Proxy reporting in after-death interviews: the use of proxy respondents in retrospective assessment of chronic diseases and symptom burden in the terminal phase of life

The path not taken: Distinguishing individuals who die by suicide from those who die by natural causes despite a shared history of suicide attempt

OBJECTIVES

This study aimed to identify variables that distinguish suicide risk among individuals with previous suicide attempts.

METHOD

Using psychological autopsy procedures, we evaluated 86 decedents who had at least one lifetime suicide attempt before eventual death by suicide (n = 65) or natural causes (n = 21).

RESULTS

The Suicide Death group was more likely to be male, to have alcohol in the toxicology report at time of death, and to have a depression diagnosis, while the Natural Cause Death group was more likely to have personality disorder traits, a polysubstance use disorder, higher reported health stress, and an antidepressant in the toxicology report at time of death. Hopelessness and ambivalence were found to distinguish between groups during the 6 months before death.

CONCLUSIONS

These findings suggest important differences between individuals with a shared history of a suicide attempt who die by suicide versus natural causes.

The Level of Distress From Fatigue Reported in the Final Two Months of Life by a Palliative Care Population: An Australian National Prospective, Consecutive Case Series

CONTEXT

Fatigue is the most commonly reported symptom in life-limiting illnesses, although not much is known about the distress it causes patients as they approach death.

OBJECTIVES

To map the trajectory of distress from fatigue reported by an Australian palliative care population in the last 60 days leading up to death.

METHODS

A prospective, longitudinal, consecutive cohort study using national data from the Australian Palliative Care Outcomes Collaboration between July 1, 2013, and December 31, 2018. Patients were included if they had at least one measurement of fatigue on a 0-10 numerical rating scale in the 60 days before death. Descriptive statistics were used to analyse patients by diagnostic cohort and functional status.

RESULTS

A total of 116,604 patients from 203 specialist palliative care services were analyzed, providing 501,104 data points. Distress from fatigue affected up to 80% of patients referred to palliative care, with the majority experiencing moderate or severe distress. Malignant and nonmalignant diagnoses were equally affected, with the neurological cohort showing the greatest variability. The degree of distress correlated with a patient's functional level; it worsened as a patient's function declined until a patient became bedbound when the reporting of distress reduced.

CONCLUSIONS

Distress from fatigue is high in this cohort of patients. Interventions to reduce this distress need to be a research priority.

Place of Death for People with Noncancer and Cancer Illness in South Australia: A Population-Based Survey

A large representative population survey of 9,500 households reports the association between place of death, diagnosis (cancer vs. noncancer), and use of palliative care services of terminally ill South Australians. Thirty-one percent (1,920) indicated that someone close to them had died of a terminal illness in the preceding five years; 18% had died of noncancer illness and 82% of cancer. Sixty-two percent of deceased individuals accessed palliative care services. More patients with cancer than noncancer had had palliative care (65% vs. 48%; p<0.0001). Compared with cancer patients, those with noncancer illness had died in hospices less frequently (9% vs. 15%; p=0.0015) and in nursing homes more frequently (15% vs. 5%; p<0.0001). Similar proportions had died in hospital (60%) and at home (16%–20%). Palliative care service involvement did not reduce institutional deaths, but shifted them from hospital to hospice.

Bereaved family members' perspectives on suffering among older rural cancer patients in palliative home nursing care: A qualitative study

Little is known about experiences with receiving home nursing care when old, living in a rural area, and suffering from end-stage cancer. The aim of this study was thus to investigate bereaved family members' perceptions of suffering by their older relatives when receiving palliative home nursing care. Qualitative semi-structured interviews were conducted with 10 family members, in Norway during autumn 2015, and directed content analysis guided by Katie Eriksson's theoretical framework on human suffering was performed upon the data. The two main categories identified reflected expressions of both suffering and well-being. Expressions of suffering were related to illness, to care and to life and supported the theory. Expressions of well-being were related to other people (e.g. familiar people and nurses), to home and to activity. The results indicate a need to review and possibly expand the perspective of what should motivate care. Nursing and palliative care that become purely disease and symptom-focused may end up with giving up and divert the attention to social and cultural factors that may contribute to well-being when cure is not the goal.

Health Care Seeking Behavior of Persons with Acute Chagas Disease in Rural Argentina: A Qualitative View

Chagas disease (CD) is a tropical parasitic disease largely underdiagnosed and mostly asymptomatic affecting marginalized rural populations. Argentina regularly reports acute cases of CD, mostly young individuals under 14 years old. There is a void of knowledge of health care seeking behavior in subjects experiencing a CD acute condition. Early treatment of the acute case is crucial to limit subsequent development of disease. The article explores how the health outcome of persons with acute CD may be conditioned by their health care seeking behavior. The study, with a qualitative approach, was carried out in rural areas of Santiago del Estero Province, a high risk endemic region for vector transmission of CD. Narratives of 25 in-depth interviews carried out in 2005 and 2006 are analyzed identifying patterns of health care seeking behavior followed by acute cases. Through the retrospective recall of paths for diagnoses, weaknesses of disease information, knowledge at the household level, and underperformance at the provincial health care system level are detected. The misdiagnoses were a major factor in delaying a health care response. The study results expose lost opportunities for the health care system to effectively record CD acute cases.

Effect of palliative care nurse champions on the quality of dying in the hospital according to bereaved relatives: A controlled before-and-after study

BACKGROUND

To improve the quality of end-of-life care, hospitals increasingly appoint palliative care nurse champions.

AIM

We investigated the effect of nurse champions on the quality of life during the last 3 days of life and the quality of dying as experienced by bereaved relatives.

DESIGN

A controlled before-and-after study (June 2009-July 2012). Halfway, in each of seven intervention wards, two nurse champions were appointed; 11 wards served as control wards. The quality of life during the last 3 days of life, quality of dying and multiple dimensions of quality of dying were compared before and after the introduction of nurse champions.

