Palliative care patients' perceptions of the work involved in understanding and managing the network of care provision surrounding them

OBJECTIVE

To explore the work carried out for cancer palliative care patients in understanding and dealing with the often large network of care provision surrounding them.

METHOD

Qualitative thematic analysis of interviews with 24 patients (aged 48-85 years) with 15 different types/sites of cancer and palliative care needs.

RESULTS

The main theme of 'patient work-their strategies and project management' is presented. Subthemes included: being organised and keeping records; planning ahead and coordinating care; information gathering; understanding the hierarchy and knowing who the key people are; strategies to remember names and roles; understanding and 'working the system'. Insights are given into the work carried out on patients' behalf by family, although it was unclear who would do this work if no family was available. Some of the challenges faced by patients and families are identified. These included limited information; uncertainty when care is transferred between different teams or locations; deciding who to contact and how; and negotiating through gatekeepers.

CONCLUSIONS

The number and variety of people contributing to the care of a cancer palliative care patient can be difficult for patients and family to comprehend. Work is required by patients or family on their behalf to achieve the level of understanding required to become accomplished at navigating the system and project managing their care organisation, and is probably influenced by role expectations and previous experience. Much of this additional, often hidden, workload for patients and family could probably be reduced with clear, timely information provision by health professionals.

Uncertainty and anxiety in the cancer of unknown primary patient journey: a multiperspective qualitative study

BACKGROUND

Patients with cancer of unknown primary (CUP) have metastatic malignant disease without an identifiable primary site; it is the fourth most common cause of cancer death.

OBJECTIVES

To explore patients' informal and professional carers' experiences of CUP to inform development of evidence-based, patient-centred care.

METHODS

Qualitative study involving development of multiple exploratory case studies, each comprising a patient and nominated informal and professional carers, with contextual data extracted from medical records.

RESULTS

17 CUP patients, 14 informal and 13 professional carers participated in the study. Two inter-related themes distinct to CUP emerged: uncertainty and continuity of care. In the absence of a primary diagnosis, patients and informal carers experienced uncertainty regarding prognosis, possible recurrence and the primary's hereditary potential. Professional carers experienced difficulty communicating uncertainty to patients, ambiguity in deciding optimal treatment plans in the absence of trial data and a test or treat dilemma: when to discontinue seeking the primary and start treatment. Common problems with care continuity were amplified for CUP patients relating to coordination, accountability and timeliness of care. The remit of multidisciplinary teams (MDTs) often excluded CUP, leading to "MDT tennis" where patients were "bounced" between MDTs.

CONCLUSIONS

The experience of those with CUP is distinctive and it can serve to amplify some of the issues encountered by people with cancer. The clinical uncertainties related to CUP compound existing shortcomings in continuity of care, increasing the likelihood of a disrupted patient journey. However, while little can be done to overcome uncertainty, more could be done to address issues regarding continuity of care.

Informing future research priorities into the psychological and social problems faced by cancer survivors: a rapid review and synthesis of the literature

PURPOSE

To establish what is known regarding the psychological and social problems faced by adult cancer survivors (people who are living with and beyond a diagnosis of cancer) and identify areas future research should address.

METHOD

A rapid search of published literature reviews held in electronic data bases was under taken. Inclusion and exclusion criteria, and removal of duplicated papers, reduced the initial number of papers from 4051 to 38. Twenty-two review papers were excluded on grounds of quality and 16 review papers were selected for appraisal.

RESULTS

The psychological and social problems for cancer survivors are identified as depression, anxiety, distress, fear of recurrence, social support/function, relationships and impact on family, and quality of life. A substantial minority of people surviving cancer experience depression, anxiety, and distress or fear associated with recurrence or follow up. There is some indication that social support is positively associated with better outcomes. Quality of life for survivors of cancer appears generally good for most people, but an important minority experience a reduction in quality of life, especially those with more advanced disease and reduced social and economic resources. The majority of research knowledge is based on women with breast cancer. The longer term implications of cancer survival have not been adequately explored.

