Improving shared decision-making about cancer treatment through design-based data-driven decision-support tools and redesigning care paths: an overview of the 4D PICTURE project

Background

Patients with cancer often have to make complex decisions about treatment, with the options varying in risk profiles and effects on survival and quality of life. Moreover, inefficient care paths make it hard for patients to participate in shared decision-making. Data-driven decision-support tools have the potential to empower patients, support personalized care, improve health outcomes and promote health equity. However, decision-support tools currently seldom consider quality of life or individual preferences, and their use in clinical practice remains limited, partly because they are not well integrated in patients' care paths.

Aim and objectives

The central aim of the 4D PICTURE project is to redesign patients' care paths and develop and integrate evidence-based decision-support tools to improve decision-making processes in cancer care delivery. This article presents an overview of this international, interdisciplinary project.

Design methods and analysis

In co-creation with patients and other stakeholders, we will develop data-driven decision-support tools for patients with breast cancer, prostate cancer and melanoma. We will support treatment decisions by using large, high-quality datasets with state-of-the-art prognostic algorithms. We will further develop a conversation tool, the Metaphor Menu, using text mining combined with citizen science techniques and linguistics, incorporating large datasets of patient experiences, values and preferences. We will further develop a promising methodology, MetroMapping, to redesign care paths. We will evaluate MetroMapping and these integrated decision-support tools, and ensure their sustainability using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework. We will explore the generalizability of MetroMapping and the decision-support tools for other types of cancer and across other EU member states.

Ethics

Through an embedded ethics approach, we will address social and ethical issues.

Discussion

Improved care paths integrating comprehensive decision-support tools have the potential to empower patients, their significant others and healthcare providers in decision-making and improve outcomes. This project will strengthen health care at the system level by improving its resilience and efficiency.

Ethical Principles in Digital Palliative Care for Children: The MyPal Project and Experiences Made in Designing a Trustworthy Approach

This paper explores the ethical dimension of the opportunity to offer improved electronic patient-reported outcome (ePRO) systems addressing personal needs of pediatric cancer patients, their parents and caregivers, with regard to technological advance of digital health. This opportunity has been explored in the MyPal research project, which aims to assess a patient-centered service for palliative care relying on the adaptation and extension of digital health tools and concepts available from previous projects. Development and implementation of ePROs need to take place in a safe, secure and responsible manner, preventing any possible harm and safeguarding the integrity of humans. To that end, although the final results will be published at the end of the project, this paper aims to increase awareness of the ethical ramifications we had to address in the design and testing of new technologies and to show the essentiality of protection and promotion of privacy, safety and ethical standards. We have thus reached a final design complying with the following principles: (a) respect for the autonomy of participants, especially children, (b) data protection and transparency, (c) fairness and non-discrimination, (d) individual wellbeing of participants in relation to their physical and psychological health status and e) accessibility and acceptability of digital health technologies for better user-engagement. These principles are adapted from the Ethics Guidelines for a trustworthy Artificial Intelligence (AI) which provide the framework for similar interventions to be lawful, complying with all applicable laws and regulations, ethical, ensuring compliance to ethical principles and values and robust, both from a technical and social perspective.

Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries

CONTEXT

Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area.

OBJECTIVES

To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries.

METHODS

A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life.

RESULTS

We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%).

CONCLUSION

Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.

Functional impairment, symptom severity, and overall quality of life in patients with advanced lung or colorectal cancer in six European countries: baseline findings from the ACTION study

BACKGROUND

People with advanced cancer often suffer from various symptoms, which can arise from the cancer itself and its treatment, the illness experience, and/or co-morbid conditions. Important patient-reported outcomes such as functional status, symptom severity, and quality of life (QoL) might differ between countries, as countries vary with regard to contextual factors such as their healthcare system.

PURPOSE

To assess self-reported emotional functioning, physical functioning, symptoms, and overall QoL in patients with advanced lung or colorectal cancer from six European countries, particularly in relation to their country of residence.

METHODS

We used baseline patient data from the ACTION trial, including socio-demographic and clinical data as well as patient-reported data regarding functioning, symptoms, and overall QoL (EORTC QLQ-C15-PAL).

RESULTS

Data from 1117 patients (55% lung cancer stage III/IV, 45% colorectal cancer stage IV) were used. The highest (worst) average symptom score was found for fatigue. We found similarities but also important differences in the outcomes across countries. The best scores (the highest for emotional functioning and QoL, the lowest for symptoms) were reported by Dutch and Danish patients. Belgian patients reported relatively low emotional functioning.

CONCLUSION

The optimization of functioning, symptom relief, and overall QoL should be important objectives of healthcare professionals who take care of patients with advanced cancer. There are similarities, but also substantial differences across countries in functional status, symptoms, and overall QoL. Policymakers should take these differences into account and invest in offering health care catered to the needs of their population.