SETTING

In a university hospital, each death at non-intensive care units was followed up by an invitation to relatives (10-13 weeks later) to answer a questionnaire.

RESULTS

For the two periods, data were collected on 86 and 84 patients in intervention wards and on 108 and 118 patients in control wards (overall response: 52%). In the intervention wards, no differences were found in the quality of life during the last 3 days of life and the quality of dying scores: in both periods, median score for the quality of life during the last 3 days of life was 3.0 and for the quality of dying 7.0. No differences were found in multiple quality of dying dimensions. In control wards, the median quality of dying score was 7.0 pre-intervention and 6.0 post-intervention (p = 0.04). Other scores were comparable with those in intervention wards.

CONCLUSION

Performing a complex intervention study in palliative care proved to be feasible. This study showed no differences in the experiences of bereaved relatives after introduction of nurse champions. The complexity of palliative care in the hospital might require more intensive and longer training of nurse champions.

Improving end-of-life care in acute geriatric hospital wards using the Care Programme for the Last Days of Life: study protocol for a phase 3 cluster randomized controlled trial

Background

The Care Programme for the Last Days of Life has been developed to improve the quality of end-of-life care in acute geriatric hospital wards. The programme is based on existing end-of-life care programmes but modeled to the acute geriatric care setting. There is a lack of evidence of the effectiveness of end-of-life care programmes and the effects that may be achieved in patients dying in an acute geriatric hospital setting are unknown. The aim of this paper is to describe the research protocol of a cluster randomized controlled trial to evaluate the effects of the Care Programme for the Last Days of Life.

Methods and design

A cluster randomized controlled trial will be conducted. Ten hospitals with one or more acute geriatric wards will conduct a one-year baseline assessment during which care will be provided as usual. For each patient dying in the ward, a questionnaire will be filled in by a nurse, a physician and a family carer. At the end of the baseline assessment hospitals will be randomized to receive intervention (implementation of the Care Programme) or no intervention. Subsequently, the Care Programme will be implemented in the intervention hospitals over a six-month period. A one-year post-intervention assessment will be performed immediately after the baseline assessment in the control hospitals and after the implementation period in the intervention hospitals. Primary outcomes are symptom frequency and symptom burden of patients in the last 48 hours of life.

Discussion

This will be the first cluster randomized controlled trial to evaluate the effect of the Care Programme for the Last Days of Life for the acute geriatric hospital setting. The results will enable us to evaluate whether implementation of the Care Programme has positive effects on end-of-life care during the last days of life in this patient population and which components of the Care Programme contribute to improving the quality of end-of-life care.

Trial registration

ClinicalTrials.gov Identifier: NCT01890239. Registered June 24th, 2013.

Long-term use of cochlear implants in older adults: results from a large consecutive case series

OBJECTIVE

To investigate rates of long-term use of cochlear implants in a large, consecutive case series of older adults (≥60 yr).

STUDY DESIGN

Consecutive case series.

SETTING

Tertiary referral center.

PATIENTS

Approximately 447 individuals 60 years or older who received their first CI from 1999 to 2011. We successfully contacted 397 individuals (89%) to ascertain data on the individual's daily CI use averaged over the past 4 weeks.

INTERVENTION

Cochlear implantation.

MAIN OUTCOME MEASURE

Regular CI use was defined as 8 hours or greater of use per day. We investigated the time from implantation to the date when an individual reported discontinuing regular CI use.

RESULTS

The overall rate of regular CI use at 13.5 years of follow-up was 82.6% (95% CI, 72.5%-89.3%). Individuals who received a CI at 60 to 74 years had significantly higher rates of regular CI use at 13.5 years of follow-up (91.1% [95% CI, 83.2%-95.4%], n = 251) than individuals who received a CI at 75 years or older (55.7% [95% CI, 24.9%-78.1%], n = 146). The rate of discontinuing regular CI use (<8 hr/d) increased on average by 7.8% (95% CI, 3.0%-12.8%) per year of age at implantation.

CONCLUSION

Rates of long-term CI use in older adults at more than 10 years of follow-up exceed 80%. The rate of discontinuing regular CI use was strongly associated with older age at implantation. These results suggest that early implantation of older adults, once critically low levels of speech recognition are present, is associated with greater usage of the device.

Hospital and nursing home use from 2002 to 2008 among U.S. older adults with cognitive impairment, not dementia in 2002

Little is known about health care use in the cognitive impairment, not dementia (CIND) subpopulation. Using a cohort of 7130 persons aged 71 years or over from the Health and Retirement Survey, we compared mean and total health care use from 2002 to 2008 for those with no cognitive impairment, CIND, or dementia in 2002. Cognitive status was determined using a validated method based on self or proxy interview measures. Health care use was also based on self or proxy reports. On the basis of the Health and Retirement Survey, the CIND subpopulation in 2002 was 5.3 million or 23% of the total population 71 years of age or over. Mean hospital nights was similar and mean nursing home nights was less in persons with CIND compared with persons with dementia. The CIND subpopulation, however, had more total hospital and nursing home nights--71,000 total hospital nights and 223,000 total nursing home nights versus 32,000 hospital nights and 138,000 nursing home nights in the dementia subpopulation. A relatively large population and high health care use result in a large health care impact of the CIND subpopulation.

Frailty and body mass index as predictors of 3-year mortality in older adults living in the community

BACKGROUND

Frailty and body mass index (BMI) are known to be predictive of late life mortality, but little is known about the combined effects of frailty and BMI on mortality.

OBJECTIVE

This study investigated the influence of frailty status and BMI category on mortality in older adults.

