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Engelberg RA, Downey L, Wenrich MD, Carline JD, Silvestri GA, Dotolo D, Nielsen EL, Curtis JR. Measuring the quality of end-of-life care. J Pain Symptom Manage 2010; 39:951-71. [PMID: 20538181 DOI: 10.1016/j.jpainsymman.2009.11.313] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 10/20/2009] [Accepted: 11/05/2009] [Indexed: 10/19/2022]
Abstract
CONTEXT Although there is a documented need to improve end-of-life care, there are few validated and brief questionnaires that are available as outcome measures for use in improving that care. OBJECTIVES To examine the measurement characteristics of the Quality of End-of-Life Care (QEOLC) questionnaire. METHODS In a multisite, cross-sectional study of a mailed questionnaire, patients with life-limiting illnesses, their families, and nurses completed the QEOLC questionnaire. Patients and nurses were identified by physicians, and families were identified by participating patients. Physicians included general internists, oncologists, cardiologists, and pulmonologists from the Southeast and Pacific Northwest of the United States. RESULTS Eight hundred one patients, 310 of their families, and 885 nurses were identified by 85 physicians. Using structural equation modeling techniques corrected for clustering under physicians, we identified a patient-specific factor based on 11 items, a family-specific factor based on 22 items, a nurse-specific factor based on 11 items, and a common single-factor solution based on 10 items. Construct validity was supported by significant associations in the hypothesized direction between the identified QEOLC factors and each of the following: physician palliative care knowledge, patients' and families' ratings of overall quality of care, and patients' levels of symptom distress. CONCLUSION Although continued testing in heterogeneous samples is necessary, the current study supported the construct validity of the QEOLC questionnaire to assess physician skill at end-of-life care, thereby providing valid measures of quality end-of-life care. Furthermore, this approach is a model for development and validation of patient- and family-centered assessments of quality of care.
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Affiliation(s)
- Ruth A Engelberg
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Harborview Medical Center, Seattle, Washington 98104-2499, USA.
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Smyth D, Farnell A, Dutu G, Lillis S, Lawrenson R. Palliative Care Provision by Rural General Practitioners in New Zealand. J Palliat Med 2010; 13:247-50. [DOI: 10.1089/jpm.2009.0097] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dot Smyth
- Glenview Medical Centre, Hamilton, New Zealand
| | | | - Gaelle Dutu
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Steven Lillis
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Ross Lawrenson
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
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Abstract
Despite advances in management of heart failure, the condition remains a major public-health issue, with high prevalence, poor clinical outcomes, and large health-care costs. Risk factors are well known and, thus, preventive strategies should have a positive effect on disease burden. Treatment of established systolic chronic heart failure includes use of agents that block the renin-angiotensin-aldosterone and sympathetic nervous systems to prevent adverse remodelling, to reduce symptoms and prolong survival. Diuretics are used to achieve and maintain euvolaemia. Devices have a key role in management of advanced heart failure and include cardiac resynchronisation in patients with evidence of cardiac dyssynchrony and implantation of a cardioverter defibrillator in individuals with low ejection fraction. Approaches for treatment of acute heart failure and heart failure with preserved ejection fraction are supported by little clinical evidence. Emerging strategies for heart failure management include individualisation of treatment, novel approaches to diagnosis and tracking of therapeutic response, pharmacological agents aimed at new targets, and cell-based and gene-based methods for cardiac regeneration.
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Affiliation(s)
- Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Difficult conversations and chronic heart failure: do you talk the talk or walk the walk? Curr Opin Support Palliat Care 2008; 1:274-8. [PMID: 18685374 DOI: 10.1097/spc.0b013e3282f3475d] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Effective communication is critical for palliative and supportive care in heart failure. This article contains a review of available information to assist clinicians in undertaking discussions regarding prognosis, treatment decisions and advance care planning. RECENT FINDINGS Emerging from a range of studies at the end of life is that patients and their families appreciate honesty and do not want to be abandoned by healthcare providers. Further, the receptivity of patients and their carers to information is highly variable, underscoring the importance of an individualized approach. SUMMARY When having these difficult conversations, clinicians need to assess the individual's need and wishes for information as well as their social and cultural background. They also need to consider the setting, timing and content of the discussion, as well as strategies to promote coping and adjustment. Most importantly, patients need a treatment plan to address palliative and supportive care needs to be implemented at the time of breaking this bad news, so that they and their families do not feel abandoned. Learning effective communication skills, implementing strategies for debriefing and the fostering of a team approach, may minimize burden on health providers and improve palliative and supportive care for people with heart failure.