Advance care planning in patients with advanced cancer: A 6-country, cluster-randomised clinical trial

BACKGROUND

Advance care planning (ACP) supports individuals to define, discuss, and record goals and preferences for future medical treatment and care. Despite being internationally recommended, randomised clinical trials of ACP in patients with advanced cancer are scarce.

METHODS AND FINDINGS

To test the implementation of ACP in patients with advanced cancer, we conducted a cluster-randomised trial in 23 hospitals across Belgium, Denmark, Italy, Netherlands, Slovenia, and United Kingdom in 2015-2018. Patients with advanced lung (stage III/IV) or colorectal (stage IV) cancer, WHO performance status 0-3, and at least 3 months life expectancy were eligible. The ACTION Respecting Choices ACP intervention as offered to patients in the intervention arm included scripted ACP conversations between patients, family members, and certified facilitators; standardised leaflets; and standardised advance directives. Control patients received care as usual. Main outcome measures were quality of life (operationalised as European Organisation for Research and Treatment of Cancer [EORTC] emotional functioning) and symptoms. Secondary outcomes were coping, patient satisfaction, shared decision-making, patient involvement in decision-making, inclusion of advance directives (ADs) in hospital files, and use of hospital care. In all, 1,117 patients were included (442 intervention; 675 control), and 809 (72%) completed the 12-week questionnaire. Patients' age ranged from 18 to 91 years, with a mean of 66; 39% were female. The mean number of ACP conversations per patient was 1.3. Fidelity was 86%. Sixteen percent of patients found ACP conversations distressing. Mean change in patients' quality of life did not differ between intervention and control groups (T-score -1.8 versus -0.8, p = 0.59), nor did changes in symptoms, coping, patient satisfaction, and shared decision-making. Specialist palliative care (37% versus 27%, p = 0.002) and AD inclusion in hospital files (10% versus 3%, p < 0.001) were more likely in the intervention group. A key limitation of the study is that recruitment rates were lower in intervention than in control hospitals.

CONCLUSIONS

Our results show that quality of life effects were not different between patients who had ACP conversations and those who received usual care. The increased use of specialist palliative care and AD inclusion in hospital files of intervention patients is meaningful and requires further study. Our findings suggest that alternative approaches to support patient-centred end-of-life care in this population are needed.

TRIAL REGISTRATION

ISRCTN registry ISRCTN63110516.

Understanding the Outcomes of Supplementary Support Services in Palliative Care for Older People. A Scoping Review and Mapping Exercise

CONTEXT

Supplementary support services in palliative care for older people are increasingly common, but with neither recommended tools to measure outcomes nor reviews synthesizing anticipated outcomes. Common clinically focused tools may be less appropriate.

OBJECTIVES

To identify stakeholder perceptions of key outcomes from supplementary palliative care support services, then map these onto outcome measurement tools to assess relevance and item redundancy.

METHODS

A scoping review using the design by Arksey and O'Malley. EMBASE, CINAHL, MEDLINE, and PSYCHinfo searched using terms relating to palliative care, qualitative research, and supplementary support interventions. Articles were imported into Endnote™, and Covidence™ was used by two reviewers to assess against inclusion criteria. Included articles were imported into NVivo™ and thematically coded to identify key concepts underpinning outcomes. Each item within contender outcome measurement tools was assessed against each concept.

RESULTS

Sixty included articles focused on advance care planning, guided conversations, and volunteer befriending services. Four concepts were identified: enriching relationships; greater autonomy and perceived control; knowing more; and improved mental health. Mapping concepts to contender tool items revealed issues of relevance and redundancy. Some tools had no redundant items but mapped only to two of four outcome themes; others mapped to all concepts, but with many redundant questions. Tools such as ICECAP-Supportive Care Measure and McGill Quality of Life had high relevance and low redundancy.

CONCLUSION

Pertinent outcome concepts for these services and population are not well represented in commonly used outcome measurement tools, and this may have implications in appropriately measuring outcomes. This review and mapping method may have utility in fields where selecting appropriate outcome tools can be challenging.

Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review

BACKGROUND

The Delphi technique is widely used for the development of guidance in palliative care, having impact on decisions with relevance for patient care.

AIM

To systematically examine the application of the Delphi technique for the development of best practice guidelines in palliative care.

DESIGN

A methodological systematic review was undertaken using the databases PubMed, CINAHL, Web of Science, Academic Search Complete and EMBASE.

DATA SOURCES

Original articles (English language) were included when reporting on empirical studies that had used the Delphi technique to develop guidance for good clinical practice in palliative care. Data extraction included a quality appraisal on the rigour in conduct of the studies and the quality of reporting.

