Promoting post-traumatic growth in cancer patients: a randomized controlled trial of guided written disclosure

Background

Cancer is a life-threatening disease that triggers not only vulnerability to distressing symptoms but also a meaning-making process that may lead to post-traumatic growth. As people often struggle to integrate cancer illness into their meaning system to reach an adaptive meaning, psychological interventions focused on a reappraisal of the illness experience can facilitate this process. This multicenter randomized controlled trial (RCT) was primarily aimed at assessing the efficacy of a writing intervention known as a guided disclosure protocol (GDP), compared to a generic writing intervention, in promoting post-traumatic growth in stage I-III breast and colon cancer patients at the end of their adjuvant chemotherapy.

Methods

Between January 2016 and August 2020 recruitment of eligible subjects took place during follow-up clinical consultations. Assessment occurred at baseline (T0), after the intervention (T1, 3 months from baseline), and at 6 months from baseline (T2). Both interventions consisted of three 20-min writing sessions to be performed once every two weeks. Change in post-traumatic growth was assessed using the Posttraumatic Growth Inventory, meaning with the Constructed Meaning Scale, and psychological distress with the Impact of Event Scale and the Hospital Anxiety and Depression Scale.

Results

In the five participating centers, 102 eligible patients were randomized and 72 participants completed follow-up evaluation. Most patients were women (79.4%), had breast cancer (68.6%), and stage I (27.5%), or stage II (44.1%) disease. Mean differences did not reach statistical significance for any of the dependent variables. However, an effect of the GDP, although not statistically relevant, was observed after the intervention in terms of enhanced post-traumatic growth and increased distress measured with the Impact of Event Scale.

Conclusion

This is the first RCT investigating the efficacy of a GDP in cancer patients having post-traumatic growth as the primary aim. Though GDP is a promising intervention in promoting post-traumatic growth, the lack of statistical significance of our findings may be due to the study being underpowered, hence this trial should be replicated with an adequate sample size, paying attention to supporting recruitment.

Clinical trial registration: ClinicalTrials.gov, identifier: 2015/0024360.

Defining a balance by compromising with fear: A grounded theory study on returning to eating after a total gastrectomy

OBJECTIVES

Gastric cancer patients undergoing total gastrectomy face nutrition-related complications and worsening quality of life after surgery. In this context, gastrectomized cancer patients are required to cope with new conditions. Little is known about their accommodating feeding to the new life condition as a negotiated process among stakeholders in real contexts. This study aimed to investigate the shaping of this process as influenced by the perspectives of patients, health-care professionals (HPs), and caregivers (CGs).

METHODS

A constructivist grounded theory study, through semi-structured interviews and interpretative coding, was designed to answer the following research question: "what is the process of returning to eating and feeding after a gastrectomy?"

RESULTS

The final sample included 18 participants. "Defining a balance by compromising with fear" is the core category explaining returning to eating as a process negotiated by all actors involved, with patients trying to find a feeding balance through a multi-layer compromise: with the information received by HPs, the proprioception drastically altered by gastric resection, new dietary habits to accept, and complex and often minimized conviviality. This process involves 4 main conceptual phases: relying on the doctors' advice, perceptive realignment, rearranging food intake, and food-regulated social interaction. Those categories are also shaped by the fear of being unwell from eating and the constant fear of tumor relapse.

SIGNIFICANCE OF RESULTS

Multiple actors can meet patients' and their CGs' nutritional, care, and psychosocial needs. A multidisciplinary approach involving nutritionists, psychologists, occupational therapists, social workers, and anthropologists can be key to effectively managing these patients' survivorship care. We suggest training all the professionals on the first level of nutritional counseling.

Mindfulness-based therapies for cancer patients and families: a systematic review

BACKGROUND

Mindfulness-based therapies (MBTs) addressed to patients with cancer have been widely studied in the last two decades, and their efficacy has been systematically reviewed and meta-analysed. Although findings from literature highlight benefits of MBTs on several patients' health outcomes, these should be appraised taking into consideration the characteristics of the selected studies. In this systematic review, we summarised the current evidence of the efficacy of MBTs in improving the quality of life of both patients with cancer and their relatives, with a focus on the methodological quality, type of MBT evaluated and population involved in existing randomised controlled trials (RCTs).

METHODS

We searched English language articles published until February 2021. Couples of authors independently applied inclusion criteria and extracted findings. Thirty RCTs were included.

RESULTS

Nearly half of the studies were performed in English-speaking countries outside of Europe, with females diagnosed with breast cancer. Most considered heterogeneous phases of illness; one study only was performed on relatives. In most cases, different measures were employed to evaluate the same outcome. The efficacy of MBTs has been demonstrated in 25 of the 30 included articles. The methodological quality of RCTs was acceptable.

CONCLUSION

The heterogeneity of studies' characteristics makes findings on the efficacy of MBTs poorly informative with reference to different clinical and cancer-related psychological conditions. Studies on more homogeneous samples by cancer site and phase, as well as performed in different cultural contexts, could provide a basis for better evaluating and targeting MBTs' protocols for the specific needs of patients with cancer and their relatives.

Content and Face Validity of the Evaluation Tool of Health Information for Consumers (ETHIC): Getting Health Information Accessible to Patients and Citizens

BACKGROUND

Health information concerns both individuals' engagement and the way services and professionals provide information to facilitate consumers' health decision making. Citizens' and patients' participation in the management of their own health is related to the availability of tools making health information accessible, thus promoting empowerment and making care more inclusive and fairer. A novel instrument was developed (Evaluation Tool of Health Information for Consumers-ETHIC) for assessing the formal quality of health information materials written in Italian language. This study reports ETHIC's content and face validity.

METHODS

A convenience sample of 11 experts and 5 potential users was involved. The former were requested to evaluate relevance and exhaustiveness, the latter both readability and understandability of ETHIC. The Content Validity Index (CVI) was calculated for ETHIC's sections and items; experts and potential users' feedback were analyzed by the authors.

RESULTS

All sections and most items were evaluated as relevant. A new item was introduced. Potential users provided the researchers with comments that partly confirmed ETHIC's clarity and understandability.

CONCLUSIONS

Our findings strongly support the relevance of ETHIC's sections and items. An updated version of the instrument matching exhaustivity, readability, and understandability criteria was obtained, which will be assessed for further steps of the validation process.

