Psychosocial issues in palliative care: a review of five cases

Caregiver strain among patients of palliative care in Sri Lanka: validation of modified caregiver strain index - Sinhala version

BACKGROUND

Care givers of Palliated patients are at risk of adverse physical, psychosocial and emotional sequelae in varied nature. Efficient and valid assessment tools facilitate early detection to take corrective measures. The Modified Caregiver Strain Index (MCSI), composed of domains associated with caregiver strain is a simple and brief tool that can be used in both clinical and field settings. This study aimed to adapt and validate this in order to cater effective palliative care services in Sri Lanka.

METHODS

After cross-cultural adaptation, 200 primary caregivers in 3 teaching hospitals were recruited. The internal consistency, item-total correlations, of the 13-item S-MCSI were performed. The criterion validity was assessed by Pearson correlation between the total scores of S-MCSI, the Karnofky Performance Scale and the Barthel index. Construct validity was determined by the principal component analysis keeping the Varimax with Keiser normalization as the rotation method. The Kaiser-Meyer-Olkin test (KMO) and Bartlett's test of sphericity statistics were also performed to determine the adequacy of the sample and correlations between items, respectively. The number of factors was determined by the Scree plot, percentage of variance explained by each component and number of Eigen values over 01 (Kaiser-Guttman rule).

RESULTS

The total MCSI score ranged 0 to 26. The overall Cronbach's alpha of the 13-item questionnaire was 0.80 while item-total corrections ranged 0.34 to 0.62, exception of one item (0.11). Inverse correlations were demonstrated in total scores of MCSI and Karnofky Performance Scale (r =- 0.32, p < 0.001) and Barthel index (r =-0.34, P < 0.001). A Kaiser-Meyer-Olkin value of 0.79 (p < 0.001) for Bartlett's test indicated adequate sampling and nonlinearity of factors. The Scree plot showed a three-factor structure explaining 57% of the variation. Items regarding personal wellbeing of caregiver loaded together while the effects on the family loaded separately. Adjustment of personal concerns and family issues along with time alteration grouped as the third factor.

CONCLUSIONS

The study showed that the Sinhala version of MCSI has adequate psychometric properties and reliability to be used as a validated tool to estimate the caregiver burden within a short time period for any health care workers.

Perspectives, perceived self-efficacy, and preparedness of newly qualified physicians' in practising palliative care-a qualitative study

BACKGROUND

Dealing with life-limiting illnesses, death, dying and grief, is uncharted territory for medical graduates. It is a field that is heavily influenced by cultural, religio-spiritual and social factors. This adds complexity to palliative and end-of-life-care, which challenges newly qualified physicians and requires the formation of appropriate knowledge, skills, and attitudes in junior doctors. This study aimed to obtain insight into the perspectives, perceived self-efficacy, and preparedness of newly qualified Nigerian physicians in practising palliative care and identify potential variables influencing them.

METHODS

The study was a cross-sectional, multi-centre survey of newly qualified Nigerian physicians, using semi-structured, in-depth qualitative interviews. The data were analysed by applying content-structuring qualitative content analysis.

RESULTS

Forty semi-structured interviews were conducted with medical house officers at two tertiary institutions in Nigeria. The perceived self-efficacy and preparedness of newly qualified Nigerian physicians in practising palliative care were reported to be higher in areas of family involvement, and pain and symptom management than in areas of breaking bad news, prognosis, and diagnosing dying. Major influences on the young physicians' perceived self-efficacy and preparedness in practising palliative care were socio-economic circumstances of a resource-limited setting and cultural-religious considerations. In addition, the perceived impact of palliative care education and experience was documented.

CONCLUSIONS

This study offers valuable insights into the perceived self-efficacy and preparedness of newly qualified physicians and reveals the influence of socio-cultural and socio-economic variables in Nigeria. Evidence of the social, cultural, and religio-spiritual dimensions of palliative care is indispensable for culturally sensitive care. These results could aid in the development of appropriate knowledge, skills, and attitudes in newly qualified physicians through culturally and contextually appropriate palliative care training measures. The results may be applicable to other sub-Saharan African settings and may be used to improve future palliative care education, training, and practice.

Evidence of palliative care stigma: The role of negative stereotypes in preventing willingness to use palliative care

OBJECTIVE

Although palliative care is critical to managing symptoms, pain, and transitions to end-of-life care among those facing serious or chronic illness, it is often underused, which may be due to stigma associated with palliative care representing giving up fighting one's illness. The goal of the present studies was to test the theoretical framework of stigma within the context of palliative care to inform future work on intervention development that addresses potential barriers to palliative care utilization.