RESULTS

A total of 30 empirical studies (1997-2015) were considered for full-text analysis. Considerable differences were identified regarding the rigour of the design and the reporting of essential process and outcome parameters. Furthermore, discrepancies regarding the use of terms for describing the method were observed, for example, concerning the understanding of a 'round' or a 'modified Delphi study'.

CONCLUSION

Substantial variation was found concerning the quality of the study conduct and the transparency of reporting of Delphi studies used for the development of best practice guidance in palliative care. Since credibility of the resulting recommendations depends on the rigorous use of the Delphi technique, there is a need for consistency and quality both in the conduct and reporting of studies. To allow a critical appraisal of the methodology and the resulting guidance, a reporting standard for Conducting and REporting of DElphi Studies (CREDES) is proposed.

Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries

PURPOSE

The purpose of the study was to explore relatives' descriptions and experiences of continuous sedation in end-of-life care for cancer patients and to identify and explain differences between respondents from the Netherlands, Belgium, and the UK.

METHODS

In-depth interviews were held between January 2011 and May 2012 with 38 relatives of 32 cancer patients who received continuous sedation until death in hospitals, the community, and hospices/palliative care units.

RESULTS

Relatives' descriptions of the practice referred to the outcome, to practical aspects, and to the goals of sedation. While most relatives believed sedation had contributed to a 'good death' for the patient, yet many expressed concerns. These related to anxieties about the patient's wellbeing, their own wellbeing, and questions about whether continuous sedation had shortened the patient's life (mostly UK), or whether an alternative approach would have been better. Such concerns seemed to have been prompted by relatives witnessing unexpected events such as the patient coming to awareness during sedation. In the Netherlands and in Belgium, several relatives reported that the start of the sedation allowed for a planned moment of 'saying goodbye'. In contrast, UK relatives discerned neither an explicit point at which sedation was started nor a specific moment of farewell.

CONCLUSIONS

Relatives believed that sedation contributed to the patient having a good death. Nevertheless, they also expressed concerns that may have been provoked by unexpected events for which they were unprepared. There seems to exist differences in the process of saying goodbye between the NL/BE and the UK.

Place of death in the Czech Republic and Slovakia: a population based comparative study using death certificates data

Background

Place of death represents an important indicator for end-of-life care policy making and is related to the quality of life of patients and their families. The aim of the paper is to analyse the place of death in the Czech Republic and Slovakia in 2011. Research questions were focused on factors influencing the place of death and specifically the likelihood of dying at home.

Methods

Whole population data from death certificates for all deaths in the Czech Republic and Slovakia in 2011 were used for bivariate and multivariate analyses. Separate analysis using binary logistic regression was conducted for subpopulation of patients who died from chronic conditions.

Results

The majority of population in both countries died in hospitals (58.4% the Czech Republic, 54.8% Slovakia), less than one-third died at home. In case of chronic conditions, death at home was significantly associated with underlying cause of death (cancer and heart failure), being male, age (older than 85, Slovakia only) and higher education (the Czech Republic only). Cancer and heart failure patients had higher chances to die at home than other chronic conditions.

Conclusions

Czech and Slovak patients with chronic conditions are more likely to die in hospitals than in some other European Union member countries. This finding should be addressed by policy makers in promoting home hospice care services and education in palliative care for staff in nursing homes and other end-of-life settings.

From sedation to continuous sedation until death: how has the conceptual basis of sedation in end-of-life care changed over time?

CONTEXT

Numerous attempts have been made to describe and define sedation in end-of-life care over time. However, confusion and inconsistency in the use of terms and definitions persevere in the literature, making interpretation, comparison, and extrapolation of many studies and case analyses problematic.

OBJECTIVES

This evidence review aims to address and account for the conceptual debate over the terminology and definitions ascribed to sedation at the end of life over time.

METHODS

Six electronic databases (MEDLINE, PubMed, Embase, AMED, CINAHL, and PsycINFO) and two high-impact journals (New England Journal of Medicine and the British Medical Journal) were searched for indexed materials published between 1945 and 2011. This search resulted in bibliographic data of 328 published outputs. Terms and definitions were manually scanned, coded, and linguistically analyzed by means of term description criteria and discourse analysis.

RESULTS

The review shows that terminology has evolved from simple to complex terms with definitions varying in length, comprising different aspects of sedation such as indications for use, pharmacology, patient symptomatology, target population, time of initiation, and ethical considerations, in combinations of a minimum of two or more of these aspects.

CONCLUSION

There is a pressing need to resolve the conceptual confusion that currently exists in the literature to bring clarity to the dialogue and build a base of commonality on which to design research and enhance the practice of sedation in end-of-life care.