CONCLUSIONS

Focussing well designed research in the identified areas where less is already known about the psychological and social impact of cancer survival is likely to have the greatest impact on the wellbeing of people surviving cancer.

Deaths of children occurring at home in six European countries

OBJECTIVES

Until now there have been no population-based European data available regarding place of death of children. This study aimed to compare proportions of home death for all children and for children dying from complex chronic conditions (CCC) in six European countries and to investigate related socio-demographic and clinical factors.

METHODS

Data were collected from the death certificates of all deceased children aged 1-17 years in Belgium, the Netherlands, Norway, England, Wales (2003) and Italy (2002). Gender, cause and place of death (home vs. outside home) and socio-demographic factors (socio-economic status, degree of urbanization and number of hospital beds in the area) were included in the analyses. Data were analysed using frequencies and multivariate logistic regression.

RESULTS

In total 3328 deaths were included in the analyses; 1037 (31.2%) related to CCC. The proportion of home deaths varied between 19.6% in Italy and 28.6% in the Netherlands and was higher for children dying from CCC in all the countries studied, varying between 21.7% in Italy and 50% in the Netherlands. Among children dying from CCC, home death was more likely for cancer patients and those aged over 10 years. After controlling for potentially related clinical and socio-demographic factors, differences in the proportion of home deaths between countries remained significant, with higher proportions in Belgium and the Netherlands as compared with Italy.

CONCLUSIONS

Although home deaths comprise a substantial proportion of all deaths of children with CCCs, variation among disease categories and across countries suggest that considerable potential still exists for further improvements in facilitating end-of-life care in the home for those children and families who desire to be in this location.

Who visits mobile UK services providing cancer information and support in the community?

People can access a variety of sources of information and support when they have questions about cancer according to their needs. There are various sources of information and support for cancer beyond the health-care setting. In this study, we set out to assess reasons for visiting two mobile cancer information and support services in the UK during 2006. Data were collected about each visitor by staff on the mobile services. The two mobiles travelled to 109 UK locations over a 7-month period. Fifty-nine per cent of visitors were women. Thirty-one per cent of visitors had (had) cancer; very few were still undergoing treatment. For 95% of visitors the visit had been spontaneous rather than pre-planned, and 89% of visits lasted <15 min. Most visitors required information or support for themselves, but a third requested information for someone else. A quarter of enquiries were about cancer prevention and early detection (e.g. screening, genetic testing, lifestyle). The mobiles appear to serve an important function in providing information and support in the community where visitors can drop in for an informal conversation with trained members of staff to ask questions and receive support in relation to cancer.

Supporting lay carers in end of life care: current gaps and future priorities

Informal carers are central to the achievement of end of life care and death at home and to policy aims of enabling patient choice towards end of life. They provide a substantial, yet hidden contribution to our economy. This entails considerable personal cost to carers, and it is recognised that their needs should be assessed and addressed. However, we lack good research evidence on how best to do this. The present position paper gives an overview of the current state of carer research, its gaps and weaknesses, and outlines future priorities. It draws on a comprehensive review of the carer literature and a consensus meeting by experts in the field. Carers' needs and adverse effects of caregiving have been extensively researched. In contrast, we lack both empirical longitudinal research and conceptual models to establish how adverse effects may be prevented through appropriate support. A reactive, "repair" approach predominates. Evaluations of existing interventions provide limited information, due to limited rigour in design and the wide variety in types of intervention evaluated. Further research is required into the particular challenges that the dual role of carers as both clients and providers pose for intervention design, suggesting a need for future emphasis on positive aspects of caregiving and empowerment. We require more longitudinal research and user involvement to aid development of interventions and more experimental and quasi-experimental research to evaluate them, with better utilisation of the natural experiments afforded by intra- and international differences in service provision.