How parents and health professionals experience prematurity in an Italian neonatal intensive care: A grounded theory study

PURPOSE

The aim of this study was to explore prematurity as a psycho-social process from the point of view of both parents and healthcare professionals.

DESIGN AND METHODS

We conducted a Grounded Theory study through semi-structured interviews. Participants were from an Italian Neonatal Intensive Care Unit, including parents of premature children, and health professionals. Interviews were analyzed according to Grounded Theory coding strategies, to hypothesize a theoretical model.

RESULTS

On one side, behaviors, emotions, and feelings of parental couples; on the other one, the activities and reactions of professionals have been interpreted in a four-phase negotiated process: 1) the initial breakup; 2) the floating family; 3) the event processing; 4) the reconstruction of a new family.

CONCLUSIONS

Managing prematurity is a negotiated process which could be better managed through a family-centered approach as fundamental in neonatal and pediatric services. Being open in listening, coherent in the given answers, and knowing the entire process and story of being suddenly parents of a premature child can make the difference in the future definition of a new family.

PRACTICE IMPLICATIONS

Perinatal care would benefit from the following suggested practical implications: i) reducing feelings of separation and solitude by integrating diverse professionals around the family systems; ii) expediting prematurity-related changes through peer-support during hospitalization and attention to rooms' organization; iii) enhancing information exchange between all professionals involved in the care of dyads/parents and new-borns, starting since the pregnancy and continuing after the child's birth by implementing multidisciplinary meetings or appropriate care pathways.

“Challenging Professional Boundaries”: A Grounded Theory Study of Health Professionals’ First Experiences of End-of-Life Care in Hospital

Little is known about health professionals first experiences of End-of-Life care in hospital. This study aims to understand the psycho-social process that occurs when hospital-based health professionals engage in caring for a dying patient for the first time. We conducted a Grounded Theory study, with 19 health professionals. Challenging professional boundaries is the core category which explains the overall process. The theoretical model we conceptualized evidenced three phases: 1) building a relationship between patient/family and professionals, 2) the disrupting impact and 3) the reaction phase. Our analysis highlighted the initial strong impact of this experience, which brought professionals to perceive emotional suffering and feelings of inadequacy. The new aspect our grounded theory revealed is that all the categories are pertinent to all the professionals involved, therefore they explain important aspects of interprofessional collaboration in End-of-Life care.

Effectiveness of a nurse-delivered (FOCUS+) and a web-based (iFOCUS) psychoeducational intervention for people with advanced cancer and their family caregivers (DIAdIC): study protocol for an international randomized controlled trial

Background

Worldwide, millions of people with advanced cancer and their family caregivers are experiencing physical and psychological distress. Psychosocial support and education can reduce distress and prevent avoidable healthcare resource use. To date, we lack knowledge from large-scale studies on which interventions generate positive outcomes for people with cancer and their informal caregivers’ quality of life. This protocol describes the DIAdIC study that will evaluate the effectiveness of two psychosocial and educational interventions aimed at improving patient-family caregiver dyads’ emotional functioning and self-efficacy.

Methods

We will conduct an international multicenter three-arm randomized controlled trial in Belgium, Denmark, Ireland, Italy, The Netherlands, and the United Kingdom. In each country, 156 dyads (936 in total) of people with advanced cancer and their family caregiver will be randomized to one of the study arms: 1) a nurse-led face-to-face intervention (FOCUS+), 2) a web-based intervention (iFOCUS) or 3) a control group (care as usual). The two interventions offer tailored psychoeducational support for patient-family caregiver dyads. The nurse-led face-to-face intervention consists of two home visits and one online video session and the web-based intervention is completed independently by the patient-family caregiver dyad in four online sessions. The interventions are based on the FOCUS intervention, developed in the USA, that addresses five core components: family involvement, optimistic outlook, coping effectiveness, uncertainty reduction, and symptom management. The FOCUS intervention will be adapted to the European context. The primary outcomes are emotional functioning and self-efficacy of the patient and the family caregiver, respectively. The secondary outcomes are quality of life, benefits of illness, coping, dyadic communication, and ways of giving support of the patient and family caregiver.

Discussion

DIAdIC aims to develop cost-effective interventions that integrate principles of early palliative care into standard care. The cross-country setup in six European countries allows for comparison of effectiveness of the interventions in different healthcare systems across Europe. By focusing on empowerment of the person with cancer and their family caregiver, the results of this RCT can contribute to the search for cost-effective novel interventions that can relieve constraints on professional healthcare.

Trial registration

Registration on ClinicalTrials.gov on 12/11/2020, identifier NCT04626349.

Date and version identifier

20211209_DIAdIC_Protocol_Article.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00895-z.

Meanings Emerging From Dignity Therapy Among Cancer Patients

CONTEXT

Generativity is a process whereby patients nearing the end of life invest in those they will soon leave behind. In recent years, the trajectory of cancer has changed, as new therapies have prolonged survival and patients often live with metastatic disease for several years. For these patients and for the healthcare professionals who care for them it can be useful to understand if the concept of generativity is clinically salient.

OBJECTIVES

To explore the meanings emerging from two dignity therapy questions, particularly salient to generativity, amongst cancer patients in different care settings.

METHODS

We conducted a multicenter, retrospective, qualitative study in 1) home palliative care (life expectancy < 3 months); 2) specialized palliative care provided by team within an oncology hospital (life expectancy > 9-12 months); and 3) oncological day hospital (potentially curable disease). We thematically analyzed the answers of two dignity therapy questions.

RESULTS

Three themes and related meanings emerged from 37 dignity therapy sessions with respect to the two questions: 1) Meanings concerning the present life and illness, including the experience of suffering; 2) Thoughts and actions towards the self, including ways in which the patients have felt alive; 3) Thoughts and actions towards significant others, especially values that are based mainly on love for oneself and for others. No notable differences across stages and care settings emerged in terms of the meanings emerging from two dignity therapy questions.

CONCLUSION

Conversations about generativity could inform clinicians on how to communicate about existential and meaning-based issues across different stages of illness.

Providing dignity therapy to patients with advanced cancer: a feasibility study within the setting of a hospital palliative care unit

BACKGROUND

Dignity is a basic principle of palliative care and is intrinsic in the daily practice of professionals assisting individuals with incurable diseases. Dignity Therapy (DT) is a short-term intervention aimed at improving the sense of purpose, meaning and self-worth and at reducing the existential distress of patients facing advanced illness. Few studies have examined how DT works in countries of non-Anglo Saxon culture and in different real-life settings. Moreover, most studies do not provide detailed information on how DT is conducted, limiting a reliable assessment of DT protocol application and of its evaluation procedure. The aim of this study was to assess the feasibility and acceptability of a nurse-led DT intervention in advanced cancer patients receiving palliative care.