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Curtis JR, Engelberg R, Young JP, Vig LK, Reinke LF, Wenrich MD, McGrath B, McCown E, Back AL. An Approach to Understanding the Interaction of Hope and Desire for Explicit Prognostic Information among Individuals with Severe Chronic Obstructive Pulmonary Disease or Advanced Cancer. J Palliat Med 2008; 11:610-20. [DOI: 10.1089/jpm.2007.0209] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J. Randall Curtis
- Department of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Ruth Engelberg
- Department of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Jessica P. Young
- Department of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Lisa K. Vig
- Department of Gerongology and Geriatric Medicine, University of Washington, Seattle, Washington
| | - Lynn F. Reinke
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington
| | | | - Barbara McGrath
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington
| | - Ellen McCown
- Department of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Anthony L. Back
- Department of Oncology, University of Washington, Seattle, Washington
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Krum H, Jelinek MV, Stewart S, Sindone A, Atherton JJ, Hawkes AL. Guidelines for the prevention, detection and management of people with chronic heart failure in Australia 2006. Med J Aust 2007; 185:549-57. [PMID: 17115967 DOI: 10.5694/j.1326-5377.2006.tb00690.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2006] [Accepted: 09/26/2006] [Indexed: 11/17/2022]
Abstract
Chronic heart failure (CHF) is found in 1.5%-2.0% of Australians. Considered rare in people aged less than 45 years, its prevalence increases to over 10% in people aged >/= 65 years. CHF is one of the most common reasons for hospital admission and general practitioner consultation in the elderly (>/= 70 years). Common causes of CHF are ischaemic heart disease (present in > 50% of new cases), hypertension (about two-thirds of cases) and idiopathic dilated cardiomyopathy (around 5%-10% of cases). Diagnosis is based on clinical features, chest x-ray and objective measurement of ventricular function (eg, echocardiography). Plasma levels of B-type natriuretic peptide (BNP) may have a role in diagnosis, primarily as a test for exclusion. Diagnosis may be strengthened by a beneficial clinical response to treatment(s) directed towards amelioration of symptoms. Management involves prevention, early detection, amelioration of disease progression, relief of symptoms, minimisation of exacerbations, and prolongation of survival.
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Affiliation(s)
- Henry Krum
- NHMRC Centre of Clinical Research Excellence in Therapeutics, Department of Epidemiology and Preventive Medicine, and Department of Medicine, Monash University, Alfred Hospital, Melbourne, VIC, Australia
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Van Vorst RF, Crane LA, Barton PL, Kutner JS, Kallail KJ, Westfall JM. Barriers to quality care for dying patients in rural communities. J Rural Health 2006; 22:248-53. [PMID: 16824170 DOI: 10.1111/j.1748-0361.2006.00040.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Barriers to providing optimal palliative care in rural communities are not well understood. PURPOSE To identify health care personnel's perceptions of the care provided to dying patients in rural Kansas and Colorado and to identify barriers to providing optimal care. METHODS An anonymous self-administered survey was sent to health care personnel throughout 2 rural practice-based research networks. Targeted personnel included clinicians, nurses, medical assistants, chaplains, social workers, administrators, and ancillary staff, who worked at hospice organizations, hospitals, ambulatory clinics, public health agencies, home health agencies, and nursing homes. FINDINGS Results from 363 completed surveys indicated that most health care personnel were satisfied with the palliative care being provided in their health care facilities (84%) and that most were comfortable helping dying patients transition from a curative to a palliative focus of care (87%). Yet, many reported that the palliative care provided could be improved and many reported that family members' avoidance of issues around dying (60%) was a barrier to providing optimal care in rural health care facilities. CONCLUSIONS Findings suggest that health care personnel perceive they are effective at providing palliative care in their rural health care facilities, yet face barriers to providing optimal end-of-life care. Results of this study suggest that differences in training and experience may influence health care personnel's perceptions of the existing barriers. It may be important in rural areas to customize interventions to both the professional role and the site of care.
