Enhancing caregiver outcomes in palliative care

The social construction of multiple sclerosis in Israel: a cultural reading of illness narratives

PURPOSE

Illness narratives are cultural artifacts that reflect the ways through which a certain culture perceives and constructs a given illness. Against this backdrop, the study explored the social construction of MS in Israeli society.

MATERIALS AND METHODS

Thematic content analysis of all (70) illness narratives posted on the Israel MS Society's website between 2012-2018, was employed.

RESULTS

Five themes were identified in our analysis, according to chronological order: (1) "Becoming ill" - consisted of framing MS as a sudden affliction or constructing MS as a gradual development. (2) "Negative changes" depicted MS as inflicting negative bodily changes and a disruption to the social order. The "happy ending" of the narratives pertained to (3) "adjustments" to MS and, (4) "never giving up" to MS. These were facilitated by embracing (5) "positive thinking and optimism."

CONCLUSIONS

MS is perceived in Israel as a form of "deviance" and as a biomedical phenomenon. Rehabilitation and healthcare staff, therefore, need to actively engage in interventions that challenge and change the ways that MS is perceived, as well as to partner with people with MS, and disability advocates to reconstruct and design policies and services that reflect a more socio-political understanding of MS.Implications for rehabilitationIllness narratives by people with multiple sclerosis (MS) can teach us about the ways though which a given society perceives and constructs MS.This study analyzed online illness narratives by Israelis with MS; it shows that MS was predominantly constructed as a bio-medical phenomenon and as a form of social deviance.Rehabilitation and healthcare professionals need to actively engage in interventions that challenge and change the ways MS is perceived among the public, policy makers, and people with multiple sclerosis.Rehabilitation and healthcare professionals should collaborate with people with MS and disability advocates in order to reconstruct and shape policies and the planning of communities such that they address the socio-cultural barriers that people with MS face.

Development of an eHealth information resource for family carers supporting a person receiving palliative care on the island of Ireland

Background

Many people receiving palliative care wish to die at home. Often, support from family or friends is key to ensuring that this wish is fulfilled. However, carers report feeling underprepared to undertake this role. This paper describes the process of developing a consensus and evidence based website to provide core information to help people support someone receiving palliative care on the island of Ireland.

Methods

The project comprised three phases: (1) a review of systematic reviews facilitated the identification of core information needs; (2) content was developed in collaboration with a Virtual Reference Group (VRG) comprising patients, carers and professionals; and, (3) subject experts within the project team worked with a web developer to précis the agreed content and ensure it was in a format that was appropriate for a website. Members of the VRG were then invited to test and approve the website before it was made available to the general public.

Results

Nineteen systematic reviews identified nine consensus areas of core information required by carers; a description of palliative care; prognosis and treatment of the condition; medication and pain management; personal care; specialist equipment; locally available support services; what to do in an emergency; nutrition; and, support for the carer. This information was shared with the VRG and used to develop website content.

Conclusions

We engaged with service users and professionals to develop an evidence-based website addressing the agreed core information needs of non-professional carers who wish to provide palliative care to a friend or relative.

Dyadic Interventions for Cancer Survivors and Caregivers: State of the Science and New Directions

OBJECTIVES

To describe caregiving and relationship challenges in cancer and the state of the science of dyadic interventions that target survivors and caregivers.

DATA SOURCES

Narrative review.

CONCLUSION

Viewing the survivor-caregiver dyad as the unit of care may improve multiple aspects of survivor and caregiver quality of life. However, several questions remain regarding how, why, and for whom dyadic interventions are effective.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should consider survivor, caregiver, and relationship needs when formulating supportive care protocols. Screening for survivor distress and extending distress screening to caregivers is an important first step in providing comprehensive psychosocial care.

Understanding Family Responses to Life-Limiting Illness: In-depth Interviews with Hospice Patients and Their Family Members

Understanding family dynamics is a key component in providing comprehensive care for persons with progressive illnesses and their caregivers. The purpose of this study was to investigate what families experience during an advancing illness and to describe their patterns of response. In-depth interviews (n=108) were conducted with families two weeks after hospice admission. Interviews were tape recorded, transcribed, and analyzed using qualitative methods. Six modes were distilled: reactive (illness generates intense responses), advocacy (vulnerability ignites assertive actions), fused (illness and decline are shared experiences), dissonant (diametrically opposed viewpoints cause struggle), resigned (decline and death are anticipated), and closed (outward responses are impassive). Three events triggered movement from one mode to another: (1) functional changes, (2) crisis events, and (3) provider communication. Providers who understand varied family reactions can ease the patient's suffering, assist relatives in providing effective care, and prepare them for the approaching death.

Depression in individuals with chronic obstructive pulmonary disease and their informal caregivers

OBJECTIVE

Individuals with chronic obstructive pulmonary disease (COPD) and their caregivers are at high risk for developing depression. Depression can adversely affect the quality of life of patients and caregivers; however, studies in COPD have largely examined predictors of patient and caregiver depression in isolation. This dyadic study examined individual-level predictors of patient and caregiver depression in COPD (i.e. actor effects) as well as how dyad members effect each other's depression (i.e. partner effects).

METHODS

Survey data were collected from 89 patient-caregiver dyads that were enrolled in a multi-site cohort study.