METHOD

This is a mixed-method study using before and after evaluation and semistructured interviews. Cancer patients referred to a hospital palliative care unit were recruited and provided with DT. The duration of sessions, and timeframes concerning each step of the study, were recorded, and descriptive statistical analyses were performed. The patients' dignity-related distress and feedback toward the intervention were assessed through the Patient Dignity Inventory and the Dignity Therapy Patient Feedback Questionnaire, respectively. Three nurses were interviewed on their experience in delivering the intervention, and the data were analyzed qualitatively.

RESULTS

A total of 37/50 patients were enrolled (74.0%), of whom 28 (75.7%) completed the assessment. In 76.7% of cases, patients completed the intervention in the time limit scheduled in the study. No statistically significant reduction in the Patient Dignity Inventory scores was observed at the end of the intervention; most patients found DT to be helpful and satisfactory. Building opportunities for personal growth and providing holistic care emerged among the facilitators to DT implementation. Nurses also highlighted too great of a time commitment and a difficult collaboration with ward colleagues among the barriers.

CONCLUSIONS

Our findings strongly support the acceptability, but only partially support the feasibility, of nurse-led DT in advanced cancer patients in a hospital setting. Further research is needed on how to transfer the potential benefits of DT into clinical practice.

TRIAL REGISTRATION

Retrospectively registered on ClinicalTrial.gov NCT04738305 .

Health professionals and students' experiences of reflective writing in learning: A qualitative meta-synthesis

BACKGROUND

Reflective writing provides an opportunity for health professionals and students to learn from their mistakes, successes, anxieties, and worries that otherwise would remain disjointed and worthless. This systematic review addresses the following question: "What are the experiences of health professionals and students in applying reflective writing during their education and training?"

METHODS

We performed a systematic review and meta-synthesis of qualitative studies. Our search comprised six electronic databases: MedLine, Embase, Cinahl, PsycINFO, Eric, and Scopus. Our initial search produced 1237 titles, excluding duplicates that we removed. After title and abstract screening, 17 articles met the inclusion criteria. We identified descriptive themes and the conceptual elements explaining the health professionals' and students' experience using reflective writing during their academic and in-service training by performing a meta-synthesis.

RESULTS

We identified four main categories (and related sub-categories) through the meta-synthesis: reflection and reflexivity, accomplishing learning potential, building a philosophical and empathic approach, and identifying reflective writing feasibility. We placed the main categories into an interpretative model which explains the users' experiences of reflective writing during their education and training. Reflective writing triggered reflection and reflexivity that allows, on the one hand, skills development, professional growth, and the ability to act on change; on the other hand, the acquisition of empathic attitudes and sensitivity towards one's own and others' emotions. Perceived barriers and impeding factors and facilitating ones, like timing and strategies for using reflective writing, were also identified.

CONCLUSIONS

The use of this learning methodology is crucial today because of the recognition of the increasing complexity of healthcare contexts requiring professionals to learn advanced skills beyond their clinical ones. Implementing reflective writing-based courses and training in university curricula and clinical contexts can benefit human and professional development.

"Achieve the best while rushing against time": A grounded theory study on caring for low-income immigrant cancer patients at end of life

BACKGROUND

Between 2000 and 2020, Europe experienced an annual net arrival of approximately 1.6 million immigrants per year. While having lower mortality rates, in the setting of severe diseases, immigrants bear a greater cancer-related burden due to linguistic and cultural barriers and socio-economic conditions. Professionals face a two-fold task: managing clinical conditions while considering the social, economic, cultural, and spiritual sphere of patients and their families. In this regard, little is known about the care provision to low-income immigrant cancer patients in real contexts.

AIM

To investigate the perspective of professionals, family members, and stakeholders on the caring process of low-income immigrant cancer patients at the end of life.

DESIGN

A Constructivist Grounded Theory study.

SETTING/PARTICIPANTS

The study, conducted at a Hospital in Northern Italy, involved 27 participants among health professionals, family caregivers, and other stakeholders who had recently accompanied immigrant cancer patients in their terminal phase of illness.

RESULTS

Findings evidenced that professionals feel they were not adequately trained to cope with immigrant cancer patients, nonetheless, they were highly committed in providing the best care they could, rushing against the (short) time the patients have left. Analyses evidenced four main categories: "providing and receiving hospitality," "understanding each other," "addressing diversity," and "around the patient," which we conceptualized under the core category "Achieve the best while rushing against time."

CONCLUSIONS

The model reveals the activation of empathic and compassionate behavior by professionals. It evidences the need for empowering professionals with cultural competencies by employing interpreters and specific training programs.

How to communicate with families living in complete isolation

IMPORTANCE

During the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals.

OBJECTIVE

This paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient's relatives under circumstances of complete isolation.

EVIDENCE REVIEW

PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure.

FINDINGS

Ten statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation.

CONCLUSIONS AND RELEVANCE

The statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Health professionals learning qualitative research in their workplace: a focused ethnography

BACKGROUND

The interest for qualitative research methodology has expanded beyond theoretical academic research on medical education, gathering interest from all healthcare professionals. Qualitative research has potentials in exploring the social, emotional, psychological aspects of care and in broadening professionals' scientific competencies. Nonetheless, qualitative research has still not been embraced within formal and academic curricula for future professionals, preventing newer generations from appreciating the value of its epistemological and methodological aspects and from using it in the development and implementation of clinical research. The purpose of this study was to comprehend the attitudes of health professionals learning and conducting qualitative studies within a practical training program developed in their workplace.

METHODS

The present work consisted of a focused ethnography, including 14 professionals during their one-year attendance training on qualitative research methodology. Strategies used for collecting data included participant observations, field notes, semi-structured interviews, and a focus group. All the data were analyzed consistently with ethnographic indications.

RESULTS

Analyses allowed us to evidence the educational, motivational, group-related and organizational factors influencing the attitudes and skill acquisition of healthcare professionals learning and conducting qualitative research within a practical training program developed in their workplace. Prior educational background was perceived as a sort of barrier. Nonetheless, the training boosted a change in attitude both in terms of appreciation of the research approach and trainees' emotional involvement with research participants. Doing a qualitative study in a multidisciplinary team raised in-group dynamics that hindered bringing the studies to conclusion. Trainees repeatedly lamented the difficulty in managing time to devote to research-related activities and questioned the feasibility of adopting this methodology for conducting research in their workplace.