METHOD

In study 1, participants (n = 152) had an oncologist describe two treatment options to a terminally ill cancer patient: (1) palliative care and (2) chemotherapy. Participants were then randomly assigned to read that the patient chose palliative care or chemotherapy. In study 2, these stereotypes about those receiving palliative care were examined as a potential mediator between perceived palliative care stigma and prospective palliative care use. Participants (n = 199) completed self-report measures of palliative care stigma, negative stereotypes about palliative care users, and prospective use of palliative care. Mediation analysis tested the mediational effects of stereotypes on the relationship between palliative care stigma and prospective usage of palliative care.

RESULT

In study 1, those in the palliative care condition endorsed significantly higher levels of negative stereotypes about the patient, viewed the decision more negatively, and saw the patient as less afraid of death. In study 2, palliative care stigma was associated with less prospective usage of palliative care for self and for one's family member. This relationship was mediated by negative stereotypes about individuals receiving palliative care.

SIGNIFICANCE OF RESULTS

Results suggest that palliative care stigma exists (study 1) and that this stigma may be a barrier to the utilization of palliative care (study 2). Future research should examine stigma reduction as a potential intervention target to improve palliative care utilization.

Symptoms in Advanced Cancer Patients in a Greek Hospital: a Descriptive Study

Background:

Advanced cancer patients experience several physical or psychological symptoms which require palliative care for alleviation.

Purpose:

To assess the prevalence and intensity of symptoms among cancer patients receiving palliative care in a Greek hospital and to examine the association between reported symptoms and social clinical and demographic characteristics.

Material-methods:

This descriptive research was conducted during a six-month period using a convenient sample of 123 advanced cancer patients. All participants were assessed for their symptoms using the Edmonton Symptom Assessment System (ESAS) with a questionnaire covering demographic and clinical characteristics.

Results:

The mean age was 63.8± 10.8 years, with lung and breast (58.5% and 11.4%, respectively) as the most common primary cancer types. The most severe symptoms were fatigue, sleep disturbance, dyspnea, depression and anxiety. Negative correlations were revealed between age and the following symptoms: pain (r = -0.354, p = 0.001), fatigue (r = -0.280, p = 0.002), nausea (r = -0.178, p = 0.049), anorexia (r = -0.188, p = 0.038), dyspnea (r = -0.251, p = 0.005), and depression (r = -0.223, p = 0.013). Advanced breast cancer patients scored higher in pain, fatigue and dyspnea compared to those with other cancers.

Conclusions:

Hospitalized cancer patients in Greece experience several symptoms during the last months of their life. These are influenced by demographic characteristics. Appropriate interventions are strongly advised with appropriate recognition and evaluation of symptoms by health professionals.

Music therapy for palliative care: A realist review

OBJECTIVE

Music therapy has experienced a rising demand as an adjunct therapy for symptom management among palliative care patients. We conducted a realist review of the literature to develop a greater understanding of how music therapy might benefit palliative care patients and the contextual mechanisms that promote or inhibit its successful implementation.

METHOD

We searched electronic databases (CINAHL, Embase, Medline, and PsychINFO) for literature containing information on music therapy for palliative care. In keeping with the realist approach, we examined all relevant literature to develop theories that could explain how music therapy works.

RESULTS

A total of 51 articles were included in the review. Music therapy was found to have a therapeutic effect on the physical, psychological, emotional, and spiritual suffering of palliative care patients. We also identified program mechanisms that help explain music therapy's therapeutic effects, along with facilitating contexts for implementation.

SIGNIFICANCE OF RESULTS

Music therapy may be an effective nonpharmacological approach to managing distressing symptoms in palliative care patients. The findings also suggest that group music therapy may be a cost-efficient and effective way to support staff caring for palliative care patients. We encourage others to continue developing the evidence base in order to expand our understanding of how music therapy works, with the aim of informing and improving the provision of music therapy for palliative care patients.

Analysis of sociodemographic parameters of patients admitted in a newly established palliative care center in a regional cancer institute of north-west India

Background:

After 4 months of the establishment of palliative care center (PCC) in our institute, we present an audit of the sociodemographic parameters of admitted patients. Such an audit can help to recognize the lacuna in the management and thus help to identify the specific requirements of cancer patients that might be overlooked in a busy cancer center.