Older patients' attitudes towards and experiences of patient-physician end-of-life communication: a secondary analysis of interviews from British, Dutch and Belgian patients

BACKGROUND

Older patients often experience sub-standard communication in the palliative phase of illness. Due to the importance of good communication in patient-centred end-of-life care, it is essential to understand the factors which influence older patients' communication with physicians. This study examines older patients' attitudes towards, and experiences of, patient-physician end-of-life (EoL) communication in three European countries.

METHODS

A secondary analysis of interviews from British, Dutch and Belgian patients over the age of 60 with a progressive terminal illness was conducted. Cross-cutting themes were identified using a thematic approach.

RESULTS

Themes from 30 interviews (Male n = 20, Median age 78.5) included: confidence and trust; disclosure and awareness; and participation in decision-making. Confidence and trust were reinforced by physicians' availability, time and genuine attention and hindered by misdiagnoses and poor communication style. Most participants preferred full disclosure, though some remained deliberately ill-informed to avoid distress. Patients expressed a variety of preferences for and experiences of involvement in medical EoL decision-making and a few complained that information was only provided about the physician's preferred treatment.

CONCLUSIONS

A variety of experiences and attitudes regarding disclosure and participation in decision-making were reported from each country, suggesting that communication preferences are highly individual. It is important that physicians are sensitive to this diversity and avoid stereotyping. In regard to communication style, physicians are advised to provide clear explanations, avoid jargon, and continually check understanding. Both the 'informed' and the 'shared' patient-physician decision-making models assume patients make rational choices based on a clear understanding of treatment options. This idealized situation was often not reflected in patients' experiences.

H-gene-mediated resistance to Hessian fly exhibits features of penetration resistance to fungi

Features shared by host-specific phytophagous insects and biotrophic plant pathogens include gene-for-gene interactions and the ability to induce susceptibility in plants. The Hessian fly shows both. To protect against Hessian fly, grasses have H genes. Avirulent larvae die on H-gene-containing resistant plants but the cause of death is not known. Imaging techniques were used to examine epidermal cells at larval attack sites, comparing four resistant wheat genotypes (H6, H9, H13, and H26) to a susceptible genotype. Present in both resistant and susceptible plants attacked by larvae were small holes in the tangential cell wall, with the size of the holes (0.1 microm in diameter) matching that of the larval mandible. Absent from attacked resistant plants were signs of induced susceptibility, including nutritive tissue and ruptured cell walls. Present in attacked resistant plants were signs of induced resistance, including cell death and fortification of the cell wall. Both presumably limit larval access to food, because the larva feeds on the leaf surface by sucking up liquids released from ruptured cells. Resistance was associated with several subcellular responses, including elaboration of the endoplasmic reticulum-Golgi complex and associated vesicles. Similar responses are observed in plant resistance to fungi, suggesting that "vesicle-associated penetration resistance" also functions against insects.

The use of cognitive interviewing methodology in the design and testing of a screening tool for supportive and palliative care needs

GOALS OF WORK

The authors describe the use of cognitive interviewing methodology in the development of a new supportive and palliative care screening measure to identify the specialist supportive and palliative care needs of patients with an advanced illness.

MATERIALS AND METHODS

A draft screening measure was developed by literature reviewing and consultation with patients, carers and health and social care professionals. Using this draft, cognitive interviews were conducted with six professionals and one consumer using the 'thinking aloud technique' to assess the perception, usefulness and interpretation of each question on the measure. The focus of these interviews was to identify unclear words or phrases and to explore how the questions worked in eliciting a response. A content analysis of the interviews was used to identify problems with the text, phrasing and format of the questions and accompanying responses.

MAIN RESULTS

The authors found the technique to be useful in identifying jargon or confusing questions. A number of perspectives were taken into account by speaking to health and social care professionals in primary care and secondary care who would be offering the measure to future patients.

CONCLUSIONS

The most sensitive questions were highlighted, and this enabled the researchers to consider how these should be asked and responded to in subsequent versions of the measure. The measure was re-drafted in light of these comments.

Research methodologies in palliative care: a bibliometric analysis

The aspiration to design and conduct high-quality research in palliative care has been an important but elusive goal. The article evaluates the nature of research methodologies presented in published research within the broad remit of palliative care. A systematic search of the Medline database between 1997 and 2006, using the keywords 'palliative care' or 'end-of-life care' and 'research methodology', identified over 318 publications. A bibliometric analysis indicates an incremental increase in published outputs per year, from 27 countries, with articles widely distributed across 108 journals. The heterogeneity of the research methodologies and the journals publishing them, present challenges in defining what constitutes 'high quality'. We argue that although this diversity leads to a lack of coherence for a single disciplinary paradigm for palliative care, there is a greater acknowledgement of the differing epistemological and theoretical frameworks used by researchers. This could be regarded as enriching our understanding of what it means to be dying in contemporary society.