Population-based study of dying in hospital in six European countries

This study examined the proportion of deaths taking place in hospitals in six European countries in relation to demographic, epidemiologic and healthcare factors. Retrospective analyses were performed on a database integrating death certificate data of all deaths in 2002 in Sweden and 2003 in Belgium, England, Scotland, the Netherlands and Wales (N = 891,780). Data were linked with regional healthcare statistics. Of all deaths, from 33.9% (the Netherlands) to 62.8% (Wales) occurred in hospital. Large country differences in hospital deaths were partly explained by the availability of care home and hospital beds. Differences between countries were strikingly large in older patients and cancer patients. Older patients had a higher probability of dying in hospital in Sweden, Scotland, England and Wales than in Flanders and, in particular, in the Netherlands. Cancer patients often died in hospitals in Sweden but less frequently so in the Netherlands and England. Country differences in the proportion of patients dying in hospital are only partly the result of differences in health care provision, and are in particular larger for certain patient categories, suggesting country-specific end-of-life practices in these categories. These findings can contribute to rational public health policies aimed at reducing hospital deaths.

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.

The effect of noninvasive ventilation on ALS patients and their caregivers

BACKGROUND

Noninvasive ventilation (NIV) reduces mortality and improves some aspects of quality of life (QoL) in ALS. However, concerns remain that progressive disability may negate these benefits and unnecessarily burden caregivers.

METHODS

Thirty-nine patients requiring NIV were offered treatment. Twenty-six were established on NIV, but 13 declined or could not tolerate NIV. Fifteen patients without respiratory muscle weakness (RMW) but with similar ALS severity and age were studied in parallel. Caregivers of 21 NIV, 7 untreated, and 10 patients without RMW participated. Patients and caregivers had detailed QoL measurements for 12 months. NIV patients underwent cognitive testing before and after treatment.

RESULTS

RMW correlated with lower QoL. The median survival of untreated patients (18 days; 95% CI 11 to 25 days) was shorter than for NIV patients (298 days; 95% CI 192 to 404 days) and non-RMW patients (370 days; 95% CI 278 to 462 days; log rank test [2 df] = 81, p = 0.00001). A wide range of QoL measures improved within 1 month of starting NIV, and improvements were maintained for 12 months. QoL of non-RMW patients declined as RMW progressed. Caregivers of NIV and non-RMW patients showed similar increases in burden, but NIV patient caregivers developed a deterioration in the Short Form-36 Vitality score. No improvements were found on measures of learning and recall in the NIV patients.

CONCLUSIONS

Respiratory muscle weakness has a greater impact on quality of life (QoL) than overall ALS severity. Noninvasive ventilation (NIV) improves QoL despite ALS progression. NIV has no impact on most aspects of caregiver QoL and does not significantly increase caregiver burden or stress.

Older patients' experiences of treatment for colorectal cancer: an analysis of functional status and service use

Age and ageing are an important part of the context within which the care and treatment of people with cancer is provided. More information is needed about the effects of cancer treatment on the lives of older people following inpatient care. We conducted a 3-year study in which older people with colorectal cancer completed a detailed questionnaire on multidimensional function and service use before and after elective treatment. Here we present an analysis of changes in functional status and service use over the pre- to post-treatment period, and set out a detailed picture of older people's experiences before and after treatment. In total, 337 patients with colorectal adenocarcinoma aged 58-95 years were interviewed before treatment using the OARS Multidimensional Functional Assessment Questionnaire (OMFAQ), Rotterdam Symptom Checklist (RSCL) and a severity of morbidity score. Study end points were defined as post-treatment functional status, symptom distress, severity of morbidity and frequency of service use. Pre- and post-treatment data were compared using matched analyses. Logistic regression was used to assess associations between age and the main outcome measures, and frequency of service use after treatment was compared between age groups using the chi2 test. Overall, patients experienced both positive and negative outcomes following treatment. It was notable that patients aged > or = 75 years showed improvement in only one of the principal outcome measures. Patterns of service use following treatment suggest that support at home is a key issue for patients. With the exception of nursing care, however, help at home is provided on a majority of occasions by families themselves. This raises important questions about how much preparation patients and families receive or would like before they leave hospital after treatment for cancer. A collaborative, family-centred approach to meeting people's needs is called for in the months following inpatient care.