METHODS

Data were from the Living Profiles of Older People Survey, a national survey of community-dwelling older people in Korea, with a baseline study of 11,844 Koreans aged 65 years and older in 2008 and a 3-year follow-up for mortality. Frailty was categorized as not frail, prefrail, and frail, based on five indicators (weight loss, exhaustion, physical activity, walking speed, and grip strength). BMI (kg/m(2)) was classified as underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9), or obese (≥30.0). A Cox proportional model was used to analyze the association of the combined frailty and BMI categories with all-cause mortality, adjusting for sociodemographics and health-related factors.

RESULTS

Adjusting for covariates, compared with the normal-weight nonfrail counterpart, the underweight or normal-weight prefrail/frail status demonstrated significantly increased rates of death. The obese frail respondents showed a significantly higher mortality risk (hazard ratio, 3.89; 95% confidence interval, 1.14-13.28). The overweight prefrail/frail group, however, exhibited no significant association with mortality.

CONCLUSION

Among older people who were of normal weight or underweight, greater frailty was associated with poorer survival. Whereas being overweight tended to be neutral of the influence of frailty on mortality, the obese frail exhibited a significantly elevated rate of death.

Musculoskeletal pain in older adults at the end-of-life: a systematic search and critical review of the literature with priorities for future research

Background

Pain is an important issue in end of life care. Although musculoskeletal pain is common in older adults, it is rarely associated with the cause of death and may be overlooked as death approaches. Hence a major target for improving quality of life may be being missed.

Methods

The aim of this study was to systematically search and critically review the literature on musculoskeletal pain at the end of life. Amed, Cinahl, Internurse, Medline, Psych Info, Web of Knowledge and Cochrane review databases were searched for relevant research up to September 2012. The search strategy combined key words expanding the terms ‘palliative’ for population, ‘musculoskeletal’ for exposure, and ‘pain’ for outcome. Predefined inclusion and exclusion criteria were applied.

Results

Five relevant papers and one letter to the editor were found, including case studies and epidemiological research. Current evidence suggests musculoskeletal pain is common in older adults at the end of life and that it can have a substantial impact on individual experience. No information about community based treatment of musculoskeletal pain at the end of life was found.

Conclusion

Priorities for future research include high quality epidemiological studies to establish the prevalence, natural history, impact, assessment, patient priorities and outcomes associated with musculoskeletal pain in the end of life period, and intervention research that provides an evidence base for treatment.

Death with dignity from the perspective of the surviving family: a survey study among family caregivers of deceased older adults

BACKGROUND

Death with dignity has been identified as important both to patients and their surviving family. While research results have been published on what patients themselves believe may affect the dignity of their deaths, little is known about what family caregivers consider to be a dignified death.

AIM

(1) To assess the prevalence of death with dignity in older adults from the perspective of family caregivers, (2) to determine factors that diminish dignity during the dying phase according to family caregivers, and (3) to identify physical, psychosocial, and care factors associated with death with dignity.

DESIGN

A survey study with a self-administered questionnaire.

PARTICIPANTS

Family caregivers of 163 deceased older (>55 years of age) adults ("patients") who had participated in the Longitudinal Aging Study Amsterdam.

RESULTS

Of the family caregivers, 69% reported that their relative had died with dignity. Factors associated with a dignified death in a multivariate regression model were patients feeling peaceful and ready to die, absence of anxiety and depressive mood, presence of fatigue, and a clear explanation by the physician of treatment options during the final months of life.

CONCLUSIONS

The physical and psychosocial condition of the patient in combination with care factors contributed to death with dignity from the perspective of the family caregiver. The patient's state of mind during the last phase of life and clear communication on the part of the physician both seem to be of particular importance.

Changes over a decade in end-of-life care and transfers during the last 3 months of life: a repeated survey among proxies of deceased older people

BACKGROUND

In the ageing population, older people are living longer with chronic diseases. Especially in the last year of life, this can result in an increased need for (complex) end-of-life care.

AIM

To study potential changes in received end-of-life care and transfers by older people during the last 3 months of life between 2000 and 2010.

DESIGN

A repeated survey in 2000 and 2010.

PARTICIPANTS

Data were collected from a sample of proxies of deceased sample members of the Longitudinal Aging Study Amsterdam in 2000 (n = 270; response = 79%) and 2010 (n = 168; response = 59%).

RESULTS

Compared to 2000, in 2010, older people had a significantly lower functional ability 3 months before death. Over the 10-year period, people were significantly less likely to receive no care (12% vs 39%) and more likely to receive formal home care (45% vs 15%). Older people aged over 80 years, females, and those in the 2010 sample were more likely to receive formal home and institutional care (formal home care - age > 80 years, odds ratio: 3.7, male odds ratio: 0.74, 2010 - odds ratio: 6.9; institutional care - age > 80 years, odds ratio: 11.6, male odds ratio: 0.34, 2010 - odds ratio: 2.5) than informal or no care. Regardless of the study year, older people receiving informal home care were more likely to die in hospital (odds ratio: 2.3).

CONCLUSION

Two scenarios of care in the last 3 months of life seem to arise: staying at home as long as possible with a higher chance of hospital death or living in a residential or nursing home, reducing the chance of hospital death.

Decision-making capacity and communication about care of older people during their last three months of life

Background

Limited decision-making capacity (DMC) of older people affects their abilities to communicate about their preferences regarding end-of-life care. In an advance directive (AD) people can write down preferences for (non)treatment or appoint a proxy as a representative in (non)treatment choices in case of limited DMC.

The aim is to study limited DMC during the end of life and compare the background, (satisfaction with) care and communication characteristics of people with and without limited DMC. Furthermore, the aim is to describe patient proxies’ opinions about experiences with the use of (appointed proxy) ADs.

Methods

Using a questionnaire, data were collected from proxies of participants of a representative sample of the Longitudinal Aging Study Amsterdam (n=168) and a purposive sample of the Advance Directive cohort study (n=184). Differences between groups (with and without limited DMC, and/or with and without AD) were tested with chi-square tests, using a level of significance of p < 0.05.