CONCLUSIONS

Continual education training on the methodological aspects and practical implications of qualitative research may foster a renewed attitude towards one's professional education, while making inter-professional relationship issues emerge. Nonetheless, broadening the perspectives of professionals on their clinical practice by means of learning qualitative methodology may have an evident quality improvement return. Strategies for future qualitative research methodology hands-on training addressed to health professionals in continuing education are proposed.

Quality of cancer end-of-life care: discordance between bereaved relatives and professional proxies

BACKGROUND

Quality of care for patients dying in hospital remains suboptimal. A major problem is the identification of valid sources of information about the views and experiences of dying patients and their relatives.

AIM

This study aimed to estimate the agreement on quality of end-of-life care from the perspectives of bereaved relatives, physicians and nurses interviewed after the patients' death.

DESIGN

In this prospective study, we interviewed, after the patient death, the bereaved relatives, the attending physicians and the reference nurses, using the Toolkit After-death Family Interview and the View Of Informal Carers-Evaluation of Services (VOICES). Agreement was assessed using Lin's concordance correlation coefficient, Cohen's kappa, overall concordance correlation coefficient and Fleiss' kappa.

SETTING/PARTICIPANTS

We enrolled a consecutive series of 40 adult patients who died of cancer between January and December 2016 who had spent at least 48 hours in the medical oncology ward of the Santa Maria Hospital of Reggio Emilia, Italy.

RESULTS

We interviewed all physicians and nurses, and 26 (65.0%) out of 40 relatives. We found a poor agreement on overall quality of care among the three proxies (+0.21; -0.04 to 0.44), between relatives and nurses (+0.05; -0.39 to +0.47), and between relatives and physicians (+0.25; -0.13 to +0.57). A similar poor agreement was observed for all the other Toolkit and VOICES scales.

CONCLUSIONS

The agreement was rather poor, confirming previous results in different settings. Information from professional proxies should not be used for assessing the quality of care or for estimating missing information from bereaved relatives.

Palliative care in the emergency department as seen by providers and users: a qualitative study

Background

Much effort has been made to explore how patients with advanced chronic illness and their families experience care when they attend the Emergency Department, and many studies have investigated how healthcare professionals perceive Palliative Care provision in the Emergency Department. Various models exist, but nonetheless incorporating palliative care into the Emergency Department remains challenging. Considering both healthcare professionals’ and users’ perspective on problems encountered in delivering and receiving appropriate palliative care within this context may provide important insight into meaningful targets for improvements in quality of care. Accordingly, this study aims at exploring issues in delivering palliative care in the Emergency Department from the perspective of both providers and users, as part of a larger project on the development and implementation of a quality improvement program in Italian Emergency Departments.

Methods

A qualitative study involving focus group interviews with Emergency Department professionals and semi-structured interviews with patients with palliative care needs in the Emergency Department and their relatives was conducted. Both datasets were analyzed using Thematic Analysis.

Results

Twenty-one healthcare professionals, 6 patients and 5 relatives participated in this study. Five themes were identified: 1) shared priorities in Emergency Department among healthcare professionals and patients, 2) the information provided by healthcare professionals and that desired by relatives, 3) perception of environment and time, 4) limitations and barriers to the continuity of care, and 5) the contrasting interpretations of giving and receiving palliative care.

Conclusions

This study provides insights into targets for changes in Italian Emergency Departments. Room for improvement relates to training for healthcare professionals on palliative care, the development of a shared care pathway for patients with palliative care needs, and the optimization of Emergency Department environment. These targets will be the basis for the development of a quality improvement program in Italian Emergency Departments.

Long-term sustainability of a quality improvement program on cancer pain management: a complex intervention in an inpatient setting

Background:

Several approaches towards pain control for admitted cancer patients have been suggested by the literature without achieving satisfactory results. In this quality improvement project, we proposed a multicomponent intervention.

Measures:

A set of indicators was established for each component of the project. The feasibility of both the intervention and its evaluation system was measured. According to the literature review and the analysis of the local context, 5 active components were identified, piloted, and assessed: training of ward professionals, education of patients and nonprofessional caregivers, regular pain assessment, specialist-level pain consultation procedures, and involvement of hospital management.

Results:

Multiprofessional training programs with daily discussions, daily pain assessment, and a readily available specialized palliative care service seem to be the active components of this complex intervention. The quality improvement project achieved 2 years sustainability.

Conclusion:

Consolidated educational and organizational methodologies support the feasibility of this complex intervention.

"I go into crisis when …": ethics of care and moral dilemmas in palliative care

Background

Recognising and knowing how to manage ethical issues and moral dilemmas can be considered an ethical skill. In this study, ethics of care is used as a theoretical framework and as a regulatory criterion in the relationship among healthcare professionals, patients with palliative care needs and family members.

This study is a part of a larger project aimed at developing and implementing a training programme on “ethical communication” addressed to professionals caring for patients with palliative care needs. The aim of this study was comprehending whether and how the ethics of care informs the way healthcare professionals make sense of and handle ethical issues in palliative care.

Methods

Qualitative study employing a theoretically driven thematic analysis performed on semi-structured interviews.

The research was conducted in a clinical cancer centre in northern Italy. Eligible participants were physicians and nurses from eleven hospital wards who assisted patients with chronic advanced disease daily and had previously attended a 4-h training on palliative care held by the hospital Palliative Care Unit.

Results

The researchers identified five themes: morality is providing global care; morality is knowing how to have a relationship with patients; morality is recognizing moral principles; moral dimension and communication; and moral dilemmas are individual conflicts.

Conclusions

Ethics of care seems to emerge as a theoretical framework that includes the belief systems of healthcare professionals, especially those assisting patients with palliative care needs; moreover, it allows the values of both the patients and professionals to come to light through the relationship of care. Ethics of care is also appropriate as a framework for ethical training.