RESULTS

Participants were predominantly women (61% of patients and 76% of caregivers) and racial/ethnic minorities (65% of patients and 63% of caregivers). Based on PHQ9 cutoffs, 30% of patients and 20% of caregivers had mild depression; 30% of patients and 8% of caregivers had moderate to severe depression. Multilevel models with the dyad as the unit of analysis showed that less frequent patient self-management, higher levels of caregiver burden, and being in poorer health were associated with higher levels of depression for both dyad members. Higher levels of depression in a partner were also associated with higher levels of depression for women, regardless of whether women were patients or caregivers.

CONCLUSION

Findings suggest that similar factors predict patient and caregiver depression in COPD and that women are at increased risk for developing depression when their partners are depressed. Dyadic psychosocial interventions that target patients and their caregivers may thus be beneficial in terms of addressing depression in this this vulnerable population.

Characteristics of the Family Caregivers Who Did Not Benefit From a Successful Psychoeducational Group Intervention During Palliative Cancer Care: A Prospective Correlational Study

BACKGROUND

Although there has been a steady increase in intervention studies aimed toward supporting family caregivers in palliative cancer care, they often report modest effect sizes and there is a lack of knowledge about possible barriers to intervention effectiveness.

OBJECTIVE

The aim of this study is to explore the characteristics of family caregivers who did not benefit from a successful psychoeducational group intervention compared with the characteristics of those who did.

INTERVENTION/METHODS

A psychoeducational intervention for family caregivers was delivered at 10 palliative settings in Sweden. Questionnaires were used to collect data at baseline and following the intervention. The Preparedness for Caregiving Scale was the main outcome for the study and was used to decide whether or not the family caregiver had benefited from the intervention (Preparedness for Caregiving Scale difference score ≤ 0 vs ≥ 1).

RESULTS

A total of 82 family caregivers completed the intervention and follow-up. Caregivers who did not benefit from the intervention had significantly higher ratings of their preparedness and competence for caregiving and their health at baseline compared with the group who benefited. They also experienced lower levels of environmental burden and a trend toward fewer symptoms of depression.

CONCLUSIONS

Family caregivers who did not benefit from the intervention tended to be less vulnerable at baseline. Hence, the potential to improve their ratings was smaller than for the group who did benefit.

IMPLICATIONS FOR PRACTICE

Determining family caregivers in cancer and palliative care who are more likely to benefit from an intervention needs to be explored further in research.

Advanced cancer caregiving as a risk for major depressive episodes and generalized anxiety disorder

OBJECTIVE

Caregivers of advanced cancer patients provide extensive care associated with high levels of caregiver distress. The degree to which cancer caregiving increases caregivers' risk for a psychiatric disorder is unknown. The current study examines whether advanced cancer caregiving poses distinct risks for initial and recurrent major depressive episodes (MDEs) and generalized anxiety disorder (GAD) relative to the general population.

METHODS

Caregivers of advanced cancer patients (N = 540) from Coping with Cancer were compared to general population controls (N = 9282) from the National Comorbidity Survey Replication. The general population comparison sample was propensity-weighted to be demographically similar to the caregiver sample.

RESULTS

Caregivers of advanced cancer patients were more likely than individuals in the general population to have an initial MDE (OR = 7.7; 95% CI, 3.5-17.0; P < .001), but no more likely than the general population to have a recurrent MDE (OR = 1.1; 95% CI, 0.6-2.1; P = .662). Caregivers were also more likely than the general population to have GAD (OR = 3.0; 95% CI, 1.9-4.8; P < .001) and comorbid MDE and GAD (OR = 2.5; 95% CI, 1.1-5.9; P = .038).

CONCLUSIONS

The increased risk of meeting diagnostic criteria for current MDE and GAD and comorbid MDE and GAD associated with advanced cancer caregiving highlights the degree of emotional burden among cancer caregivers. Clinical services that assess, prevent, and treat depression and anxiety in cancer caregivers are needed to reduce the burden of caregiving and improve the mental health of this growing population.

The Effects of a Patient-Caregiver Education and Follow-Up Program on the Breast Cancer Caregiver Strain Index

Background:

In recent years, the caregiving responsibilities of cancer patients’ family members have increased dramatically. Reducing caregiver strain and burden supports the mission of professional nursing.

Objectives:

The aim of this study was to determine and compare the caregiver strain index scores of breast cancer informal caregivers, before and after a patient-caregiver educational and telephone follow-up program.

Patients and Methods:

This is an experimental two-group design study. Participants were recruited from an outpatient chemotherapy unit of the largest hematology and oncology research center in Northwest Iran. Thirty patient-caregiver pairs were randomly allocated to intervention and control groups. The intervention group received 2 face-to-face education sessions at bedside and 4 subsequent telephone follow-up sessions. The control group received routine care. Pre and post tests were administered in both groups pre and post intervention. To analyze the data, SPSS (13th version) software was used.

Results:

The caregiver strain index decreased significantly in the intervention group after the patient-caregiver education and follow-up (P < 0.001), while the control group’s scores did not change (P = 0.04).

Conclusions:

It appears that the patient-caregiver education and follow-up program had a beneficial effect on the caregiver strain index compared to the usual care.

Oncologic Patients' Knowledge Expectations and Cognitive Capacities During Illness Trajectory: Analysis of Critical Moments and Factors

Cancer and its management affect patients' cognitive resources and education needs in several ways. The objective of this study is to identify significant factors affecting cognitive resources and knowledge expectations of adult patients with cancer during the course of their illness trajectory. Current or former patients with cancer (n = 53) were recruited to focus group interviews and individual in-depth interviews. The informants' knowledge expectations vary during their illness trajectory and are affected by personal, situational, and clinical factors. These should be acknowledged to provide person-centered, holistic nursing care and patient education.