Results

At a month before death 27% of people had limited DMC; this increased to 67% of people having limited DMC in the last week of life. The care received was in accordance with the patient’s preferences for the majority of older people, although less often for people who had limited DMC for more than a week. The majority of the proxies were satisfied with the communication between physician and the patient and them, regardless of DMC of the patient. Of people with an AD, a small majority of relatives indicated that the AD had been of additional value. Finally, no differences were found in the role of the relative and the satisfaction with this role between people with and without a proxy AD.

Conclusions

Although relatives have positive experiences with ADs, our study does not provide strong evidence that (proxy) ADs are very influential in the last phase of life. They can best be seen as a tool for advance care planning.

Investigating violence and control dyadically in a help-seeking sample from Mozambique

A sample of 1442 women attending a Forensic Healthcare Service provided information on their own and their partners' use of controlling behaviors, partner violence, and sexual abuse, as well as their own experiences of childhood abuse. Using Johnson's typology, the relationships were categorized as Nonviolent, Intimate Terrorism, or Situational Couple Violence. Findings suggest that help-seeking women's experiences of intimate violence may be diverse, with their roles ranging from victim to perpetrator.

Late-life depressive symptoms, religiousness, and mood in the last week of life

Aim of the current study is to examine whether previous depressive symptoms modify possible effects of religiousness on mood in the last week of life. After-death interviews with proxy respondents of deceased sample members of the Longitudinal Aging Study Amsterdam provided information on depressed mood in the last week of life, as well as on the presence of a sense of peace with the approaching end of life. Other characteristics were derived from interviews with the sample members when still alive. Significant interactions were identified between measures of religiousness and previous depressive symptoms (CES-D scores) in their associations with mood in the last week of life. Among those with previous depressive symptoms, church-membership, church-attendance and salience of religion were associated with a greater likelihood of depressed mood in the last week of life. Among those without previous depressive symptoms, church-attendance and salience of religion were associated with a higher likelihood of a sense of peace. For older adults in the last phase of life, supportive effects of religiousness were more or less expected. Fore those with recent depressive symptoms, however, religiousness might involve a component of existential doubt.

Agreement on cause of death between proxies, death certificates, and clinician adjudicators in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

Death certificates may lack accuracy and misclassify the cause of death. The validity of proxy-reported cause of death is not well established. The authors examined death records on 336 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a national cohort study of 30,239 community-dwelling US adults (2003-2010). Trained experts used study data, medical records, death certificates, and proxy reports to adjudicate causes of death. The authors computed agreement on cause of death from the death certificate, proxy, and adjudication, as well as sensitivity and specificity for certain diseases. Adjudicated cause of death had a higher rate of agreement with proxy reports (73%; Cohen's kappa (κ) statistic = 0.69) than with death certificates (61%; κ = 0.54). The agreement between proxy reports and adjudicators was better than agreement with death certificates for all disease-specific causes of death. Using the adjudicator assessments as the "gold standard," for disease-specific causes of death, proxy reports had similar or higher specificity and higher sensitivity (sensitivity = 50%-89%) than death certificates (sensitivity = 31%-81%). Proxy reports may be more concordant with adjudicated causes of death than with the causes of death listed on death certificates. In many settings, proxy reports may represent a better strategy for determining cause of death than reliance on death certificates.

Evaluating a palliative care intervention for veterans: challenges and lessons learned in a longitudinal study of patients with serious illness

CONTEXT

Longitudinal studies examining care for seriously ill patients are needed to understand patients' experience of illness, evaluate interventions, and improve quality of care. Unfortunately, such studies face substantial methodological challenges.

OBJECTIVES

This article describes such challenges and the strategies used to overcome them in a successfully implemented palliative care intervention trial for veterans.

METHODS

Veterans admitted with a physician-estimated moderate-to-high one-year mortality risk were enrolled and followed up to three years, until death or study completion. Study protocols, procedures, and process data were intermittently analyzed to identify and develop strategies to address issues affecting study enrollment and interview completion rates.

RESULTS

Of 561 patients who were eligible, 400 (71%) enrolled in the study; 357 (87%) alive at the end of Month 1 completed interviews; and 254 (88%) alive at Month 6 completed interviews. Of the 208 patients who died during the study and had identified a caregiver, we were able to conduct an after-death interview with 154 (74%) caregivers. A variety of strategies, such as systematic tracking and check-in calls, minimizing respondent burden, and maintaining interviewer-respondent dyads over time, were used to maximize enrollment rates, data collection, and retention.

CONCLUSION

These data demonstrate that the use of diverse strategies and flexibility with regard to study protocols can result in successful recruitment, data collection, and retention of participants with serious illness. They thus show that longitudinal research can be successfully implemented with this population to evaluate interventions and examine patient experiences.

End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP

Differences in the general focus of care among hospitals, nursing homes, and homes may affect the adequacy of end-of-life decision making for the dying. We studied end-of-life decision-making practices for cancer patients who died in each of these settings and assessed the impact of the Liverpool Care Pathway for the Dying Patient (LCP), a template for care in the dying phase. Physicians and relatives of 311 deceased cancer patients completed questionnaires. The LCP was introduced halfway through the study period. During the last three months of life, patients who died in hospital received anticancer therapy and medication to relieve symptoms more often than those in both other settings. During the last three days of life, patients who died in the hospital or nursing home received more medication than those who died at home. The LCP reduced the extent to which physicians used medication that might have hastened death. Relatives of patients who died in the hospital tended to be least positive about the patient's and their own participation in the decision making. We conclude that cancer patients who die in the hospital are more intensively treated during the last phase of life than those who die elsewhere. The LCP has an impact on the use of potentially life-shortening medication during the dying phase. Communication about medical decision making tends to be better in the nursing home and at home.

Caregivers for people with end-stage lung disease: characteristics and unmet needs in the whole population

Introduction

End-stage lung disease (ESLD) (predominantly caused by chronic obstructive pulmonary disease and restrictive lung disease) is a significant cause of death. Little is known about community care for people with ESLD especially in the period leading to death. This paper describes demographic characteristics of caregivers, and key characteristics of the deceased irrespective of specialist service utilization.