Undergoing head and neck cancer surgery: A grounded theory

Surgery is the treatment of choice in most head and neck cancers. Very often, the surgery is radical with high impact on the psychosocial, functional and aesthetic fields. The aim of this study is to gain a deeper understanding of the patient's, clinician's and key informant's point of view when surgery is proposed, to improve the quality of pathways in terms of patients' practical, psychological and relational needs. We followed a Grounded Theory approach with semi-structured interviews. Seventeen participants (six patients, nine healthcare professionals and two volunteers) were interviewed immediately before surgery. The study generated a process of "persuading the patient of an obligation" as the core category. The other principal categories that emerged highlighted the patients' doubts and fears regarding the surgery consequences and, in parallel, strategies employed by the healthcare professionals to rebut hindering issues impeding surgery. In particular, healthcare professionals involved patients in an affiliation process through simplified communication to sustain the choice of surgery; the family plays a supportive role in this process. The interplay between the organisational process and patients' experience results in "I will let you convince me" at the end of the decision-making process, where the main aim was to save and be saved.

An Unconventional Cancer Treatment Lacking Clinical Efficacy Remains Available to Italian Cancer Patients

Aims and Background

An unconventional cancer treatment known as “Di Bella multitherapy” gained popularity among Italian cancer patients during the 90's. In 1999, it was shown to lack any detectable antitumor activity. Access to the multitherapy was investigated three years later within the post-bereavement Italian Survey of the Dying of Cancer (ISDOC), whose broader aim was to investigate the end-of-life care experiences of terminal cancer patients.

Methods

ISDOC was carried out in a two-stage probability sample of 2,000 out of 160,000 Italian cancer patients deceased between March 2002 and June 2003. For each cancer patient, a non-professional caregiver, i.e., the closest and the best-informed person about her/his last three months of life, was identified. A specific question concerning the “Di Bella multitherapy” was included in a semi-structured questionnaire that was administered face-to-face to the caregivers by trained interviewers. Weighted estimates of the frequency of patients receiving the multitherapy in the target population and their 95% confidence intervals were computed by taking into account stratification and clustering of observations.

Results

During their last three months of life, 0.7% (95% CI, 0.3–1.6) of terminal cancer patients, corresponding to some 1,100 subjects (range, 480–2,560), received the multitherapy. No statistically significant difference was observed for age at death, cancer type, gender, education, marital status, or residence.

Conclusions

The finding indicates that an unconventional cancer treatment proven to lack clinical efficacy remained accessible to Italian cancer patients. Ethical, deontologic, and economic implications call for a routine monitoring of provision of and access to unproven cancer treatments.

Is early integration of palliative care feasible and acceptable for advanced respiratory and gastrointestinal cancer patients? A phase 2 mixed-methods study

BACKGROUND

There is evidence that early integration of palliative care improves quality of life, lowers spending and helps clarify preferences and goals for advanced cancer patients. Little is known about the feasibility and acceptability of early integration.

AIM

Assessing feasibility of early integration of palliative care, and exploring concerns perceived and problems encountered by patients, relatives and oncologists.

DESIGN

A phase 2 mixed-methods study ( ClinicalTrials.Gov :NCT02078700).

METHODS

Oncologists of two outpatient clinics offered a specialised palliative care intervention integrated with standard oncological care to all consecutive newly diagnosed metastatic respiratory/gastrointestinal cancer patients. We interviewed samples of patients, relatives and oncologists to explore strengths and weaknesses of the intervention.

RESULTS

The intervention was proposed to 44/54 eligible patients (81.5%), 40 (90.1%) accepted, 38 (95.0%) attended the first palliative care visit. The intervention was completed for 32 patients (80.0%). It did not start for three (7.5%) and was interrupted for three patients who refused (7.5%). The Palliative Care Unit performed 274 visits in 38 patients (median per patient 4.5), and 24 family meetings with relatives of 16 patients. All patients and most relatives referred to the usefulness of the intervention, specifically for symptoms management, information and support to strategies for coping. Oncologists highlighted their difficulties in informing patients on palliative intervention, sharing information and coordinating patient's care with the palliative care team.

CONCLUSION

Early integration of palliative care in oncological setting seems feasible and well accepted by patients, relatives and, to a lesser extent, oncologists. Some difficulties emerged concerning patient information and inter-professional communication.

Promoting post-traumatic growth in cancer patients: A study protocol for a randomized controlled trial of guided written disclosure

This multicenter study investigates the efficacy of the guided disclosure protocol in promoting post-traumatic growth, through meaning reconstruction, in cancer patients after adjuvant chemotherapy. Participants will be randomized to guided disclosure protocol or to an active control condition. Both conditions consist of three 20-minute writing sessions. Experimental participants verbalize emotions, describe events, and reflect on trauma effects. Control participants write about their past week’s daily routine. Patients, blinded to treatment assignment, will complete questionnaires at pre-intervention, post-intervention, and 6-month follow-up. This study will improve knowledge concerning the effects of writing interventions on psychological health and well-being in cancer patients.

Validity, reliability and responsiveness to change of the Italian palliative care outcome scale: a multicenter study of advanced cancer patients

BACKGROUND

There is an increasing requirement to assess outcomes, but few measures have been tested for advanced medical illness. We aimed to test the validity, reliability and responsiveness of the Palliative care Outcome Scale (POS), and to analyse predictors of change after the transition to palliative care.

METHODS

Phase 1: multicentre, mixed method study comprising cognitive and qualitative interviews with patients and staff, cultural refinement and adaption. Phase 2: consecutive cancer patients on admission to 8 inpatient hospices and 7 home-based teams were asked to complete the POS, the EORTC QLQ-C15-PAL and the FACIT-Sp (T0), to assess internal consistency, convergent and divergent validity. After 6 days (T1) patients and staff completed the POS to assess responsiveness to change (T1-T0), and agreement between self-assessed POS and POS completed by the staff. Finally, we asked hospices an assessment 24-48 h after T1 to assess its reliability (test re-test analysis).

RESULTS

Phase I: 209 completed POS questionnaires and 29 cognitive interviews were assessed, revisions made and one item substituted. Phase II: 295 consecutive patients admitted to 15 PCTs were approached, 175 (59.3 %) were eligible, and 150 (85.7 %) consented. Consent was limited by the severity of illness in 40 % patients. We found good convergent validity, with strong and moderate correlations (r ranged 0.5-0.8) between similar items from the POS, the QLQ-C15-PAL and the FACIT-Sp. As hypothesised, the physical function subscale of QLQ-C15-PAL was not correlated with any POS item (r ranged -0.16-0.02). We found acceptable to good test re-test reliability in both versions for 6 items. We found significant clinical improvements during the first week of palliative care in 7/10 items assessed-pain, other symptoms, patient and family anxiety, information, feeling at peace and wasted time.

