness of palliative care, and education surrounding this, are widely needed. This study aims to evaluate a palliative care link nurse initiative (PCLN) in an NHS acute hospital, identifying key factors affecting link nurses' ability to influence palliative care practice. This qualitative study used semi-structured interviews and a focus group to show the anticipated and actual influence of link nurses on practice. Findings suggest that link nurses had increased knowledge and skills in palliative care due to education provided. Link nurses were seen to have an influence on the presence and quality of palliative care practice in hospital wards. Factors that could help link nurses to have greater influence are reported, as are difficulties in providing care and accessing training.

Psychological morbidity and burnout in palliative care doctors in Western Australia

BACKGROUND

Medicine and particularly palliative care are considered to be stressful professions, with risks of psychological morbidity and burnout. There is little published work quantitatively documenting their prevalence among medical practitioners practising in palliative care.

METHODS

Three questionnaires, including the General Health Questionnaire (GHQ-12) and the Maslach Burnout Inventory, were sent to palliative care practitioners in Western Australia.

RESULTS

Forty-one of 43 (95%) practitioners completed the questionnaires. The mean score on the GHQ-12 was 1.9 (range 0-8), with 11 (27%) scoring 4 or more. On the Maslach Burnout Inventory, mean scores on the emotional exhaustion (EE, mean 17.5, range 1-47) and depersonalization subscales (DP, 4.5, 0-24) fell within the low range, with scores for personal accomplishment (39, 32-46) falling within the average range. Ten respondents (24%) scored high on either the EE subscale or the DP subscale, meeting criteria for burnout. GHQ-12 scores were associated with hours of work per week in palliative care (P = 0.004). The EE (P = 0.024) and DP (P = 0.006) components of burnout were associated with years of work in palliative care. Specialist practitioners were more likely to score in the high category for GHQ-12 (odds ratio = 4.8, P = 0.036) and EE (odds ratio = 8.33, P = 0.031). GHQ (P = 0.038) and DP (P = 0.006) scores were higher in those working in tertiary institutions, with tertiary practitioners more likely to be in the high EE category (odds ratio = 7.5, P = 0.034).

CONCLUSION

Levels of psychiatric morbidity and burnout in palliative medicine are not higher than in other specialties.

Does social support from family and friends work as a buffer against reactions to stressful life events such as terminal cancer?

OBJECTIVE

To examine the relationship between social support and emotional functioning and stress reactions. Our hypothesis is that patients who reported a high degree of social support will experience better emotional functioning and less serious stress reactions than patients with a low degree of social support.

METHOD

The sample was comprised of 434 patients at the Palliative Medicine Unit (PMU), University Hospital of Trondheim in Norway. The patients completed a questionnaire monthly including questions about social support from the MacAdam's Scale, subjective stress measured by the Impact of Event Scale (IES), and emotional functioning measured by the subscale in the EORTC QLQ-30.

RESULTS

Although our hypothesis was not supported at the baseline assessment, it was supported at the second assessment, 2 months later. Patients with high social support reported better emotional functioning and less serious stress reactions, in terms of lower scores on the IES avoidance subscale, than patients with a low degree of social support. SIGNIFICANCE OF THE RESULTS: The mixed findings may indicate that social support has only small effects on emotional functioning and stress reactions. Our results on the second assessment indicate, however, that social support might work as a buffer against reactions toward external stressful events such as terminal cancer.

Oncology nurses' perceptions of their supportive care for parents with advanced cancer: challenges and educational needs

Despite the emotional impact for children with a parent with advanced cancer, most families receive limited information and support to assist them. A project is underway to determine the acceptability and effectiveness of a supportive and educational intervention for parents with advanced cancer to be delivered by specially trained oncology nurses. To assess the perceptions of oncology nurses about this role, explore potential challenges, and understand their educational needs, oncology nurses were recruited from three metropolitan hospitals to participate in focus groups. This data was supplemented with data from individual interviews conducted with rurally based nurses unable to participate in focus groups held in a metropolitan location. Four focus groups were held, with 24 participants. Individual telephone interviews were conducted with five nurses. Nurses identified the emotional burden of the supportive care role as a key challenge, along with health care systems which were not attuned to the needs of families. Attention to self-care and professional confidence, and access to role-models emerged as key elements required in education, along with information about the impact of parental cancer on children and their developmental stages, and ways to promote more open parental communicate with children.

Caring for dying patients outside special palliative care settings: experiences from a nursing perspective

The aim of the study was to describe nurses' experiences in caring for gravely ill and dying patients outside special palliative care settings. Tape-recorded qualitative interviews were conducted with a total of nine nurses in primary home care, community care and hospitals. The interviews were analysed according to phenomenological methodology, which resulted in the three common structures: ambition and dedication, everyday encounters, and satisfaction/dissatisfaction. In the 'everyday encounters' structure, the following key constituents emerged: responsibility, cooperation, experience and knowledge, feelings, and time and resources. The results describe the nurses' high ambitions to give dying patients and their relatives high-quality care. Despite this, they experienced greater or lesser degrees of dissatisfaction because of insufficient cooperation, support, time and resources. They experienced satisfaction through contact with patients and relatives, functioning collegial cooperation, and the knowledge, experience and personal growth the care had given them. The results indicate that nurses need the resources such as time, improved methods of communication and cooperation as well as more support in order to give quality palliative care and achieve satisfaction with the outcome. The need for discussion about the conditions for giving palliative care outside the hospices and other special palliative care settings is also elucidated.