Methods

The South Australian Health Omnibus is an annual, random, face-to-face, cross-sectional survey conducted statewide. For the last eight years questions about end of life have been asked of 3000 respondents annually (participation rate 77.9%). Directly standardized to the whole population, this study describes people who cared for someone with ESLD until death.

Results

One third (6370/18267) had someone die in the last five years from a terminal illness, 644 from ESLD (3.5% of respondents; 10.2% of deaths). One in five (20.8%) provided physical care: 43 respondents provided day-to-day and 63 provided intermittent hands-on care for an average of 40.1 months (SD 56.9). Caregivers were on average 51.2 years old (range 17–85; SD 16.5) and one in five was a spouse. Additional support to provide physical care was an unmet need by 17% of caregivers. The deceased were an average of 73.9 years old (range 47–92; SD 10.4). Only 31.1% were assessed as ‘comfortable’ or ‘very comfortable’ in the last fortnight of life.

Discussion

Given the health consequences of caregiving, caregivers of people with ESLD would benefit from prospectively defining their needs given the time for which intense caregiving is provided.

How patients and relatives experience a visit from a consulting physician in the euthanasia procedure: a study among relatives and physicians

This study investigated the impact of a visit from a consulting physician on the patient and the relatives during the euthanasia procedure in The Netherlands. Data on experiences with the consultant's visit were collected from 86 relatives and 3,614 general practitioners, who described their most recent request for euthanasia or physician-assisted suicide. More than three-quarters of the patients experienced the visit as they had expected, or became more positive. Although about 1 out of 5 patients had negative experiences, this study indicates that, in general, a visit from a consulting physician is not perceived to be burdensome for patients.

Defining distinct caregiver subpopulations by intensity of end-of-life care provided

Interventions designed to assist informal caregivers who serve individuals at or near the end of life have predominantly focused on caregiving spouses. Can we define other caregiver subpopulations--by intensity of care provided--so as to enable better a) identification of caregiver needs and b) targeting of support to caregivers? The Health Omnibus Survey, an annual face-to-face survey in South Australia, collects health-related data from a representative sample of 4400 households. Piloted questions included in the 2001-2005 Health Omnibus surveys addressed death of a loved one, caregiving provided, impact of caregiving and caregiver characteristics. Of 18,224 respondents, 5302 reported a loved one's death due to terminal illness in the previous 5 years. In all, 502 (10%) provided daily care [5-7 days/week], 619 (12%) provided intermittent care [2-4 days/week] and 425 (8%) provided rare care. Active (daily plus intermittent) caregivers, compared with non-active (rare) caregivers, were more often women (63% vs 50%; P < 0.0001). Daily caregivers were distinguishable from intermittent; daily caregivers were more often widowed (95% vs 7%; P < 0.0001) and >or=60 years (80% vs 64%; P < 0.0001); intermittent caregivers were more commonly children/parents (35%), other relatives (33%), or friends (26%; P < 0.0001) and were better educated, more active in paid work and wealthier. Financial burden, experience at time of death, ability to move on after the death and need for grief support also differed by intensity of caregiving. Caregiver subpopulations can be defined according to intensity of caregiving with distinct demographic features helping to distinguish them.

Daily symptom burden in end-stage chronic organ failure: a systematic review

Chronic diseases are nowadays the major cause of morbidity and mortality worldwide. Patients with end-stage chronic organ failure may suffer daily from distressful physical and psychological symptoms. The objective of the present study is to systematically review studies that examined daily symptom prevalence in patients with end-stage chronic organ failure, with attention to those that included patients with either congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or chronic renal failure (CRF). Thirty-nine articles (8 CHF, 7 COPD, 2 CHF and COPD, 22 CRF) have been included. The included studies used various study designs. There was a wide range of daily symptom prevalence that may be due to the heterogeneity in methodology used. Nevertheless, findings suggest significant symptom burden in these patients. This review highlights the need for further prospective and longitudinal research on symptom prevalence in patients with end-stage CHF, COPD and CRF to facilitate the development of patient-centred palliative care programs.

Specialized palliative care services are associated with improved short- and long-term caregiver outcomes

GOALS OF WORK

The goal of this study was to evaluate, at a population level, the association between specialized palliative care services (SPCS) and short- and long-term caregiver outcomes.

PATIENTS AND METHODS

The Health Omnibus Survey, a face-to-face survey conducted annually in South Australia since 1991, collects health-related data from a rigorously derived, representative sample of 4,400 households. This study included piloted questions in the 2001, 2002, and 2003 Health Omnibus Survey on the impact of SPCS. Sample size was 9,088 individuals. "Unmet needs," a short-term outcome relevant to the caregiving period during a life-limiting illness, were tallied. "Moving on," a long-term caregiver-defined outcome reflecting the caregiver's adaptation and return to a new equilibrium after the death, was assessed with and without SPCS.

RESULTS

Thirty-seven percent (3,341) indicated that someone close to them had died of a terminal illness in the preceding 5 years, of whom 949 (29%) reported that they provided care. SPCS were involved in caring for 60% of deceased patients. Day-to-day caregivers indicated fewer unmet needs when SPCS were involved (p = 0.0028). More caregivers were able to "move on" with their lives when SPCS were involved than when SPCS were not involved (86 vs 77%, p = 0.0016); this effect was greatest in the first 2 years after the loved one's death.

CONCLUSION

At a population level, SPCS were associated with meaningful improvements in short-term ("unmet needs") and long-term ("moving on") caregiver-defined outcomes.