The lasting impact of the therapeutic alliance: Patient-oncologist alliance as a predictor of caregiver bereavement adjustment

BACKGROUND

Caregivers of patients with advanced cancer provide extensive care and experience high levels of psychosocial distress. The patient-oncologist therapeutic alliance may be a modifiable factor that can prevent or reduce negative caregiver outcomes.

METHODS

Coping with Cancer (CwC) was a prospective, longitudinal, multisite cohort study of terminally ill cancer patients (life expectancy ≤6 months) and their informal caregivers, who were followed into bereavement (n = 68). Trained raters interviewed patients and caregivers upon study entry and also interviewed caregivers 6 months after the patient's death. Patients answered quantitative questions assessing their perception of the patient-oncologist therapeutic alliance (The Human Connection scale), and caregivers completed a measure of health-related quality of life (Medical Outcomes Study Short Form-36). Interviewers rated caregivers' level of emotional well being. Associations between therapeutic alliance and caregiver outcomes were analyzed using univariate analysis of variance and logistic regression analyses, controlling for baseline caregiver measures and confounding sample characteristics.

RESULTS

A strong patient-oncologist therapeutic alliance was bivariately associated with caregiver self-report of less role limitation because of emotional problems, better social function and mental and general health-related quality of life, and better interviewer-rated emotional well being after the patient's death. After controlling for baseline measures and confounding sample characteristics, the correlation between patient-perceived therapeutic alliance and bereaved caregivers' mental health and interviewer ratings of bereaved caregivers' emotional well being remained significant.

CONCLUSIONS

The influence of the patient-oncologist alliance may generalize beyond the patient to positively impact the caregiver. By developing a strong relationship with the patient, the oncologist may benefit the caregiver and the patient. This caregiver benefit may extend into bereavement.

Effectiveness of web-based versus folder support interventions for young informal carers of persons with mental illness: a randomized controlled trial

OBJECTIVE

Compare the impact of two interventions, a web-based support and a folder support, for young persons who care for people who suffer from mental illness.

METHODS

This study was a randomized control trial, following the CONSORT statements, which compared the impact of two interventions. Primary outcome variable was stress, and secondary outcome variables were caring situation, general self-efficacy, well-being, health, and quality of life of young informal carers (N=241). Data were collected in June 2010 to April 2011, with self-assessment questionnaires, comparing the two interventions and also to detect changes.

RESULTS

The stress levels were high in both groups at baseline, but decreased in the folder group. The folder group had improvement in their caring situation (also different from the web group), general self-efficacy, well-being, and quality of life. The web group showed increase in well-being.

CONCLUSION

Young informal carers who take on the responsibility for people close to them; suffer consequences on their own health. They live in a life-situation characterized by high stress and low well-being. This signals a need for support.

PRACTICE IMPLICATIONS

The non-significant differences show that each intervention can be effective, and that it depends upon the individual's preferences. This highlights the importance of adopting person-centered approach, in which young persons can themselves choose support strategy.

Web-based interventions for caregivers of cancer patients: A review of literatures

Diagnosed with cancer is a traumatic event; it does not only affect the diagnosed patients, but also their caregivers. It brings along negative impacts on biopsychosocial health to the caregivers. Supportive interventions are essential for the caregivers to go through the cancer trajectory. In the past, interventions were being delivered in either face-to-face format or delivering written documents. Although Internet becomes a popular platform for delivering interventions given its substantial growth in usage, the effectiveness of this mode of intervention delivery is unclear. The aim of this review is to review existing literatures regarding efficacy of web-based interventions in psychological outcomes of cancer caregivers. A Literature search was performed in December 2012 from seven databases, including, Ovid MEDLINE, EMBASE, PsycINFO, CINHAL, ERIC, British Nursing Index and EBM Reviews. The following keywords were used in the search but were not limited to "paediatric", "parent", "caregiver", "cancer", "web-based", and "psycho education". Totally 4668 citations were identified, after excluding the duplicated and irrelevant citations; finally six studies were included in this review. A review of the literatures identified that the web-based interventions including either online support group only or a combination of informational website and online support group significantly improved coping skills, in a way reduced anxiety, stress, depression, burden, as well as negative mood and perceived bonding in cancer caregivers. It is concluded that a web-based format as a potential platform for delivering intervention to the caregivers of cancer patients for its unique advantage of easy accessibility, and no geographic or time barriers.

The promise of clinical interventions for hepatocellular carcinoma from the west to mainland China

OBJECTIVE

Hepatocellular carcinoma (HCC) presents a major health problem with its steadily increasing incidence in Western countries, and persistent high fatality rates worldwide. The well-recognized complexity and toxicity of its treatment as well as inadequate care and limited resources in mainland China exacerbate the difficulty of maintaining quality of remaining life of patients living with this illness. The goal of this comprehensive literature review was to identify promising clinical interventions for improving quality of life (QOL) of people with advanced HCC in mainland China.

METHOD

A comprehensive literature review was performed in China Academic Journals (CAJ), Cochrane, and PubMed databases. The review was confined to studies of randomized controlled trials (RCT) for adults, in Chinese and English, from 1980 to 2012.

RESULTS

A total of 676 studies in Chinese and 391 studies in English were identified. Eighteen RCTs were selected for the final review, among which three were conducted in mainland China.