Materials and Methods:

A total of 234 patients were admitted in our PCC since its inception in October 2013. The study design was retrospective, collecting the data from the medical records of the patients. The descriptive statistics of all these data were calculated in terms of frequencies and percentage of categorical variables.

Results:

Out of 234 patients admitted in PCC, 156 (66%) were male. The median age of the patients was 54 years. A total of 44% patients had primary malignancy of head and neck, 14% of cervical, 17% of lung cancer, 6% of breast, and 5% of colon, respectively. Metastatic disease was present in 76% of the patients admitted in the PCC. Liver was the most common (46%) metastatic site. Total 13 symptoms were identified with mean number of symptoms per patient at admission in PCC being 5.17.

Conclusions:

Palliative care services are an indispensable part of a tertiary regional cancer care center. The oncologists should be made aware of the requirement of better relief of pain and other distressing symptoms to provide better quality of life to the patients suffering from advanced cancer.

An Exploratory Analysis of Levels of Evidence for Articles Published in Indian Journal of Palliative Care in the years 2010-2011

CONTEXT

Indian Journal of Palliative Care (IJPC) provides a comprehensive multidisciplinary evidence base for an evidence-informed clinical decision making.

AIMS

To analyze the levels of evidence of articles published in IJPC in the years 2010-2011.

SETTINGS AND DESIGN

Systematic review of palliative care journals.

MATERIALS AND METHODS

Systematic review of articles was done and was scored according to Center for Evidence-Based Medicine levels of evidence into any of the five grades. The articles were categorized based upon article type, number of authors, study approach, age focus, population focus, disease focus, goals of care, domains of care, models of care, and year of publication.

STATISTICAL ANALYSIS USED

All descriptive analysis was done using frequencies and percentiles, and association between all categorical variables was done using Chi-square test at 95% confidence interval (CI) using Statistical Package for Social Sciences (SPSS) version 16 for Windows (SPSS Inc, Chicago, IL).

RESULTS

There was a greater prevalence of low level evidence (level 4: n = 46, 51%; level 5: n = 35, 39%) among the 90 selected articles, and article type (original articles with higher level of evidence, P = 0.000), article approach (analytical studies with higher level of evidence, P = 0.000), domains of palliative care (practice-related studies with higher level of evidence, P = 0.000) and models of care (biological or psychosocial model with higher level of evidence, P = 0.044) had a significant association with the grade of levels of evidence. Association with other factors was not statistically significant (P < 0.05).

CONCLUSIONS

The levels of research evidence for palliative care provided by articles published in IJPC were predominantly level 4 and level 5, and there is scope for more high quality evidence to inform palliative care decisions in the developing countries.

Attitudes and Beliefs About Chronic Pain Among Nurses-Biomedical or Behavioral? A Cross-sectional Survey

CONTEXT

Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in chronic pain. Several reasons have been identified including inadequacies in nursing education, absence of curriculum content related to pain management, and attitudes and beliefs related to chronic pain.

AIMS

The objective of this paper was to assess the chronic pain-related attitudes and beliefs among nursing professionals in order to evaluate the biomedical and behavioral dimensions of their perceptions on pain.

SETTINGS AND DESIGN

Cross-sectional survey of 363 nurses in a multispecialty hospital.

MATERIALS AND METHODS

The study utilized a self-report questionnaire - pain attitudes and beliefs scale (PABS) - which had 31 items (statements about pain) for each of which the person had to indicate the level at which he or she agreed or disagreed with each statement. Factor 1 score indicated a biomedical dimension while factor 2 score indicated a behavioral dimension to pain.

STATISTICAL ANALYSIS USED

Comparisons across individual and professional variables for both dimensions were done using one-way ANOVA and correlations were done using the Karl-Pearson co-efficient using SPSS version 11.5 for Windows.

RESULTS

The overall factor 1 score was 52.95 ± 10.23 and factor 2 score was 20.93 ± 4.72 (P = 0.00). The female nurses had a higher behavioral dimension score (21.1 ± 4.81) than their male counterparts (19.55 ± 3.67) which was significant at P < 0.05 level.

CONCLUSIONS

Nurses had a greater orientation toward the biomedical dimension of chronic pain than the behavioral dimension. This difference was more pronounced in female nurses and those nurses who reported very "good" general health had higher behavioral dimension scores than those who had good general health. The study findings have important curricular implications for nurses and practical implications in palliative care.