Planning for End-of-Life Care

The authors examined Black-White differences in the likelihood of completing written advance directives for end-of-life health care and engaging in informal verbal communication about advanced wishes. Data from the 1998 Health and Retirement Study (HRS) were combined with data from the 2000 HRS exit interview to analyze Black and White participants' completion rates. Whites were more likely than Blacks to grant durable power of attorney for health care, to complete a written will, and to informally communicate their wishes; group differences remained after controlling for personal characteristics. Also, Blacks were less likely than Whites to engage in more than one form of end-of-life planning. The authors speculate that sociocultural differences in trust in the medical system and knowledge about advance directives may partially account for these findings. The findings may aid policy makers and practitioners in increasing the level of participation in advance directives.

Comfort in the last 2 weeks of life: relationship to accessing palliative care services

INTRODUCTION

Specialised palliative care services (SPCS) aim to address the needs of patients and caregivers confronting life-limiting illnesses but only half of the potential cohort are referred. Randomised controlled trials of SPCS provision can no longer be ethically justified so there is a need to develop new methods to evaluate the net impact of SPCS for the whole community, not just for those who access SPCS. The aim of this study was to assess whether perceived comfort in the last 2 weeks of life was associated with accessing SPCS.

METHODS

This study utilised a whole-of-population random survey (n = 4,366) in South Australia. A total of 802 respondents had someone close to them die within the last 5 years due to a terminal illness, and they had the complete data. A subsequent question was asked whether SPCS had been accessed. Perceived comfort levels for those who had used SPCS were compared with those who did not by using stereotype logistic regression, weighted to a standardised population.

RESULTS

Higher levels of comfort of the deceased having been assessed 'very comfortable' was associated with the use of SPCS (p = 0.04; odds ratio, 1.78; 95% confidence interval, 1.02-3.08). For people who accessed SPCS, 13.3% were reported as 'very comfortable' compared with 8.0% without SPCS. Almost one half of respondents (48.4%) reported that the deceased was considered 'uncomfortable' or 'very uncomfortable', irrespective of SPCS access.

DISCUSSION

While this study provides further incremental evidence of benefit from access to SPCS, there is much that still needs to be done to improve care for the whole community at the end of life.

The effect of the Liverpool Care Pathway for the dying: a multi-centre study

We studied the effect of the Liverpool Care Pathway (LCP) on the documentation of care, symptom burden and communication in three health care settings. Between November 2003 and February 2005 (baseline period), the care was provided as usual. Between February 2005 and February 2006 (intervention period), the LCP was used for all patients for whom the dying phase had started. After death of the patient, a nurse and a relative filled in a questionnaire. In the baseline period, 219 nurses and 130 relatives filled in a questionnaire for 220 deceased patients. In the intervention period, 253 nurses and 139 relatives filled in a questionnaire for 255 deceased patients. The LCP was used for 197 of them. In the intervention period, the documentation of care was significantly more comprehensive compared with the baseline period, whereas the average total symptom burden was significantly lower in the intervention period. LCP use contributes to the quality of documentation and symptom control.

Symptom Burden: A Concept Analysis and Implications for Oncology Nurses

PURPOSE/OBJECTIVES

To analyze the concept of symptom burden and discuss implications for symptom research and symptom management.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, Cochrane Reviews, and published literature.

DATA SYNTHESIS

Through Rodgers's evolutionary method of concept analysis, attributes of symptom burden were identified as dynamic, multidimensional, quantifiable, subjective, and physiologic. The major antecedent was multiple symptoms related to worsening disease status. Consequences of symptom burden included decreased survival, poor prognosis, delay or termination of treatment, increased hospitalizations and medical costs, decreased functional status, and lowered self-reported quality of life. Symptom burden is defined as the subjective, quantifiable prevalence, frequency, and severity of symptoms placing a physiologic burden on patients and producing multiple negative, physical, and emotional patient responses.

CONCLUSIONS

Symptom burden is an important concept in the symptoms experience, separate from symptom distress and other related terms. The continued differentiation of symptom concepts is important for sound methodologic research and meaningful interventions that affect and improve patient experiences.

IMPLICATIONS FOR NURSING

Clarifying multiple symptom concepts in the symptoms experience, determining appropriate measurement methodologies for the concepts, and identifying appropriate strategies will lessen the burden of symptoms and contribute to improved quality of life and better patient outcomes.

Can family caregivers of terminally ill patients be a reliable source of information about the severity of patient symptoms?

This study examines the reliability of family caregivers' assessments of a terminally ill patient's symptoms and identifies patient and caregiver characteristics that affect the reliability of caregiver reports. It compares the reports of 143 patients in home hospice units with those of their family caregiver about patient symptoms during the 3 days preceding the interview (Edmonton scale). Correlation coefficients between the patients' and proxies' reports were 0.5 to 0.8, indicating moderate-to-high agreement. Characteristics that had an independent effect on identical reporting were the patient being fully disabled, the care-giver being a woman in good health, the caregiver living with the patient, and the caregiver providing assistance with activities of daily living and medical care. These results suggest that primary caregivers can be a good source of information about a patient's symptoms, although their reports should be used with caution.

Prevalence of pain in patients with cancer: a systematic review of the past 40 years

BACKGROUND

Despite the abundant literature on this topic, accurate prevalence estimates of pain in cancer patients are not available. We investigated the prevalence of pain in cancer patients according to the different disease stages and types of cancer.

PATIENTS AND METHODS

A systematic review of the literature was conducted. An instrument especially designed for judging prevalence studies on their methodological quality was used. Methodologically acceptable articles were used in the meta-analyses.

RESULTS

Fifty-two studies were used in the meta-analysis. Pooled prevalence rates of pain were calculated for four subgroups: (i) studies including patients after curative treatment, 33% [95% confidence interval (CI) 21% to 46%]; (ii) studies including patients under anticancer treatment: 59% (CI 44% to 73%); (iii) studies including patients characterised as advanced/metastatic/terminal disease, 64% (CI 58% to 69%) and (iii) studies including patients at all disease stages, 53% (CI 43% to 63%). Of the patients with pain more than one-third graded their pain as moderate or severe. Pooled prevalence of pain was >50% in all cancer types with the highest prevalence in head/neck cancer patients (70%; 95% CI 51% to 88%).