SIGNIFICANCE OF RESULTS

Nurse-led home-based comprehensive interventions using a collaborative care approach addressing multiple dimensions of QOL show promise for enhancing clinical outcomes for people with advanced HCC in mainland China. Education and psychosocial support combined with symptom management early in the illness trajectory and ongoing close attention to physical symptoms, emotional distress, as well as spiritual well-being are crucial for maintaining QOL of people with advanced HCC. Telephone monitoring appears to be a feasible way in rural as well as urban areas. Families are advised to be part of overall interventions. It is warranted that promising interventions aiming at improving QOL for advanced cancer patients reported in Western literature be further tested in mainland China.

Experiences of family of patient with newly diagnosed advanced terminal stage hepatocellular cancer

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the third leading cause of cancer-related death worldwide due to its generally poor prognosis. Caregiver burden for liver cancer cases is higher than with other cancer and needs especial attention.

METHODS

To explore the experiences of families of patients with newly diagnosed advanced terminal stage hepatocellular cancer by interview.

RESULTS

Nine participants were recruited in this study. Content analysis of the interviews revealed four themes: blaming oneself, disrupting the pace of life, searching all possible regimens, and not letting go.

CONCLUSIONS

This study provides new insight into the needs and support of family members especially when they are facing loved ones with newly diagnosed advanced terminal stage HCC. These results will inform future supportive care service development and intervention research aimed at providing assistance in reducing unmet supportive care needs and psychological distress of these family members.

Racial differences in social support and coping among family caregivers of patients with prostate cancer

More than 60 million Americans are informal caregivers to adults, which can negatively affect their health. Data from 126 White and 62 African American female caregivers in North Carolina were analyzed to describe social support and coping among family caregivers of patients with prostate cancer and to assess for racial differences. Social support amount and some coping methods differed by race. There was no racial difference in social support satisfaction. Borderline significant difference in social support by health status was found and this differed by race. These racial differences should be explored further to better understand the availability of caregiving resources and their health effects.

A life course perspective on stress and health among caregivers of children with asthma in Detroit

Low-income caregivers raising children with asthma experience many obstacles to their own health, including stress. To understand and describe their daily experiences, researchers conducted 40 qualitative interviews supplemented with descriptive quantitative surveys in Detroit, Michigan, as part of a community-based participatory research partnership of Community Action Against Asthma. Prevalence of chronic illness is noticeably higher among participants than the general US population. Caregivers identified stress processes that may influence disproportionate health outcomes and risk-related behaviors over their lifetime. Applying a life course perspective, findings suggest that public health interventions should address family-level comorbidities, increase instrumental social support, and acknowledge practical coping mechanisms.

Touch, Caring, and Cancer: randomized controlled trial of a multimedia caregiver education program

Purpose

A randomized controlled trial was conducted to evaluate outcomes of a multimedia instructional program for family caregivers in simple touch-based techniques to provide comfort to cancer patients at home.

Methods

A multilingual 78-min DVD and 66-page manual were produced for homebased instruction. Content addresses attitudes and communication about touch in cancer, psychological preparation for giving and receiving touch, safety precautions, massage techniques for comfort and relaxation, acupressure for specific cancer-related symptoms, and practice in the home setting. Materials were produced in English, Spanish, and Chinese versions. A community-based multiethnic sample of 97 adult patient/caregiver dyads was randomized to experimental (massage) or attention control (reading) groups for 4 weeks. Massage dyads received the program and instructions to practice at least three times per week, while control caregivers read to their patients for the same frequency. Self-report instruments assessed change in symptom severity, quality of life, perceived stress, and caregiver attitudes.

Results

Significant reductions in all symptoms occurred for patients after both activities: 12–28 % reductions after reading vs. 29–44 % after massage. Massage caregivers showed significant gains in confidence, comfort, and self-efficacy using touch and massage as forms of caregiving.

Conclusions

Multimedia instruction in touch and massage methods may offer family members a viable means of enhancing self-efficacy and satisfaction in caregiving while decreasing patient pain, depression, and other symptoms. Family members may be able to learn and apply safe and simple methods that increase patient comfort and reduce distress.

Functional Impairments and Caregiver Depressive Symptoms in the Context of Brain Tumour and Other Cancers: A Mediating Effect of Strain

This study aimed to examine the associations among functional impairments, strain and depressive symptoms for caregivers of individuals with brain tumour and other cancers. Sixty-three caregivers (71% female) of individuals with brain tumour (n = 27) and other cancers (n = 36) were recruited from community services. Participants rated their level of depressive symptoms and strain and the functional impairments of the individual with cancer. Overall, approximately 25% of the total caregiver sample was in the clinical range for depressive symptoms. For caregivers of individuals with brain tumour, strain was significantly related to depressive symptoms (r = .57) and the individual's functional impairments (r = –.58); however, level of depressive symptoms was not significantly related to functional impairments (p > .05). For caregivers of individuals with other cancer, level of depressive symptoms was significantly correlated with strain (r = .50) and their relatives' degree of cognitive, interpersonal and emotional difficulties (r = –.36–.46), but not with activities of daily living (p > .05). In a multivariate analysis involving all the caregivers, strain predicted depressive symptoms (R2 = .32, p < .001) after controlling for gender and cancer type. In addition, strain was found to significantly mediate the effects of the interpersonal and emotional difficulties of individuals with cancer on caregiver depressive symptoms. Overall, these findings highlight the need to develop and evaluate strategies for alleviating the role strain associated with supporting individuals with cancer.