Palliative care in stroke: a critical review of the literature

The aim of this literature review was to identify the palliative care needs of stroke patients. Stroke results in high levels of mortality and morbidity, yet very little is known about the nature and extent of palliative care services that are available to this patient group, and the ways in which such services could be delivered. A critical review of the international literature found only seven papers that attempted to identify the palliative care needs of patients diagnosed with stroke. The results of the review showed that the preferences of stroke patients and their families in relation to palliative care services are largely unknown. The review also indicated the paucity of data in regard to the distinction between provision of palliative care services for patients who die in the acute phase of stroke and for those patients who die later. Establishing reliable assessments of need are central to designing and implementing effective interventions and further research is required in this area. Further data on how the input of palliative care experts and expertise could be of benefit to patients, and the most effective ways these inputs could be targeted and delivered is required.

An exploration of family carers' experience of respite services in one specialist palliative care unit

BACKGROUND

Changing patterns of care for terminally ill people mean that 90% of patients in the UK now spend the majority of their last year of life at home. It is now widely accepted that supporting individuals to die at home relies heavily on the availability of family carers to provide the majority of the care needed. However, one of the most common reasons for unplanned admissions near the end of life is carers' inability to provide continuing care. One strategy to overcome these challenges has been to offer planned respite care. Despite recent studies, in reality little is known about respite services for patients with life limiting illness, in particular how respite is experienced by the caregivers or to what extent respite services address their needs.

METHODS

This prospective study, comprising mixed methods of data collection, explored the experiences of 25 family carers whose relative had been admitted to the local hospice for inpatient respite care. Semi-structured interviews were conducted at two time points: pre- and post-respite. The Relative Stress Scale Inventory was administered at both interviews.

RESULTS

Just over half of the sample were caring for a relative with a diagnosis of cancer (n=13); the majority of the others had a number of neurological conditions (n = 12). The data demonstrate that managing care for relatives with a life limiting illness was perceived to be hard work, both physically and mentally. Inpatient respite care was considered important as it enabled family carers to have a break from the ongoing care-giving responsibilities, as well as being an opportunity to experience 'normal life' independently. The majority of family carers felt that their expectations of respite for themselves had been achieved. The respite service was well evaluated in relation to: standard of nursing care; alternative facilities on offer, atmosphere; and other care homes.

DISCUSSION

Currently, inpatient respite services are provided to two patient groups--those in the last year of life and those with a chronic life limiting illness. However, on closer analysis, the current model of service delivery, a two-week inpatient stay, may not be best suited to those caring for a relative in the last year of life. Similarly, it might be questioned whether an inpatient hospice is the most suitable setting for those patients needing supportive care, rather than specialist palliative care. The study has raised many issues that need to be considered in the support of carers caring for relatives with a life limiting illness with uncertain trajectories.

Systematic review of the problems and issues of accessing specialist palliative care by patients, carers and health and social care professionals

OBJECTIVES

To determine the problems and issues of accessing specialist palliative care by patients, informal carers and health and social care professionals involved in their care in primary and secondary care settings.

DATA SOURCES

Eleven electronic databases (medical, health-related and social science) were searched from the beginning of 1997 to October 2003. Palliative Medicine (January 1997-October 2003) was also hand-searched.

STUDY SELECTION

Systematic search for studies, reports and policy papers written in English.

DATA EXTRACTION

Included papers were data-extracted and the quality of each included study was assessed using 10 questions on a 40-point scale.

RESULTS

The search resulted in 9921 hits. Two hundred and seven papers were directly concerned with symptoms or issues of access, referral or barriers and obstacles to receiving palliative care. Only 40 (19%) papers met the inclusion criteria. Several barriers to access and referral to palliative care were identified including lack of knowledge and education amongst health and social care professionals, and a lack of standardized referral criteria. Some groups of people failed to receive timely referrals e.g., those from minority ethnic communities, older people and patients with nonmalignant conditions as well as people that are socially excluded e.g., homeless people.

CONCLUSIONS

There is a need to improve education and knowledge about specialist palliative care and hospice care amongst health and social care professionals, patients and carers. Standardized referral criteria need to be developed. Further work is also needed to assess the needs of those not currently accessing palliative care services.