CONCLUSION

Despite the clear World Health Organisation recommendations, cancer pain still is a major problem.

The prevalence of symptoms in end-stage renal disease: a systematic review

Symptoms in end-stage renal disease (ESRD) are underrecognized. Prevalence studies have focused on single symptoms rather than on the whole range of symptoms experienced. This systematic review aimed to describe prevalence of all symptoms, to better understand total symptom burden. Extensive database, "gray literature," and hand searches were undertaken, by predefined protocol, for studies reporting symptom prevalence in ESRD populations on dialysis, discontinuing dialysis, or without dialysis. Prevalence data were extracted, study quality assessed by use of established criteria, and studies contrasted/combined to show weighted mean prevalence and range. Fifty-nine studies in dialysis patients, one in patients discontinuing dialysis, and none in patients without dialysis met the inclusion criteria. For the following symptoms, weighted mean prevalence (and range) were fatigue/tiredness 71% (12% to 97%), pruritus 55% (10% to 77%), constipation 53% (8% to 57%), anorexia 49% (25% to 61%), pain 47% (8% to 82%), sleep disturbance 44% (20% to 83%), anxiety 38% (12% to 52%), dyspnea 35% (11% to 55%), nausea 33% (15% to 48%), restless legs 30% (8%to 52%), and depression 27% (5%to 58%). Prevalence variations related to differences in symptom definition, period of prevalence, and level of severity reported. ESRD patients on dialysis experience multiple symptoms, with pain, fatigue, pruritus, and constipation in more than 1 in 2 patients. In patients discontinuing dialysis, evidence is more limited, but it suggests they too have significant symptom burden. No evidence is available on symptom prevalence in ESRD patients managed conservatively (without dialysis). The need for greater recognition of and research into symptom prevalence and causes, and interventions to alleviate them, is urgent.

The influence of end-of-life cancer care on caregivers

The purpose of this secondary analysis was to glean from prospective data whether those caring for elderly family members recently diagnosed with cancer who ultimately died reported different caregiver depressive symptomatology and burden than caregivers of those who survived. Findings from interviews with 618 caregivers revealed that caregiver depressive symptomatology differed based on family members' survival status, and spousal caregivers experienced greater burden when a family member was near death than did non-spousal caregivers. Family member symptoms and limitations in daily living, as well as caregiver health status, age, and employment, were associated with caregiver depressive symptomatology and burden; however, these associations had no interaction with family member survival status.

Relatives' perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands

This study used retrospective interviews with 87 relatives to describe the experiences of patients who died by euthanasia or physician-assisted suicide (EAS) in the Netherlands. Most of the patients suffered from cancer (85%). The relatives were most often a partner (63%) or a child (28%) of the patient. Before explicitly requesting EAS most patients (79%) had spoken about their wishes concerning medical end-of-life decisions to be made at a later date. Hopeless suffering, loss of dignity, and no prospect of recovery were the most prevalent reasons for explicitly requesting EAS. According to the relative, in 92% of patients EAS had contributed favourably to the quality of the end of life, mainly by preventing or ending suffering.

Symptom experience in the last year of life among individuals with cancer

Individuals with cancer often experience many symptoms that impair their quality of life at the end of life. This study examines symptom experience at end of life among individuals with cancer, and determines if symptom experience changes with proximity to death, or differs by depressive symptomatology, sex, site of cancer, or age. A secondary analysis of data from three prospective, descriptive, longitudinal studies (n=174) was performed, using a three-level hierarchical linear model. Fatigue, weakness, pain, shortness of breath, and cough were the five most prevalent symptoms in the last year of life. The symptom experience in the last year of life was significantly associated with site of cancer, depressive symptomatology, dependencies in activities of daily living, and independent activities of daily living at the start of the study. These findings shed light on the symptom experience in the last year of life for individuals with cancer. With greater understanding of the symptom experience, intervention strategies can be targeted to achieve the desired outcome of increased quality of life at the end of life.

The last 3 months of life: care, transitions and the place of death of older people

Many older people die in hospitals, whereas research indicates that they would prefer to die at home. Little is known about the factors associated with place of death. The aim of the present study was to investigate the care received by older people in the last 3 months of their life, the transitions in care and the predictors of place of death. In this population-based study, interviews were held with 270 proxy respondents to obtain data on 342 deceased participants (79% response rate) in the Longitudinal Aging Study Amsterdam. In the last 3 months of life, the utilisation of formal care increased. Half of the community-dwelling older people and their families were confronted with transitions to institutional care, in most cases to hospitals. Women relied less often on informal care only, and were more dependent than men on institutional care. For people who only received informal care, the odds of dying in a hospital were 3.68 times the odds for those who received a combination of formal and informal home care. The chance of dying in a hospital was also related to the geographical region. The authors argue that future research is needed into the association that they found in the present study, i.e. that decedents who received both formal and informal care were more likely to die at home. In view of the differences found in geographical region in relation to place of death, further investigation of regional differences in the availability and accessibility of care is indicated.

Preferences in end-of-life care of older persons: after-death interviews with proxy respondents

This population-based study employing after-death interviews with proxies describes older persons' preferences regarding medical care at the end of life. Interviews were held with 270 proxy respondents of 342 deceased persons (age range 59-91) in the Netherlands, The deceased were respondents to the Longitudinal Aging Study Amsterdam. The prevalence of advance directives (ADs), preferences for medical decisions at the end of life (i.e. withholding treatment, physician-assisted suicide euthanasia) and preferences about the focus of treatment in the last week of life (i.e. comfort care versus extending life) were examined. Written ADs were present in 14% of the sample. A quarter had designated a surrogate decision-maker. Co-morbidity and perceived self-efficacy (PSE) were positively associated with ADs. About half the sample had expressed a preference in favour or against one or more medical decisions at the end of life. Predictors positively associated with expressing a preference were co-morbidity, dying from cancer, and PSE. Being religious was negatively associated with expressing a preference. The knowledge of the proxy regarding the older person's preference for the focus of treatment was dependent on the patient's symptom burden as perceived by the proxy. The majority of older persons had died without either an AD, or having expressed preferences for end-of-life care. Stimulating the formulation of ADs may help professionals who work with older people to understand these preferences better, especially in the case of non-cancer patients and those with low PSE.