Treatment decisions in older patients with colorectal cancer: the role of age and multidimensional function

The aim of the study was to investigate the role of age and multidimensional functional status in treatment decisions in older patients with colorectal cancer. Three hundred and thirty-seven patients aged 58-95 years with adenocarcinoma of the colon or rectum were interviewed before and after treatment using the OARS Multidimensional Functional Assessment Questionnaire (OMFAQ), a self-reported severity of morbidity scale, and the Rotterdam Symptom Checklist (RSCL). The OMFAQ rates five dimensions of function: social resources, economic resources, mental and physical health and self-care capacity. The likelihood of patients with Duke's C colorectal cancer receiving adjuvant chemotherapy decreased significantly with age (P = 0.001, trend). Differences in treatment received were not explained by differences in morbidity, economic, mental or physical function, self-care capacity, or any of the RSCL measures. After controlling for age, Duke's C patients who received adjuvant chemotherapy were less impaired in social resources than Duke's C patients who did not (P = 0.06). No other significant pre-treatment differences in functional status were found. Differences in age and social resources exist between patients who do and do not receive adjuvant chemotherapy. Care should be taken to ensure that patients are not excluded from treatment with known survival benefits because of their age, and the question of providing appropriate social support during adjuvant chemotherapy should be re-examined.

Research sensitivities to palliative care patients

This paper considers the methodological challenges of researching the health care experiences of palliative care patients and their families. Difficulties in defining a 'palliative care patient' are highlighted, and the question of whether there are specific ethical issues when researching palliative care explored. Methodological issues are discussed, including the negotiation of access via health professionals, the choice of appropriate data collection methods and tools, the consequences of high attrition rates and the use of retrospective surveys of bereaved relatives. Key areas for research are identified. These include patients' and families' experiences of research participation, the impact of being approached on those who decline, how the characteristics of those who participate differ from those who do not and the likely impact of this on findings. Research is also needed into patient and family motivations for participation, and whether and how these change as the disease progresses. To ensure that the voices of palliative care patients and their families are heard by both service providers and policy-makers, research in this area needs to address the methodological challenges raised in this paper, as well as continuing to explore users' views.

Depression in advanced disease: a systematic review Part 1. Prevalence and case finding

OBJECTIVE

To identify all literature regarding depression in patients with advanced cancer and among mixed hospice populations, and to summarise the prevalence of depression according to different definitions.

METHODS

A systematic review was performed using extensive electronic and hand searches. All studies with quantitative data on prevalence of depression were included and categorised according to their definition of depression.

RESULTS

We identified 46 eligible studies giving information on the prevalence of depression, and a further four which gave information on case finding. The most widely used assessment of depression was the Hospital Anxiety and Depression Scale (HADS), which gave a median prevalence of 'definite depression' (i.e., a score on the depression subscale of > 10) of 29%, (interquartile range, IQR, 19.50-34.25%). Studies that used psychiatric interviews indicated a prevalence of major depressive disorder ranging from 5% to 26%, with a median of 15%. Studies were generally small (median sample size 88.5, IQR 50-108), had high numbers of nonresponders, and rarely gave confidence intervals for estimates of prevalence.

CONCLUSIONS

Depression is a common problem in palliative care settings. The quality of much of the available research is poor, based on small samples of patients with very high nonparticipation rates. The clinical importance of depression is described in subsequent papers.

After-death interviews with surrogates/bereaved family members: some issues of validity

After-death interviews with bereaved respondents are an important tool in the repertoire of researchers evaluating the quality of end-of-life care or investigating the experiences of people at the end of life. Despite the importance of after-death interviews to our understanding of the last months of life, the validity of the information gathered has received little attention. In this article, we review some of the available information, drawing on evidence from cognitive psychology as well as from palliative care studies. Findings from cognitive psychology indicate that memory is a dynamic process, influenced by emotion state and the individual's perspective at the time of the event and at recall. Further research is therefore needed to understand better the circumstances, types of information and research questions for which bereaved relatives are valid surrogates for people who have died.