Access and referral to specialist palliative care: patients’ and professionals’ experiences

The aim of this study was to explore the reasons why patients and families are referred to specialist palliative care. Semi-structured interviews were undertaken with patients and professionals from primary care and specialist palliative care services in the north of England. A content analysis of the transcripts was undertaken, key issues were identified and common themes grouped. Twelve professionals working in specialist palliative care, three GPs, six community nurses and thirteen patients were interviewed (n = 34). Five key themes are reported: reasons why patients are referred to specialist palliative care; reasons why patients are not referred to specialist palliative care; timeliness of referrals; continuity of care; and use of referral criteria. It was found that the professionals in primary care would like more training and education about how to refer patients to specialist palliative care and how to deal with issues of death and dying. The patients were generally satisfied with the service but wanted to be able to be supported at home in their final days. Further training and education may improve the knowledge of professionals who refer patients to specialist palliative care. There are currently no standardized criteria in the UK to determine when a referral should be triggered. The development of a set of standardized referral criteria may be useful in aiding a referral decision.

Nonlinear optical properties of LaCa(4)O(BO(3))(3)

We have grown LaCa(4)O (BO(3))(3) (LaCOB), an isostructural member of GdCa(4)O(BO(3))(3) (GdCOB) family and characterized its nonlinear optical properties. At 1064nm, d(eff) of 0.52+/-0.05 pm /V and an angular sensitivity of 1224+/-184(cm rad)(-1) for type I frequency doubling in LaCOB were determined relative to those of KTiOPO(4) , beta-BaB(2)O(4) , KD(2)PO(4) , LiB(3)O(5) , YCa(4)O(BO(3))(3) (YCOB), and GdCOB. The d(alphabetabeta) and d(gammabetabeta) coefficients of the nonlinear optical tensor for LaCOB, GdCOB, and YCOB were determined to be equivalent within the experimental uncertainty and have values of ?0.26+/-0.04?pm/V and ?1.69+/-0.17?pm /V , respectively. From phase-matching angle measurements at 1064 and 1047nm, we predict that LaCOB is noncritically phase matched at 1042+/-1.5 nm .

Consideration of Stimulated Raman Scattering in Yb:Sr(5)(PO(4))(3)F Laser Amplifiers

The stimulated Raman-scattering (SRS) gain coefficient has been measured quantitatively for the first time to our knowledge in Yb:Sr(5)(PO(4))(3)F to be 1.23 ? 0.12 cm/GW at 1053 nm. These data, along with surface and bulk losses, feedback that is due to surface reflections, gain saturation, and bandwidth, have been applied to a quantitative model that predicts the effects of SRS within a laser amplifier system where the laser gain media show SRS gain. Limitations and impact to the laser amplifier performance are discussed, along with possible techniques to reduce SRS loss.

High-power dual-rod Yb:YAG laser

We describe a diode-pumped Yb:YAG laser that produces 1080 W of power cw with 27.5% optical optical efficiency and 532 W Q-switched with M(2)=2.2 and 17% optical-optical efficiency. The laser uses two composite Yb:YAG rods separated by a 90 degrees quartz rotator for bifocusing compensation. A microlensed diode array end pumps each rod, using a hollow lens duct for pump delivery. By changing resonator parameters we can adjust the fundamental mode size and the output beam quality. Using a flattened Gaussian intensity profile to calculate the mode-fill efficiency and clipping losses, we compare experimental data with modeled output power versus beam quality.

Three-level Q-switched laser operation of ytterbium-doped Sr(5)(PO(4))(3)F at 985 nm

Ytterbium-doped Sr(5)(PO(4))(3)F was successfully lased at 985 nm in quasi-cw mode with a slope efficiency of 74% and an absorbed threshold energy of 18 mJ. Q-switched slope efficiencies of 21% were obtained with a maximum energy of 9.4 mJ in 8.8-ns pulses.

Gain saturation measurements of ytterbium-doped Sr5(PO4)3 F

We report on the experimental measurement of the saturated gain of Yb(3+):Sr(5)(PO(4))(3)F at the 1047-nm laser line as a function of pump fluence and probe energy. The emission line was accurately modeled as a single homogeneous extraction, yielding values of 6.2 x 10(-20) cm(2) for the emission cross section and 3.3 J/cm(2) for the saturation fluence.

Creating and maintaining 'optimism' in cancer care communication

This study investigates nurse-patient communication in the cancer care context. Interviews with nurses and patients about their communication experiences and audio-recorded nurse-patient conversations were collected and analysed. A theme of 'optimism' largely manifesting as 'constructive realism' was one of four features identified by the qualitative analysis. The health professional has traditionally been viewed as the party with the power and control over conversation progression and topics. In particular, the superficial, positive and chatty nature of nurse-patient interaction has often been attributed to a lack of nurses' communication skills training. This research indicates that both patient and nurse are active in its construction and argues that the optimistic cheerful nature of nurse-patient interaction may be better viewed as a jointly produced institutional feature of cancer care. This paper illustrates and examines some of the ways this outcome was created and maintained by participants and discusses the implications of this.