Agreement among family members in their assessment of the Quality of Dying and Death

Improving end-of-life care requires accurate indicators of the quality of dying. The purpose of this study was to measure the agreement among family members who rate a loved one's dying experience. We administered the Quality of Dying and Death instrument to 94 family members of 38 patients who died in the intensive care unit. We measured a quality of dying score of 60 out of 100 points and found moderate agreement among family members as measured by an intraclass correlation coefficient (ICC) of 0.44. Variability on individual items ranged from an ICC of 0.15 to 1.0. Families demonstrated more agreement on frequencies of events (ICC 0.54) than on determinations of quality (ICC 0.32). These findings reveal important variability among family raters and suggest that until the variability is understood, multiple raters may generate more comprehensive end-of-life data and may more accurately reflect the quality of dying and death.

Palliative care units in The Netherlands: changes in patients' functional status and symptoms

Although efforts have been made to define optimal terminal care in palliative care units (PCUs), comprehensive longitudinal evaluations of care outcomes in PCUs at the end of life are scarce. In this study, changes in functional status (assistance needed for walking, and toilet use) and symptoms (pain, nausea, shortness of breath, depression, and anxiety) were assessed in all patients (n=355) admitted to 10 PCUs in Dutch nursing homes. Outcomes were measured at 24 hours, 48 hours, one week, and two weeks before death, and at PCU admission. Results show that functional status deteriorated from admission to one week before death, but most symptoms did not worsen in the last three weeks before death. Decreases in pain, anxiety, and nausea were observed. The results suggest that the care provided in the PCUs stabilized the symptom levels. Patients who die between two and four weeks appeared to have more favorable symptom change patterns than patients who die within two weeks, which supports the recommendation to admit eligible patients in earlier phases of their disease. Limitations include the use of proxy measures and some forms of selection bias, which may lead to underestimation of symptom levels.

The end of life: informal care for dying older people and its relationship to place of death

OBJECTIVE

This study examined the features of informal end-of-life care of older people living in the community and the association between informal care characteristics and dying at home.

METHODS

Retrospective data were obtained from interviews and self-administered questionnaires of 56 persons who had been primary caregivers of older relatives in the last three months of their lives.

RESULTS

Results showed that informal caregivers of terminally ill older people living in the community provided a considerable amount of personal, household, and management care. Secondary informal caregivers and formal caregivers assisted resident primary caregivers less often than nonresident primary caregivers. Primary caregivers who felt less burdened, who gave personal care more intensively, and/or who were assisted by secondary caregivers, were more likely to provide informal end-of-life care at home until the time of death.

CONCLUSIONS

Our study showed that informal care at the end of life of older people living in the community is complex, since the care required is considerable and highly varied, and involves assistance from secondary informal caregivers, formal home caregivers as well as institutional care. Burden of informal care is one of the most important factors associated with home death. More attention is needed to help ease the burden on informal caregivers, specifically with regard to resident caregivers and spouses. Since these resident caregivers were disadvantaged in several respects (i.e., health, income, assistance from other carers) compared to nonresident caregivers, interventions by formal caregivers should also be directed towards these persons, enabling them to bear the burden of end-of-life care.

Specialist palliative care needs of whole populations: a feasibility study using a novel approach

BACKGROUND

Defining whether people with life-limiting illnesses (PLLI) who do not access specialized palliative care services (SPCS) have unmet needs is crucial in planning and evaluating palliative care. This study seeks to establish the viability of a whole-of-population method to help characterize SPCS access through proxy report.

METHODS

Questions were included in a piloted annual face-to-face health survey of 3027 randomly selected South Australians on the need for, uptake rate of, and satisfaction with SPCS in 2000. The survey was representative of the cross-section of South Australians by age, gender, socioeconomic status and region.

RESULTS

One in three people surveyed (1069) indicated that someone 'close to them' had died of a terminal illness in the preceding five years. Of those who identified that a palliative service had not been used (38%, 403), reasons cited included family/friends provided the care (34%, 136) and the service was not wanted (21%, 86). Respondents with income > AU dollars 60000 per year were more likely to report that a SPCS had been used (P = 0.01). People who had cancer as their life-limiting illness were more likely to access SPCS (P < 0.001). The results generate a model comparing SPCS utilization with client benefit. The survey was acceptable to interviewees.

DISCUSSION

Uptake rates of SPCS in this survey are consistent with other South Australian whole population estimates of SPCS utilization. Although there are limitations in this survey approach and the questions asked, this method can be developed to improve our understanding of the characteristics and needs of PLLI and their carers.

Symptom burden in the last week of life

In order to investigate symptom burden in the last week of life, we conducted after-death interviews with close relatives of deceased older persons from a population-based sample of older people in The Netherlands (n=270). Results show that fatigue, pain, and shortness of breath were common (83%, 48% and 50%, respectively). Other symptoms were confusion (36%), anxiety (31%), depression (28%), and nausea and/or vomiting (25%). Cancer patients and patients with chronic obstructive pulmonary disease were clearly at a disadvantage with respect to pain and shortness of breath, respectively. Furthermore, cognitive decline turned out to be predictive of specific symptom burden. Persons with cognitive decline in the last three months had a higher symptom burden and different symptoms compared to patients with no cognitive decline. It is suggested that older persons with cognitive decline require specific attention.