CONCLUSIONS

Both the patient self-assessed and professional POS versions are valid and with an acceptable internal consistency. POS detected significant clinical improvements during palliative care, at a time when patients are usually expected to deteriorate. These results suggest that there is room for substantial improvement in the management of patients with advanced disease, across all key domains-symptoms, psychological, information, social and spiritual.

'Less ticking the boxes, more providing support': A qualitative study on health professionals' concerns towards the Liverpool Care of the Dying Pathway

BACKGROUND

Despite being widely used, research into the effectiveness of the Liverpool Care of the Dying Pathway (LCP) and associated cases of malpractice does not match dissemination. No study exists focusing on concerns voiced by professionals.

AIM

To explore the views of professionals who, during the hospital implementation of the Italian version of the Liverpool Care of the Dying Pathway (LCP-I), voiced or showed concerns towards it.

DESIGN

A qualitative study nested within the LCP-I randomized cluster trial, with semi-structured interviews analysed using thematic analysis.

SETTING AND PARTICIPANTS

Six nurses and five physicians from six out of the eight hospital wards who completed the LCP-I implementation were interviewed. Eligibility criteria were having taken part in all steps of the LCP-I Programme, voiced or somehow shown concerns, or failed to fully engage with the implementation process.

RESULTS

A total of 12 categories were identified, referring to four topics: the Implementation Programme, the LCP-I clinical documentation, the hospital environment and the educational and professional background of hospital healthcare staff. Issues raised by participants concerned both 'real' characteristics of the LCP-I and a misinterpretation of the LCP-I approach and clinical documentation. Furthermore, difficulties were reported which were not linked to the Programme but rather to end-of-life care.

CONCLUSION

This study provides insights into the experience of professionals with negative opinions of or concerns with the LCP-I. A more comprehensive approach to professional training in palliative care is needed and may envisage the development of new interventions aimed at improving the quality of care throughout the illness trajectory.

Feasibility of assessing quality of care at the end of life in two cluster trials using an after-death approach with multiple assessments

BACKGROUND

In 2009 two randomised cluster trials took place to assess the introduction of the Italian Version of the Liverpool Care Pathway in hospitals and hospices. Before and after data were gathered. The primary aim of this study is to evaluate the feasibility of using a combination of assessment methods aimed at different proxy respondents to create a means of measuring quality of care at the end of life. We also aim to explore whether there are differences in response to this approach between the hospice and hospital inpatient settings.

METHODS

A retrospective design was used. Eligible deaths were traced through death registries, and proxies were used to give information. Four procedures of assessment were used to measure different dimensions. Feasibility was assessed through compliance and adherence to the study instruments, and measured against standards derived from previous after-death studies. The proxy caregiver's rating of the study tools was also measured, to gauge feasibility and effectiveness. All consecutive cancer deaths that occurred in the study period were eligible. In both trials, deaths were excluded if the patient was a relative of hospital/hospice staff. 145 patients were recruited from the Hospital setting, and 127 from Hospice.

RESULTS

A high proportion of non-professional caregivers were interviewed - in both hospital (76.6%) and hospice (74.8%). There was no significant difference in the median number of days in each setting. 89.0% of hospital patients' GPs and 85.0% of hospice patients' GPs were interviewed. Care procedures were recorded in all hospice cases, and were missing in only 1 hospital case.52.7% of Hospital patients' relatives and 64.12% Hospice relatives were assessed to have been caused a low level of distress through the study.

CONCLUSIONS

The data shows high levels of compliance and adherence to the study instruments. This suggests that this approach to assessing quality of care is feasible, and this coupled with low levels of distress caused by the study instruments suggest effectiveness. There were no substantial differences between the hospice and hospital settings.

Students, Severe Illness, and Palliative Care: Results From a Pilot Study on a School-Based Intervention

This study was aimed at piloting a school-based intervention on severe illness, within a project focused on spreading knowledge of palliative care among high school students (phases 0-2 Medical Research Council Framework). The intervention entailed the screening of a topic-related movie, 2 classroom meetings, and the development of a class-based multimedia production. Five classes from 5 high schools participated in this study, and a before-after evaluation was used to assess intervention feasibility and impact. Valid questionnaires were filled in by 84% (before) and 79% (after) of the 89 students. Concerning students' knowledge on palliative care, the after evaluation showed a significantly higher paired proportions of students reporting on "improving patient quality of life" and "life-threatening illness." Intervention components were deemed helpful by students, and positive feedback on the experience was given.

Liverpool Care Pathway for patients with cancer in hospital: a cluster randomised trial

BACKGROUND

The quality of care provided to patients with cancer who are dying in hospital and their families is suboptimum. The UK Liverpool Care Pathway (LCP) for patients who are dying was developed with the aim of transferring the best practice of hospices to hospitals. We therefore assessed the effectiveness of LCP in the Italian context (LCP-I) in improving the quality of end-of-life care for patients with cancer in hospitals and for their family.

METHODS

In this pragmatic cluster randomised trial, 16 Italian general medicine hospital wards were randomly assigned to implement the LCP-I programme or standard health-care practice. For each ward, we identified all patients who died from cancer in the 3 months before randomisation (preintervention) and in the 6 months after the completion of the LCP-I training programme. The primary endpoint was the overall quality of care toolkit scale. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01081899.

FINDINGS

During the postintervention assessment, data were gathered for 308 patients who died from cancer (147 in LCP-I programme wards and 161 in control wards). 232 (75%) of 308 family members were interviewed, 119 (81%) of 147 with relatives cared for in the LCP-I wards (mean cluster size 14·9 [range eight to 22]) and 113 (70%) of 161 in the control wards (14·1 [eight to 22]). After implementation of the LCP-I programme, no significant difference was noted in the distribution of the overall quality of care toolkit scores between the wards in which the LCP-I programme was implemented and the control wards (score 70·5 of 100 vs 63·0 of 100; cluster-adjusted mean difference 7·6 [95% CI -3·6 to 18·7]; p=0·186).

INTERPRETATION

The effect of the LCP-I programme in our study is less than the effects noted in earlier phase 2 trials. However, if the programme is implemented well it has the potential to reduce the gap in quality of care between hospices and hospitals. Further research is needed to ascertain what components of the LCP-I programme might be effective and to develop and assess a wider range of approaches to quality improvement in hospital care for people at the end of their lives and for their families.