4.0-4.5-mum lasing of Fe:ZnSe below 180 K, a new mid-infrared laser material

Lasing of Fe:ZnSe is demonstrated, for the first time to the authors' knowledge, for temperatures ranging from 15 to 180 K. The output wavelength of the Fe:ZnSe laser was observed to tune with temperature from 3.98mum at 15 K to 4.54mum at 180 K. With an Er:YAG laser operating at 2.698mum as the pump source, a maximum energy per pulse of 12muJ at 130 K was produced. Laser slope efficiencies of 3.2% at 19 K and 8.2% at 150 K were determined for an output coupling of 0.6%. A laser emission linewidth of 0.007mum at 3.98mum was measured at 15 K. Absorption and emission spectra and emission lifetimes for Fe:ZnSe are also discussed.

Room-temperature laser action at 4.34.4 mum in CaGa(2)S(4):Dy(3+)

We report room-temperature mid-IR laser operation in a new low-phonon-frequency nonhygroscopic host crystal, calcium thiogallate (CaGa(2)S(4)) . Laser action at 4.314.38 mum on the Dy(3+)H(11/2)(6)?H(13/2)(6) transition occurred with a maximum slope efficiency of 1.6%.

Terminally ill patients' and lay-carers' perceptions and experiences of community-based services

This paper reports on terminally ill patients' and their lay-carers' perceptions and experiences of community-based services. It forms part of a larger investigation which examined the extent of service provision and any perceived gaps and problems from the perspectives of both clients and providers of community-based assistance for the terminally ill. The participants were nine terminally ill patients and 12 lay-carers receiving community nursing care. Fifteen face-to-face, semi-structured interviews were conducted to elicit their experiences and perceptions of the care being provided. Qualitative, thematic analysis was carried out on the audio-taped interviews. On the whole, respondents reported a high level of satisfaction and appreciation for the help provided. Several areas appeared more problematic, however, and warrant further consideration. These include perceptions of health professionals, particularly their role domains, power and expertise, and some of the practical disadvantages and problems faced by some patients and their families. These are illustrated and the implications for dying patients, their lay-carers and community-based health professionals are discussed.

A comparative study of death anxiety in hospice and emergency nurses

This paper describes a preliminary cross-sectional study which aimed to compare levels of death anxiety and coping responses in palliative care and accident and emergency (A & E) nurses. Forty-three nurses (23 from palliative care and 20 from A & E) were recruited from a district general hospital and nearby hospice. Both sites had the same mean annual death rate of 150 patients. Death anxiety was measured by the Death Attitude Profile-Revised Questionnaire and coping responses were elicited by a semi-structured interview. As hypothesized, hospice nurses had lower death anxiety and they were more likely to recall both good and difficult experiences related to patient care. Unlike the hospice nurses, a subgroup (20%) of A & E nurses reported that they were unable to discuss problems with colleagues. The study has implications for the development of institutional support for staff to enable nurses to provide good quality care for dying patients and bereaved people.

Analysis of an intracavity-doubled diode-pumped Q-switched Nd:YAG laser producing more than 100 W of power at 0.532 microm

A diode-pumped Nd:YAG laser was frequency doubled to 0.532 microm with an intracavity KTiOPO(4) crystal in a V-cavity arrangement, achieving an output power of 140 W. Acousto-optic Q switching was employed at repetition rates of 10-30 kHz, and the beam quality was assessed at M(2) approximately 50. It was deduced on the basis of our model that the strength of the nonlinear frequency conversion is the main parameter determining the pulse width.

Dissonant Loss: the experiences of donor relatives

Narrative type interviews were carried out with a purposive sample of 24 relatives of organ donors. Relatives were recruited through 3 Regional transplant co-ordinating centres in England. The study examined in-depth the relatives': emotional reactions to the death and donation, perceptions of the decision-making process, assessment of the problems donation caused for them, as well as the benefits it provided. An understanding of what the experience meant to them was elicited, as was the identification of their needs. The interviews were audiotaped and transcribed. The transcripts were analysed using a grounded theory approach, based on the constant comparative method. Themes emerging from the data were named to form categories. Categories were defined and integrated around the central theme of the research to form an analytical version of the story. Donor relatives' experiences were found to revolve around a process of conflict and resolution. Their experience is explained as a theory of "Dissonant Loss".

Dissonant Loss: the experiences of donor relatives

Narrative type interviews were carried out with a purposive sample of 24 relatives of organ donors. Relatives were recruited through 3 Regional transplant co-ordinating centres in England. The study examined in-depth the relatives': emotional reactions to the death and donation, perceptions of the decision-making process, assessment of the problems donation caused for them, as well as the benefits it provided. An understanding of what the experience meant to them was elicited, as was the identification of their needs. The interviews were audiotaped and transcribed. The transcripts were analysed using a grounded theory approach, based on the constant comparative method. Themes emerging from the data were named to form categories. Categories were defined and integrated around the central theme of the research to form an analytical version of the story. Donor relatives' experiences were found to revolve around a process of conflict and resolution. Their experience is explained as a theory of "Dissonant Loss".