A comparison of the palliative care needs of patients dying from chronic respiratory diseases and lung cancer

This paper reports on data from the Regional Study of Care for the Dying, conducted in 1990, and compares symptoms, care and service utilization for patients with chronic lung diseases (CLD) and lung cancer (LC) in the final 12 months of life. Post-bereavement structured interviews were conducted with informal carers of 449 LC patients and 87 CLD patients. The LC patients were significantly younger than those with CLD (P = 0.001) and these respondents were more likely to have been a spouse (P = 0.034). No differences were found in the mean number of symptoms reported by the two groups in the final year or week of life, although the CLD patients were more likely to have experienced these symptoms for longer. Significantly more patients with CLD than LC experienced breathlessness in the final year (94% CLD vs 78% LC, P < 0.001) and final week (91% CLD vs 69% LC, P < 0.001) of life. Significantly more LC patients were reported to have experienced anorexia (76% LC vs 67% CLD, P = 0.06) and constipation (59% LC vs 44% CLD, p = 0.01) in the final year of life. There were no differences in general practitioner use, but LC patients were reported to have received more help from district nurses (52% LC vs 39% CLD, P = 0.025) and from a palliative care nurse (29% LC vs 0% CLD, P < 0.001). More CLD patients were reported to have received help from social services (29% CLD vs 18% LC, P = 0.037). LC patients were reported to be more likely to have known they might die (76% LC vs 62% CLD, P = 0.003) and to have been told this by a hospital doctor (30% LC vs 8% CLD, P = 0.001). Among those that knew, LC patients were told earlier prior to death than CLD patients. This study suggests that patients with CLD at the end of life have physical and psychosocial needs at least as severe as patients with lung cancer.

Cancer services. Left to chance

Most primary care groups/trusts have cancer lead posts and have some involvement in planning and commissioning cancer services. Cancer is not a high priority in comparison to other national service frameworks and the transition to PCT status. PCG/Ts want help and information about developing cancer services but not all want this now. Most PCG/Ts have some involvement in cancer networks but information needs exist about their role and potential.

Educational opportunities in palliative care: what do general practitioners want?

It is important to support general practitioners (GPs) in maintaining and developing their palliative care skills as most of the final year of a patient's life is spent at home under the care of the primary health care team. The training needs and uptake of GPs have been explored, but little is known about how GP educational preferences vary. The aim of this study was to explore the current educational preferences of GPs in different geographical locations as part of an evaluation of an educational intervention. The methods used included postal questionnaires sent to 1061 GPs. Results from 640 (60%) of GPs revealed that half (51%) wanted education in symptom control for non-cancer patients. More inner-city GPs wanted education in opiate prescribing (43%), controlling nausea and vomiting (45%), and using a syringe driver (38%) than their urban and rural colleagues (26%, 29% and 21%, respectively). Increased educational preference and increased difficulty in accessing information was associated with reduced confidence in symptom control. To maximize educational uptake it will be important for educational strategies to be developed and targeted according to variations in demand, and in particular to respond to the need for palliative care education in symptom control for patients suffering from advanced non-malignant disease.

Quality of life assessment and outcome of palliative care

Quality of life (QoL) assessment is crucial for the evaluation of palliative care outcome. In this paper, our methodological approach was based on the creation of summary measures. Fifty-eight Palliative Care Units (PCUs) in Italy participated in the study. Each PCU randomly selected patients to be 'evaluated' among the consecutively 'registered' patients. At baseline (first visit) and each week the patient was asked to fill in a QoL questionnaire, the Therapy Impact Questionnaire (TIQ). Short-survivors (<7 days) were not included in the QoL study. The random sample of patients (n = 601) was highly representative of the general patient population cared for by the PCUs in Italy. The median survival was 37.9 days. We collected 3546 TIQ, 71.4 % completed by the patients. A Summary Measure Outcome score was calculated for 409 patients (81% of the patients included in the QoL study). The results of this national study showed that cooperative clinical research in palliative care is possible and QoL measures can be used to assess the outcome.