Cancer Carepartners: Improving patients' symptom management by engaging informal caregivers

BACKGROUND

Previous studies have found that cancer patients undergoing chemotherapy can effectively manage their own symptoms when given tailored advice. This approach, however, may challenge patients with poor performance status and/or emotional distress. Our goal is to test an automated intervention that engages a friend or family member to support a patient through chemotherapy.

METHODS/DESIGN

We describe the design and rationale of a randomized, controlled trial to assess the efficacy of 10 weeks of web-based caregiver alerts and tailored advice for helping a patient manage symptoms related to chemotherapy. The study aims to test the primary hypothesis that patients whose caregivers receive alerts and tailored advice will report less frequent and less severe symptoms at 10 and 14 weeks when compared to patients in the control arm; similarly, they will report better physical function, fewer outpatient visits and hospitalizations related to symptoms, and greater adherence to chemotherapy. 300 patients with solid tumors undergoing chemotherapy at two Veteran Administration oncology clinics reporting any symptom at a severity of ≥4 and a willing informal caregiver will be assigned to either 10 weeks of automated telephonic symptom assessment (ATSA) alone, or 10 weeks of ATSA plus web-based notification of symptom severity and problem solving advice to their chosen caregiver. Patients and caregivers will be surveyed at intake, 10 weeks and 14 weeks. Both groups will receive standard oncology, hospice, and palliative care.

DISCUSSION

Patients undergoing chemotherapy experience many symptoms that they may be able to manage with the support of an activated caregiver. This intervention uses readily available technology to improve patient caregiver communication about symptoms and caregiver knowledge of symptom management. If successful, it could substantially improve the quality of life of veterans and their families during the stresses of chemotherapy without substantially increasing the cost of care.

TRIAL REGISTRATION

NCT00983892.

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.

Caregiver-assisted coping skills training for lung cancer: results of a randomized clinical trial

CONTEXT

Lung cancer is one of the most common cancers in the United States and is associated with high levels of symptoms, including pain, fatigue, shortness of breath, and psychological distress. Caregivers and patients are adversely affected. However, previous studies of coping skills training (CST) interventions have not been tested in patients with lung cancer nor have systematically included caregivers.

OBJECTIVES

This study tested the efficacy of a caregiver-assisted CST protocol in a sample of patients with lung cancer.

METHODS

Two hundred thirty-three lung cancer patients and their caregivers were randomly assigned to receive 14 telephone-based sessions of either caregiver-assisted CST or education/support involving the caregiver. Patients completed measures assessing pain, psychological distress, quality of life (QOL), and self-efficacy for symptom management; caregivers completed measures assessing psychological distress, caregiver strain, and self-efficacy for helping the patient manage symptoms.

RESULTS

Patients in both treatment conditions showed improvements in pain, depression, QOL, and self-efficacy, and caregivers in both conditions showed improvements in anxiety and self-efficacy from baseline to four-month follow-up. Results of exploratory analyses suggested that the CST intervention was more beneficial to patients/caregivers with Stage II and III cancers, whereas the education/support intervention was more beneficial to patients/caregivers with Stage I cancer.

CONCLUSION

Taken together with the broader literature in this area, results from this study suggest that psychosocial interventions can lead to improvements in a range of outcomes for cancer patients. Suggestions for future studies include the use of three-group designs (e.g., comparing two active interventions with a standard-care control) and examining mechanisms of change.

Burden in caregivers of older adults with advanced illness

OBJECTIVES

To examine caregiver burden over time in caregivers of patients with advanced chronic disease.

DESIGN

Observational cohort with interviews over 12 months.

SETTING

Community.

PARTICIPANTS

Caregivers of 179 community-living persons aged 60 and older with advanced cancer, heart failure (HF), or chronic obstructive pulmonary disease (COPD).

MEASUREMENTS

Caregiver burden was assessed using a short-form of the Zarit Burden Inventory to measure psychosocial distress.

RESULTS

At baseline, the median caregiver burden was 5 (interquartile range (IQR) 1-11), which indicates that the caregiver endorsed having at least two of 10 distressing concerns at least some of the time. Only 10% reported no burden. Although scores increased modestly over time, the association between time and burden was not significant in longitudinal multivariable analysis. High burden was associated with caregiver need for more help with daily tasks (odds ratio (OR)=23.13, 95% confidence interval (CI)=5.94-90.06) and desire for greater communication with the patient (OR=2.53, 95% CI=1.16-5.53). The longitudinal multivariable analysis did not yield evidence of associations between burden and patient sociodemographic or health characteristics.

CONCLUSION

Caregiver burden was common in caregivers of patients with cancer, HF, and COPD. High burden was associated with the caregiver's report of need for greater help with daily tasks but not with objective measures of the patient's need for assistance, such as symptoms or functional status, suggesting that burden may be a measure of the caregiver's ability to adapt to the caregiving role.