Perceptions of a 'good' death: a comparative study of the views of hospice staff and patients

The literature suggests that health professionals working in palliative care have developed an idealised concept of dying which has been labelled the 'good' death. This paper reports the results of a preliminary qualitative study which compared the concepts of a 'good' death used by patients and staff in a palliative care unit. Semistructured interviews designed to elicit perceptions of 'good' and 'bad' deaths were conducted with 18 patients and 20 health professionals. The transcribed interviews were content analysed. There were major differences between the views of patients and staff. The patients' descriptions of a "good' death were diverse and included: dying in one's sleep, dying quietly, with dignity, being pain free and dying suddenly. In comparison, staff characterised a "good' death in terms of adequate symptom control, family involvement, peacefulness and lack of distress, while a "bad' death was described as involving uncontrolled symptoms, lack of acceptance and being young. The findings suggest that patients and staff differ in their conceptualisations of a "good' death.

Properties of Cr:LiSrAIF(6) crystals for laser operation

We have performed several physical and optical measurements on the Cr:LiSAF (LiSrAlF(6)) laser material that are relevant to its laser performance, including thermal and mechanical properties, water durabilities, and Auger upconversion constants. The expansion coefficient, Young's modulus, fracture toughness, thermal conductivity, and heat capacity are all used to determine an overall thermomechanical figure of merit for the crystal. An investigation of the water durability suggests that the cooling solution should be maintained at pH = 7 to ameliorate problems associated with water dissolution. The Auger constant was found to become much more significant at higher Cr doping, in which excited-state migration leads to a substantial increase in the upconversion rate. We propose a design for a 50-W Cr:LiSAF laser system that is based on a detailed knowledge of all the relevant material parameters.

Gift Exchange Theory: a critique in relation to organ transplantation

Organ transplantation is becoming more important as a viable method of treatment for certain severe medical conditions. It is a complex and demanding process for all involved. Nursing as a developing science must respond to cultural and economic changes. Therefore, a need exists to develop a body of empirically based knowledge to understand and support the process of organ transplantation. This paper will argue that as trading in organs is unacceptable to the moral standards of western society and outlawed in many countries, an alternative framework must be considered for understanding the mechanisms through which organs are donated and utilized. The donating and receiving of organs may be equated with gift-giving, as there is no barter of commodities involved. Therefore, a useful framework to explore this phenomenon will be one that underpins the process of giving and receiving of gifts. Gift Exchange Theory will be evaluated and critically examined in relation to organ transplantation and the role of nurses in this process.

A study of quality of life in cancer patients receiving palliative chemotherapy

Although primary treatment for cancer has been associated with psychosocial distress, less research has focused on patients with advanced disease. Traditionally, the outcomes of treatment have been assessed using biomedical criteria, including tumour regression, progression and survival. It is argued that these data are inadequate to understand the impact of cancer upon the patient. Instead, quality of life considerations are crucial when treatments are aversive, especially when the aims are palliative rather than curative. Fifty-three patients with advanced breast cancer or ovarian cancer were studied prospectively for 6 months to assess whether the site and method of chemotherapy administration influenced their quality of life. Patients received palliative chemotherapy either at home or in hospital. Quality of life was operationalized as measurement of anxiety, depression, self-esteem, health locus of control, physical performance and symptoms. In addition, semi-structured interviews explored social roles, relationships, and perceptions of treatment. Hospital administered chemotherapy was perceived to be most distressing. Regression analysis indicated that anxiety and depression accounted for most of the variance in quality of life. Patients who died during the study 13 (24%) experienced considerable psychological and physical morbidity. Women over 60 years, experienced less psychological and physical distress. Quality of life broadens the criteria by which cancer treatments are evaluated, to include the experience of the patient.

Dispersion effects in four-wave mixing measurements of ions in solids

We have performed nondegenerate four-wave mixing measurements on Cr(3+) ions in three crystals: BeAl(2)O(4), Gd(3)Sc(2)Ga(3)O(12), and LaMgAl(11)O(19). Two laser beams of the same frequency were used to resonantly pump one of the absorption bands of Cr(3+), and probe beams with three different wavelengths ranging from 442 to 1064 nm were used to generate a signal from the laser-induced population grating. The observed four-wave mixing signal strength was found to increase as the wavelength of the probe beam was decreased. A model was utilized to explain these results based on the change in polarizability of the Cr(3+) ions when they are in the metastable state versus the ground state, and it was found that the dispersion effects can be described by a single-oscillator model with the lowest-energy charge-transfer transition of Cr(3+) making the dominant contribution to the signal.