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Farber SJ, Egnew TR, Herman-Bertsch JL, Taylor TR, Guldin GE. Issues in end-of-life care: patient, caregiver, and clinician perceptions. J Palliat Med 2003; 6:19-31. [PMID: 12710572 DOI: 10.1089/10966210360510082] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Review of published research indicates the need to better incorporate patient and caregiver perceptions when providing end-of-life (EOL) care. Although considerable research regarding patient and caregiver experience of EOL has been done, little research has studied patients, caregivers, and clinicians as a connected system. OBJECTIVE To study the perceptions of patients, caregivers, and physicians who are already connected with one another in an EOL care experience. DESIGN Qualitative study consisting of in-depth, open-ended, face-to-face interviews and content analysis. SETTING Community family practice residency programs in rural and urban settings in the Affiliated Family Practice Residency Network of the Department of Family Medicine, University of Washington School of Medicine. PARTICIPANTS Forty-two patients and 39 caregivers facing EOL were interviewed either alone or together after referral by their physicians. Additionally, results of previously published findings from interviews with 39 family practice faculty were included. OUTCOME MEASURES Perceptions of participants on EOL issues. RESULTS Participants identified four primary issues related to their experience of EOL care: awareness of impending death, management/coping with daily living while attempting to maintain the management regimen, relationship fluctuations, and the personal experiences associated with facing EOL. Participants expected their physicians to be competent and to provide a caring relationship. CONCLUSIONS Awareness of these crucial patient and caregiver EOL issues and expectations and how they differ from clinician perspectives can assist clinicians to appropriately explore and address patient/caregiver concerns and thereby provide better quality EOL care.
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Affiliation(s)
- Stuart J Farber
- Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington 98195-6390, USA.
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Abstract
PURPOSE This article reviews the literature on "The Experience of Dying" and presents data from a larger, ongoing study of an ethnography of dying in nursing homes. The purpose of the ethnographic study was to investigate the process of providing end-of-life care to residents who were dying in nursing homes. DESIGN AND METHODS Participant observation, in-depth interviews, and event analysis were used to obtain data in three nursing facilities. RESULTS The review of the literature disclosed that research on the experience of dying is limited; most of the studies have been conducted in acute care hospitals among people who were dying of cancer. The ethnographic study found that lack of attention to cultural needs, cognitive status, inadequate staffing, and inappropriate and inadequate communication between health care providers and nursing home residents and their families were the predominant factors that influenced the experience of dying. IMPLICATIONS Future research is needed on: The experience of dying for patients with dementia, for people in a comatose state, and for non-English speaking patients; symptom management; health care provider/patient-family interaction; the burden of caregiving for families; and the consequences of the constraints within our health care system for people who are dying in various settings.
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Affiliation(s)
- Jeanie Kayser-Jones
- Department of Physiological Nursing, University of California, San Francisco, CA 94143-0610, USA.
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Abstract
To describe symptom prevalence, frequency, and severity among hospice patients, from the perspective of hospice providers, a cross-sectional study was conducted among 16 hospices participating in the Population-based Palliative Care Research Network (PoPCRN). Hospice staff estimated symptom presence, frequency, and severity, using the Memorial Symptom Assessment Scale. Among the 348 patients (median age 78 years, 55% female, 55% cancer diagnosis), the most common symptoms noted by hospice staff were lack of energy (83%), pain (76%), lack of appetite (63%), drowsiness (61%), difficulty concentrating (60%), and sadness (51%). When present, lack of energy was rated by hospice providers as both frequent (75% "frequently" or "almost constantly") and severe (46% "severe" or "very severe"). Symptoms varied by care setting and by diagnosis. Hospice staff often lacked sufficient information to rate potentially important symptoms, such as problems with sexual interest or activity (63%), change in self image (30%), and worrying (26%). This study identifies a significant burden of unrelieved symptoms among hospice patients, suggesting a need for more widespread institution of symptom management strategies with proven effectiveness and additional investigation into treatment of common symptoms for which few effective treatment strategies are known.
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Affiliation(s)
- J S Kutner
- Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, CO 80262, USA
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Abstract
Most terminally ill patients experience symptoms that require treatment as death approaches. The most common symptoms are pain (5% to 51%), dyspnea (28%), oral and respiratory secretions (25%), nausea and vomiting (10% to 14%), confusion (10%), myoclonus (12%), and bowel and bladder problems (over 20%). These symptoms can be well controlled in up to 90% of individuals with appropriate communication; emotional, spiritual, and social support; noninvasive clinical evaluation; and therapy focused on symptom palliation. Types of drugs that are important in symptom control include opioids, co-analgesics, anxiolytics, and anticholinergics. To be effective, these medications must be readily available for use and often need to be given by a non-oral route.
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Affiliation(s)
- J D Cowan
- Palliative Medicine of East Tennessee, 1915 White Avenue, Knoxville, TN 37916, USA.
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