Part 1: Home-based family caregiving at the end of life: a comprehensive review of published quantitative research (1998-2008)

The changing context of palliative care over the last decade highlights the importance of recent research on home-based family caregiving at the end of life. This article reports on a comprehensive review of quantitative research (1998-2008) in this area, utilizing a systematic approach targeting studies on family caregivers, home settings, and an identified palliative phase of care (n = 129). Methodological challenges were identified, including: small, non-random, convenience samples; reliance on descriptive and bivariate analyses; and a dearth of longitudinal research. Robust evidence regarding causal relationships between predictor variables and carer outcomes is lacking. Findings suggest the need for knowledge regarding: family caregiving for patients with non-malignant terminal conditions; whether needs and outcomes differ between family caregivers at the end of life and comparison groups; and caregiver outcomes in bereavement. Clear definitions of 'family caregiving', 'end of life', and 'needs' are required as well as greater application and testing of theoretical and conceptual explanations.

A systematic review of psychosocial interventions for family carers of palliative care patients

BACKGROUND

Being a family carer to a patient nearing the end of their life is a challenging and confronting experience. Studies show that caregiving can have negative consequences on the health of family carers including fatigue, sleep problems, depression, anxiety and burnout. One of the goals of palliative care is to provide psychosocial support to patients and families facing terminal illness. A systematic review of interventions for family carers of cancer and palliative care patients conducted at the start of this millennium demonstrated that there was a dearth of rigorous inquiry on this topic and consequently limited knowledge regarding the types of interventions likely to be effective in meeting the complex needs of family carers. We wanted to discern whether or not the evidence base to support family carers has improved. Furthermore, undertaking this review was acknowledged as one of the priorities for the International Palliative Care Family Carer Research Collaboration http://www.centreforpallcare.org.

METHODS

A systematic review was undertaken in order to identify developments in family carer support that have occurred over the last decade. The focus of the review was on interventions that targeted improvements in the psychosocial support of family carers of palliative care patients. Studies were graded to assess their quality.

RESULTS

A total of fourteen studies met the inclusion criteria. The focus of interventions included psycho-education, psychosocial support, carer coping, symptom management, sleep promotion and family meetings. Five studies were randomised controlled trials, three of which met the criteria for the highest quality evidence. There were two prospective studies, five pre-test/post-test projects and two qualitative studies.

CONCLUSIONS

The systematic review identified a slight increase in the quality and quantity of psychosocial interventions conducted for family carers in the last decade. More rigorous intervention research is required in order to meet the supportive care needs of family carers of palliative care patients.

[Tension attributes of the family caregiver of frail older adults]

The objective of this study was to assess both theoretically and empirically the tension attributes of the family caregiver of frail older adults. The theoretical phase consisted of analyzing 52 studies addressing this issue. The analysis showed that the phenomenon is evidenced by the caregiver through physical and emotional changes, unbalance between activity and rest, and compromised individual coping. In the field phase, an assessment was made of 30 women who, during the nursing consultation, showed evidence of tension due to their role as caregiver. Data collection was performed through interviews at home, which were recorded and followed a script created based on the theoretical findings. Every time it was considered adequate, excerpts from the caregivers' discourses were added to improve understanding. The empirical assessment confirmed the tension attributes revealed in the theoretical analysis.

Treating cancer patients who are near the end of life in the emergency department

Cancer-related visits to the emergency department (ED) can be expected to increase in the next decade as the population ages. Some of the these patients and their caregivers will come to the ED without prior end-of-life care planning, and others will require modification of prior plans based on disease progression. In this article, we discuss some of these end-of-life issues related to and including those of legal documents, transmission of patient wishes, limiting factors in implementing those wishes, and the new horizon of palliative care in the ED.

A narrative review of interventions to support family carers who provide physical care to family members with cancer

OBJECTIVES

Most reports of cancer caregivers' needs focus on information and psychosocial needs. Less is known about practical knowledge and support carers need to provide physical care in the home. This review aimed to identity and critique studies of the development and/or evaluation of interventions to enable family carers to provide physical/practical care to a family member with cancer.

DESIGN

Narrative review.

DATA SOURCES

Studies which included adult carers who provided care to a family member with cancer (any stage). Search sources included Psych Info., Cochrane Central Register of Controlled Trials, Embase Ovid, Embase, Ovid Medline, CINAHL, other databases, systematic and other reviews.

REVIEW METHODS

All types of study designs were included. Initially, multiple and broadly defined search strategies and terms were used to capture the range of potential studies; later more refined procedures were applied.

RESULTS

In total, 19 studies were included in the review. Interventions focused on skills development (n=1), managing symptoms (n=9), problem solving (n=5) and learning (n=4). Few studies were identified with well-defined and evaluated interventions to assist carers to provide physical care for their family member with cancer.

CONCLUSIONS

Future research is needed to develop well-defined interventions on practical skills and evaluate the outcomes for patients and caregivers.

Palliative care services for Indian migrants in australia: experiences of the family of terminally ill patients

BACKGROUND

The way that health care systems in developing countries like India care for dying patients, has an impact on the expectations of such care for those who migrate to other countries faces. At the end of life, cultural issues may impact on the quality of life remaining and for that reason, it is important that particular cultural practices are understood. This paper describes a study that investigated the cultural issues of access to palliative care services for Indian migrants in Australia.

PURPOSE OF THE STUDY

To investigate the experiences of the family members of terminally ill Indian migrants in Victoria, Australia.

OBJECTIVE OF THE STUDY

To explore the issues related to accessing palliative care services for Indian migrants; to identify the effectiveness of palliative care in supporting the patient and family and to recommend strategies for improving this care.

MATERIALS AND METHODS

A qualitative descriptive design was utilized. Up to 6 family members were selected for in-depth interviews in understanding cultural issues related to the palliative care services for a family member.