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: clinical effectiveness

OBJECTIVE

To compare the clinical effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.

DESIGN

Prospective, controlled trial with randomised and patient preference allocation arms.

SETTING

General practices in London and greater Manchester.

PARTICIPANTS

464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion.

INTERVENTIONS

Usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists.

MAIN OUTCOME MEASURES

Beck depression inventory scores, other psychiatric symptoms, social functioning, and satisfaction with treatment measured at baseline and at 4 and 12 months.

RESULTS

197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. All groups improved significantly over time. At four months, patients randomised to non-directive counselling or cognitive-behaviour therapy improved more in terms of the Beck depression inventory (mean (SD) scores 12.9 (9.3) and 14.3 (10.8) respectively) than those randomised to usual general practitioner care (18.3 (12.4)). However, there was no significant difference between the two therapies. There were no significant differences between the three treatment groups at 12 months (Beck depression scores 11.8 (9.6), 11.4 (10.8), and 12.1 (10.3) for non-directive counselling, cognitive-behaviour therapy, and general practitioner care).

CONCLUSIONS

Psychological therapy was a more effective treatment for depression than usual general practitioner care in the short term, but after one year there was no difference in outcome.

Which terminally ill cancer patients in the United Kingdom receive care from community specialist palliative care nurses?

This study investigates how cancer patients who receive care from community specialist palliative care (CSPC) nurses differ from those who do not. This was achieved by secondary data analyses from the Regional Study of Care for the Dying, a retrospective interview survey of deaths in 1990 in 20 nationally representative health districts. Interviews were obtained for 2,074/2,915 (71%) of randomly selected cancer deaths; 574 (27.8%) were reported to have received care from a Macmillan nurse, hospice home-care nurse, or other community specialist palliative care nurse. Using logistic regression analysis 10 factors were found to predict independently CSPC use. Being dependent with dressing/undressing, needing help at night, having constipation, experiencing vomiting/nausea, being mentally confused, having breast cancer and being under the age of 75 years increased the likelihood of receiving CSPC. Having a lymphoma, leukaemia or myeloma, a brain tumour and being dependent on others for help with self-care for more than 1 year decreased the likelihood. The use of CSPC nurses to provide expertise in symptom control and to support families of dependent patients is consistent with the aims of palliative care, and therefore appears appropriate. Further research is, however, needed to investigate the apparent age bias in access to these services, and to ensure that CSPC services are provided on the basis of need, irrespective of patient age.

Providing palliative care in primary care: how satisfied are GPs and district nurses with current out-of-hours arrangements?

The complex needs of palliative care patients require an informed, expert, and swift response from out-of-hours general medical services, particularly if hospital admission is to be avoided. Few general practitioners (GPs) reported routinely handing over information on their palliative care patients, particularly to GP co-operatives. District nurses and inner-city GPs were least satisfied with aspects of out-of-hours care. Most responders wanted 24-hour availability of specialist palliative care. This indicates a need to develop and evaluate out-of-hours palliative care procedures and protocols, particularly for GP co-operatives, and to improve inter-agency collaboration.

'All the services were excellent. It is when the human element comes in that things go wrong': dissatisfaction with hospital care in the last year of life