FUNDING

Italian Ministry of Health and Maruzza Lefebvre D'Ovidio Foundation-Onlus.

The Liverpool Care Pathway for cancer patients dying in hospital medical wards: a before-after cluster phase II trial of outcomes reported by family members

BACKGROUND

Hospital is the most common place of cancer death but concerns regarding the quality of end-of-life care remain.

AIM

Preliminary assessment of the effectiveness of the Liverpool Care Pathway on the quality of end-of-life care provided to adult cancer patients during their last week of life in hospital.

DESIGN

Uncontrolled before-after intervention cluster trial.

SETTINGS/PARTICIPANTS

The trial was performed within four hospital wards participating in the pilot implementation of the Italian version of the Liverpool Care Pathway programme. All cancer patients who died in the hospital wards 2-4 months before and after the implementation of the Italian version of Liverpool Care Pathway were identified. A total of 2 months after the patient's death, bereaved family members were interviewed using the Toolkit After-Death Family Interview (seven 0-100 scales assessing the quality of end-of-life care) and the Italian version of the Views of Informal Carers - Evaluation of Services (VOICES) (three items assessing pain, breathlessness and nausea-vomiting).

RESULTS

An interview was obtained for 79 family members, 46 (73.0%) before and 33 (68.8%) after implementation of the Italian version of Liverpool Care Pathway. Following Italian version of Liverpool Care Pathway implementation, there was a significant improvement in the mean scores of four Toolkit scales: respect, kindness and dignity (+16.8; 95% confidence interval = 3.6-30.0; p = 0.015); family emotional support (+20.9; 95% confidence interval = 9.6-32.3; p < 0.001); family self-efficacy (+14.3; 95% confidence interval = 0.3-28.2; p = 0.049) and coordination of care (+14.3; 95% confidence interval = 4.2-24.3; p = 0.007). No significant improvement in symptom' control was observed.

CONCLUSIONS

These results provide the first robust data collected from family members of a preliminary clinically significant improvement, in some aspects, of quality of care after the implementation of the Italian version of Liverpool Care Pathway programme. The poor effect for symptom control suggests areas for further innovation and development.

The Ligurian high-school educational project on palliative care: development and piloting of a school-based intervention on bereavement and severe illness

This study was aimed at developing and piloting a school-based intervention on severe illness-induced bereavement through a project focused on spreading knowledge of palliative care among high school students (phases 0-II Medical Research Council Framework). The intervention entailed the screening of a topic-related movie and a classroom meeting. Eight classes from 2 high schools participated, and a before-after evaluation was used to assess intervention feasibility and impact. Valid questionnaires, including 2 open-ended questions focusing on bereavement and strategies for coping with loss, were filled in by 89% (before) and 84% (after) of the 159 students. In the after evaluation, content analysis on the "strategies" question showed that answers concerning closeness and sharing were reported more frequently. Positive feedback was collected as regards the overall experience.

Implementation of the Liverpool Care Pathway (LCP) for the dying patient in the inpatient hospice setting: development and preliminary assessment of the Italian LCP program

BACKGROUND

The Liverpool Care Pathway (LCP) is extensively used in hospices, but the literature on the process of implementation is scarce.

AIM

Developing, piloting, and preliminarily assessing the LCP program within the inpatient hospice setting.

METHODS

This is a phase 0-1 study, according to the Medical Research Council (MRC) Framework, divided into three phases: literature review on LCP in hospice and development of the Italian version of the LCP program (LCP-I), development of a procedure for assessing the quality of the implementation process and assessing the feasibility of the implementation process, and piloting the procedure in 7 inpatient Italian hospices.

RESULTS

The LCP was implemented in all the hospices involved. A high proportion of physicians (50%-100%) and nurses (94%-100%) attended the self-education program. The self-implementation of the LCP-I program was completed in all hospices. The proportion of patients who died on LCP-I ranged between 35.6% and 89.1%. Professionals from 2 hospices reported a positive impact of the LCP-I. Conversely, professionals from 2 hospices did not recognize a positive impact of the program and did not agree to maintain the LCP-I in hospice. Finally, professionals from the other 3 hospices reported intermediate evaluations (1 stopped to use the LCP-I). Some weaknesses emerged from the external audits, related to the self-education and the self-implementation approach. Professionals required an external support from a trained palliative care team with reference to both phases.

CONCLUSIONS

The LCP-I implementation within hospices is feasible, and the process of implementation is evaluable. Issues that occurred within the implementation process suggest the introduction of an external support from a trained palliative care team in implementing the LCP program.

Methodological issues in a before-after study design to evaluate the Liverpool Care Pathway for the Dying Patient in hospital

BACKGROUND

In 2006, as the first step of a 3-year research programme to assess the Liverpool Care Pathway for the Dying Patient (LCP) in hospital, the original LCP documentation was translated and piloted in four Italian hospital wards in Genoa. The primary aim was to evaluate the feasibility of LCP implementation in the Italian context. The secondary aim of the study was to evaluate the effectiveness of the LCP with an uncontrolled before-after design.

AIM

The aim of the study was to discuss and critically evaluate the methodological issues in designing and interpreting the results of the before-after study design.

SETTING/PARTICIPANTS

All cancer deaths which occurred in four hospital wards (three general medicine and one respiratory disease) 4 months before and 4 months after LCP implementation (2 months for the respiratory disease ward) were registered. Caregivers were interviewed after the patient's death using the Toolkit After-Death Bereaved Family Member Interview.

RESULTS

A total of 111 cancer deaths were identified (63 before and 48 after) and 79 caregivers (71.2%) were interviewed (46 before and 33 after). The analyses on number and characteristics of the patients, interviewed caregivers, compliance and modality of assessment showed significant differences before and after. A remarkable internal correlation coefficient for all of the Toolkit scales within the four hospital wards was observed.

CONCLUSIONS

This analysis confirms the high risk of selection and information bias inherent the uncontrolled before- after study design. The high internal correlation strongly suggests that clustering should be taken into account in this kind of study.