RESULTS

ANALYSIS OF THE INTERVIEWS REVEALED THAT FAMILIES OF INDIAN PATIENTS EXPERIENCE DIFFICULTIES WHILST RECEIVING PALLIATIVE CARE SERVICES, WHICH FELL INTO THREE MAIN CATEGORIES: Indian support systems, cultural issues, and caring experiences. Although each of these issues had a direct influence on the experience of terminal care that their family member received, cultural issues and support systems also influenced the caring experiences.

CONCLUSION

Despite the successful implementation of palliative care services across Australia, there are still problems in accessing and receiving the services among minority and disadvantaged groups like various cultural groups.

The influence of developmental life stage on quality of life in survivors of prostate cancer and their partners

INTRODUCTION

Although prostate cancer is prevalent, little information is available on how it affects couples' quality of life (QOL) according to their age cohort. The purpose of this study was to examine how quality of life, self-efficacy and appraisal of the illness experience vary among men with prostate cancer and their partners according to age cohort: middle age (50-64); young-old (65-74); and old-old (75-84). Using an Adult Developmental and Family Stress framework, this study focuses on how normative (developmental stage) and non-normative stressors (prostate cancer) may affect a couple's ability to adapt.

METHODS

A descriptive, comparative design was used to examine age-related differences in quality of life and selected psychosocial variables in 69 men with prostate cancer and their spouses. Cross-sectional data were obtained using standardized instruments with adequate reliability and validity. ANCOVA and MANCOVA were used to determine differences among age groups.

RESULTS

Findings indicated that patients who were ages 65-74 had better QOL and higher self-efficacy than patients ages 50-64 and less negative appraisal of illness than the other two groups. Spouses ages 50-64 reported the most distress related to sexual changes in their husbands. Spouses in both the middle age and old-old group had more bother related to hormone therapy than the young-old spouses.

IMPLICATIONS FOR CANCER SURVIVORS

Findings suggest that interventions should be tailored to dyads' developmental life stage. Younger and older prostate cancer survivors and their partners may benefit from tailored interventions designed to improve their quality of life and confidence in managing their treatment outcomes during the survivorship period.

Preferences for location of death of seriously ill hospitalized patients: perspectives from Canadian patients and their family caregivers

Previous studies involving palliative patients suggest a preference for dying at home. The purpose of this paper is to examine, prospectively, patient and family caregiver preferences for, and congruence with, location of death for hospitalized patients with cancer and end-stage medical conditions. Questionnaires were administered to 440 eligible in-patients and 160 family caregivers in five hospitals across Canada. This paper reports results of 138 patient/family caregiver dyads who answered a question about preference for location of death. The results suggest that only half of all patients and family caregivers report a preference for a home death. Furthermore, half of the patient/family caregiver dyads disagree on preferred location of death. If one of the primary goals of end of life care is to enhance the quality of life of dying patients and their family caregivers, policies directed towards ensuring that patients die in their location of choice ought to be a priority and resources should be allocated to promote the development of excellent care, not only in the home, but also within our institutional settings.

Improving well-being in caregivers of terminally ill patients. Making the case for patient suffering as a focus for intervention research

Family caregivers are integral to the care of patients with physical or mental impairments. Unfortunately, providing this care is often detrimental to the caregivers' health. As a result, in the last decade, there has been a proliferation of interventions designed to improve caregivers' well-being. Interventions for caregivers of persons at end of life, however, are relatively few in number and are often underdeveloped. They also are typically designed to help reduce the work of caregiving or to help caregivers cope with the physical and emotional demands of providing care. Although useful, these interventions generally ignore a primary stressor for family caregivers -- a loved one's suffering. Patient suffering, whether physical, psychosocial, or spiritual, has a major impact on family caregivers. However, interventions that focus on the relief of patient suffering as a way to improve caregiver well-being have rarely been tested. It is our view that more research in this area could lead to new and more effective interventions for family caregivers of seriously or terminally ill patients. In support of our view, we will define suffering and review the relationships between patient suffering and caregiver well-being. We will then discuss a conceptual framework for intervention design. Finally, we conclude with a discussion of implications and future directions for intervention research.

The caregiver reaction assessment: psychometrics, and temporal stability in primary caregivers of Norwegian cancer patients in late palliative phase

BACKGROUND

Limited research has been done on the situation of primary caregivers (PCs) to patients staying at home with cancer in the palliative phase. This study uses the Caregiver Reaction Assessment (CRA) to examine PCs caregiver burden and well-being.

PATIENTS AND METHODS

The sample consisted of 85 PCs examined at baseline, among them 42 were re-examined four months later. We explored the psychometric properties of the CRA at baseline, and introduced a CRA sum score. The CRA sum score was correlated with the Short Form 36 (SF-36) and The Hospital Anxiety and Depression Scale (HADS) scores.

RESULTS

The internal consistency of the CRA dimensions varied between alpha 0.57 and 0.85, and the factor structure was in line with earlier studies. The CRA sum score correlated significantly with all mental dimensions on the SF-36 and the HADS. At baseline the PCs showed significantly worse scores except for family support when compared to newly diagnosed cancer patients. The mean scores on the CRA dimensions as well as the total score did not change significantly from baseline to follow-up.

CONCLUSION

We have confirmed the psychometric properties of the CRA, which seems to be an appropriate instrument for assessment the PCs caregiver situation.

Primary caregivers of cancer patients in the palliative phase: a path analysis of variables influencing their burden

Research has shown that several variables influence the burden of primary caregivers of cancer patients staying at home in the palliative phase, but the associations between these variables have hardly been explored. The aim of this study was to examine the associations of theory-driven variables with the caregivers' burden by means of path analysis. The sample consisted of 96 caregivers of cancer patients in the palliative phase staying at home recruited from a hospital trust in Norway. The dimensions of burden from the Caregiver Reaction Assessment, namely self esteem, lack of family support, impact on finances, and impact on daily schedule, were used as the dependent variable. The following independent variables were tested in the models: the patients' levels of pain, fatigue, and nausea; and the caregivers' physical quality of life, anxiety and depression, and social support. The Partial Least Squares approach to structural equation modelling was used for the path analysis. Model 1 shows the direct associations between the independent variables and the dependent variable, explaining 16% of the variance in caregiver burden. Model 1 supports the finding that only caregivers' depression has a direct significant association with caregiver burden, and shows further that the effects of the other independent variables on burden are mediated through depression. In Model 2, anxiety and depression are mediating factors between three other independent variables and caregiver burden, and 12% of the variance is explained. Model 2 supports none of the independent variables as antecedents of burden. Testing of the models suggested that caregivers' depression was the main factor associated with caregiver burden, but also an important mediator of indirect associations of indirect associations of caregivers' anxiety and physical health.

Spousal responses to prostate cancer: an integrative review

Prostate cancer is the most frequently diagnosed cancer in the United States. Survival rates of localized cancer are excellent, with more than 96 percent of men surviving 5 years after diagnosis. However, treatment such as radical prostatectomy may leave the patients and their spouses to deal with long-term side effects, including impotence and urinary incontinence. While previous studies have shown how men react to these treatment effects, studies are now emerging that focus on the responses of their spouses to diagnosis and treatment side effects. This integrative literature review examines the psychosocial responses of spouses whose husbands have undergone prostatectomy. Studies that report on spouses' responses to diagnosis, treatment, and side effects were reviewed. The literature shows that spouses are significantly more distressed overall than are patients. Sources of distress include lack of information, fear of the unknown, fear of what the future will hold, and treatment-related concerns. Only one controlled intervention study was found that attempted to address these concerns. Further controlled studies are needed to address spousal distress.

A conceptual model and key variables for guiding supportive interventions for family caregivers of people receiving palliative care

According to the World Health Organization, the patient and family should be viewed as the "unit of care" when palliative care is required. Therefore family caregivers should receive optimal supportive care from health professionals. However, the impact of supporting a dying relative is frequently described as having negative physical and psychosocial sequalae. Furthermore, family caregivers consistently report unmet needs and there has been a dearth of rigorous supportive interventions published. In addition, comprehensive conceptual frameworks to navigate the family caregiver experience and guide intervention development are lacking. This article draws on Lazarus and Folkman's seminal work on the transactional stress and coping framework to present a conceptual model specific to family caregivers of patients receiving palliative care. A comprehensive account of key variables to aid understanding of the family caregiver experience and intervention design is provided.

Measuring the psychosocial characteristics of family caregivers of palliative care patients: psychometric properties of nine self-report instruments

Researchers and clinicians have experienced substantial difficulties locating measures that are suitable for use within palliative care settings. This article details the psychometric properties of nine instruments designed to assess the following psychosocial characteristics of family caregivers: competence, mastery, self-efficacy, burden, optimism, preparedness, social support, rewards, and mutuality. Results are based on the responses of 106 primary family caregivers caring for relatives dying of cancer. Principal components extraction with varimax rotation was used to explore the underlying structure of each measure. Following the exclusion of complex variables, suggested components for most measures comprised relatively homogenous items, which were good to excellent measures of each component. Some components comprised only two items; however, Cronbach's alphas typically indicated moderate to high levels of internal consistency. Overall, the results of this study suggest that most of the measures analyzed, excepting the mastery and mutuality scales, can be recommended to examine the family caregiver experience and test supportive interventions.

Changes in Prognostic Awareness among Seriously Ill Older Persons and Their Caregivers

PURPOSE

To examine changes in patients' and caregivers' understanding of prognosis with progression of the patient's illness.

SUBJECTS AND METHODS

Community-dwelling persons 60 years of age and older who were seriously ill with cancer, congestive heart failure, or chronic obstructive pulmonary disease and their caregivers were interviewed every 4 months and more frequently with a decline in the patient's status for up to one year. We examined responses to, "If you had to take a guess, how long do you think that (you/the patient) might have to live?" at baseline and at the interview closest to death.

RESULTS

Among 218 patients, 87 died within 1 year. At their initial interview 46% were uncertain about their life expectancy (LE) and 9% believed LE was 1 year or less; at their final interview, 55% were uncertain and 17% believed LE was 1 year or less. At the caregiver's initial interview, 29% were uncertain about the patient's LE and 20% believed LE was 1 or less; at their final interview, 30% were uncertain and 34% believed LE was 1 year or less. Among those interviewed within 30 days of the patient's death, 31% of patients and 52% of caregivers believed LE was 1 year or less. Patients' estimates of the LE did not differ according to their diagnosis.

CONCLUSIONS

There was little change in prognostic awareness over time. Even close to death, a large proportion of patients and caregivers were uncertain about prognosis, and few believed the patient had a limited life expectancy. Whether or not patients should know their prognosis is the subject of active debate; the persistence of prognostic misperception suggests that prognostic awareness may be difficult to change.