Expectations about and impact of the Liverpool Care Pathway for the dying patient in an Italian hospital

This study is aimed at exploring the expectations about and the impact on healthcare staff of the Liverpool Care Pathway for the dying patient (LCP) in an Italian hospital. Qualitative information was derived from four focus group (FG) meetings that were carried out separately by profession and scheduled before the beginning and after the end of the implementation process of the Italian version of LCP for hospitals (LCP-I). Interview topics concerned end-of-life care related problems and expectations about the impact of the LCP-I programme. Tape recordings of the FGs were transcribed verbatim, and transcripts analysed independently by two research psychologists using thematic analysis. Five major topics were identified: managing pain and discontinuing inappropriate treatments, communicating with patients, communicating with relatives, communicating between professionals and practical issues. As compared with those reported in the initial FGs, responses from the final FGs highlighted that physicians felt more confident with pain management and with discontinuing inappropriate treatment, and were more inclined to recognize the value of the nurses' work. Nurses underlined advantages in using pro re nata medication, but stressed lack of personnel and time as obstacles in consistent improvement of end-of-life care. All participants seemed to acquire greater awareness of their difficulties in communication and, paradoxically, became more uncertain of their ability to liaise with dying patients and their families. LCP-I implementation may improve both knowledge about physical symptom management and professional awareness of the problems related to emotional and informative support in end-of-life care.

[Improving quality of end-of-life care. A possible and necessary change]

This article describes the phases of development and assessment of a continuous quality improvement program focused on hospital end-of-life care for cancer patients. Although most patients would like to die at home, a high proportion still die in hospital. Many studies showed non appropriate end-of-life care for patients dying in hospital and their families. During the last years, a number of hospital end-of-life pathways have been developed but only partially assessed. Among the different care pathways the most structured and proficient seems to be the Liverpool Care Pathway for the dying patient (LCP). Although it is currently in use in over 20 countries, evidence for its effectiveness are weak. The Medical Research Council framework has been used for designing the process of implementation and assessment of the Italian LCP Program for cancer patients dying in hospital. In the first step (preclinical and phase I) results from literature review have been used to develop the Italian version of the Program. Subsequently, LCP-I Program has been piloted in the Medical and Respiratory Disease wards of the "Villa Scassi Hospital" of Genoa by a Palliative Care Team (phase I-II). The implementation process has been assessed with a mixed model. Focus groups, performed on samples of doctors and nurses before and after the implementation of the LCP-I, showed a perception of effectiveness of the Program, particularly in pain management and in communication with patients and their families. Quantitative analyses, performed on consecutive series of cancer deaths before and after the introduction of the Program, allowed to test process and outcomes measures for assessing the quality of end-of-life care. According to the results from the previous phases, a cluster randomised trial was designed with the aim of assessing the effectiveness of the LCP-I Program in improving quality of end-of-life care (phase III). This study is ongoing and final results will be available by 2012. In conclusion, development and assessment of the LCP Program in Italy shows that it is possible to perform studies aimed at assessing complex interventions in end-of-life care.

THE ETIOLOGY OF HYPERTENSION DUE TO COMPLETE RENAL ISCHEMIA

1. Perfusates of totally ischemic kidneys of cats contain a pressor substance which is not present in the perfusates of normal kidneys, ischemic hind limbs, or ischemic gravid uteri. 2. The pressor material in ischemic renal perfusates originates directly in the kidney as a result of complete ischemia. 3. The pressor principle contained in ischemic renal perfusates is the cause of the hypertension which follows the reestablishment of circulation in completely ischemic kidneys, since perfusates of unreleased completely ischemic kidneys contain more pressor material than perfusates of released ischemic kidneys of the same animal. 4. The pressor principle in ischemic renal perfusates is presumed to be renin for the following reasons, (a) Both substances are destroyed by boiling, (b) Both substances induce tachyphylaxis. (c) The configuration of both pressor curves is identical, (d) The pressor action of both is not reversed by 933F, proving they are not epinephrine-like substances. (e) When incubated with plasma, both form a heat-stable pressor substance. (f) The pressor effect of both is uninfluenced by a previous injection of cocaine, (g) Unreleased, completely ischemic kidneys yield more pressor material on extraction than do released ischemic kidneys of the same animal. 5. The perfusates of blood-free ischemic kidneys contain more renin than those of blood-filled ischemic kidneys. 6. A method is described by which the power of various substances to inhibit or enhance the production of renin in the ischemic kidney may be tested. 7. A small amount of the heat-stable pressor substance, presumably angiotonin or hypertensin, is formed by the reaction of the pressor material (renin) and plasma in the vessels of the kidney during the period of complete ischemia.

Illness Awareness in Hospice: Application of a Semi-Structured Interview

This study describes the results of a semi-structured interview to assess the illness awareness of cancer patients in Hospice. The results of this study are based on the interviews made in Rimini and Savignano sul Rubicone Hospices (n = 51). Psychologists evaluated illness awareness of the participants interviewed independently from the code system that is provided for the interview. According to the psychologists, 18 patients (35%) were aware, 11 patients (22%) were unaware, and 22 patients (43%) were aware with defense mechanisms. According to the code system of the interview, the results were the following: 18 patients (35%) were aware, 2 patients (4%) were unaware, and 29 patients (57%) were aware with defense mechanisms. Two participants had to be reassessed because of inconsistency in some factors. In conclusion, the data analysis underlined that the congruence of the 2 assessment methods was found in 33 of the 51 patients examined (65%) and that the degree of concordance was rather low (κ = .46; 95% CI = 0.24-0.68).

End-of-life care in Italy: personal experience of family caregivers. A content analysis of open questions from the Italian Survey of the Dying of Cancer (ISDOC)

OBJECTIVE

This study aims at describing the emotional and practical experience of a representative sample of Italian non-professional caregivers when caring for a terminally ill family member and is part of the 'Italian Survey of the Dying of Cancer', which involved 2000 adult cancer deaths representative of the whole country.

METHODS

Information on patients' experience was gathered from non-professional caregivers by an interview. A specific question was asked about the caregivers' emotional and practical experiences while assisting a terminally ill relative. A content analysis of the open question on caregivers' perceptions was performed on transcribed answers. Three researchers independently generated categories. Subsequently, areas where they differed were reconsidered and an interpretation was agreed upon.

RESULTS

Valid interviews were obtained from 1231 non-professional caregivers. Answers were classified according to the perception of the experience as positive (33.1%), negative (65.1%) or neutral (1.8%).

CONCLUSION

Assisting a family member with cancer in his/her last three months of life is a very strong physical and mental stress for the caregiver. In some cases, this experience is nevertheless perceived as an evolution chance. Health-care providers should need to develop programs to ensure that family caregivers' needs for information and support are given great importance.