Patient satisfaction surveys are seen as an important way of obtaining 'user views' of health service provision. However, there is a growing body of research and theoretical literature that questions the validity of the concept of 'patient satisfaction' and hence the use of this type of survey. A postbereavement survey of people who registered a random sample of cancer deaths in an inner London health authority was undertaken in 1996/7. The survey questionnaire (VOICES) included 14 open-ended questions which asked respondents to add any comments they felt were relevant about the care of the deceased. This paper uses these data to examine the causes of dissatisfaction with hospital-based care. Of the 229 informants responding to the questionnaire, 138 included some written comment about care in hospital. At least one negative comment was made by 59% (82) of those making any comment. Of these, 55% (44) rated the care given by doctors as 'excellent' or 'good' and 63% (50) rated that given by nurses as 'excellent' or 'good'. Qualitative analysis of responses to open questions suggest that expressions of dissatisfaction arise from a sense of being 'devalued', 'dehumanized' or 'disempowered' and from situations in which the 'rules' governing the expected health professional-patient relationships were broken. As such, the causes of dissatisfaction for this particular group of patients are similar to the causes of dissatisfaction with health care in general reported elsewhere. The palliative care approach emphasizes patient- and family-centred care and aims to promote physical and psychosocial well-being. The study findings suggest that adoption of the palliative care approach could reduce the experience of dissatisfaction for many service users, not only those whose deaths are anticipated.

Terminal cancer patients and timing of referral to palliative care: a multicenter prospective cohort study. Italian Cooperative Research Group on Palliative Medicine

This study describes the characteristics of a representative sample of terminally ill cancer patients at admission to Italian palliative care programs, the rate and reasons for discontinuation of care, and survival after enrollment. All Italian palliative care units (PCUs) specifically committed to palliative care were asked to consecutively register all new patients (n = 3901) between January and June, 1995. Fifty-eight of the 62 PCUs contacted by the Steering Committee completed the study. A random sample of 589 evaluable patients was prospectively selected from the 2667 eligible patients. Patients were mostly referred by a general practitioner (31.2%) or a specialist (42.1%). Most patients (84.7%) were followed until death. Seventy-seven discontinued care because of hospital admission (6.6%), change of residence (3.9%), refusal (1.7%), or improvement (0.8%). Median survival was 37.9 days; 14.3% of the patients died within 7 days, and 15.3% lived longer than 180 days. A statistically significant association between survival and gender, cancer type, setting of the first visit, and type of unit was observed. In Italy, as in other countries with different health systems, referral of cancer patients to palliative care tends to occur late in the course of the disease. This study suggests that the process of enrollment and the duration of patients' survival in palliative care, when studied in large unselected populations, can provide important information relevant to the care of terminally ill patients.

[Quality of life at the end of life. Analysis of the quality of life of oncologic patients treated with palliative care. Results of a multicenter observational study (staging)]

Outcome in palliative care can be defined as patients' quality of life, quality of death and satisfaction with care. In an Italian multicentre prospectic study ('Staging') the quality of life of 571 palliative care patients with advanced cancer disease was assessed since the beginning of palliative care till the end of the study. We analyzed the tissue of quality of life missing data and the possibility to input the missing quality of life evaluation through the quality of life evaluation made by a proxy (doctor, nurse). The greatest functional impairment and an increasing level of some symptoms (fatigue, general malaise, emotional status) were observed during the last two weeks of life, whereas for other symptoms (gastro-intestinal, pain) some degree of control was possible. The quality of life analysis for palliative care patients should consider the different response of different quality of life components to the palliative care intervention.

Extending specialist palliative care to all?

How to extend palliative care services to all patients needing them is an issue currently exercising a range of bodies in contemporary Britain. This paper first considers the evidence regarding the needs of dying patients with long term conditions other than cancer and concludes that there is evidence to support their presumed need for palliative care. It then considers five potential barriers to extending specialist palliative care services to non-cancer patients in Britain. These are the skill base of current specialists in palliative care, difficulties in identifying candidates for specialist palliative care, the views of potential users of these services, resource implications and vested interests in present health service arrangements.

A randomised controlled trial of postal versus interviewer administration of a questionnaire measuring satisfaction with, and use of, services received in the year before death

STUDY OBJECTIVES

To develop a short form of an interview schedule used successfully in previous national surveys of care for the dying, and to investigate the effect of administering it by post on response rate, response bias and on the nature of responses to questions.

DESIGN

Randomised controlled trial.

SETTING

An inner London health authority.

PARTICIPANTS

Informants (person registering death) of random sample of cancer deaths between June 1995 and July 1996.

MAIN RESULTS

The shortened questionnaire (VOICES) has 158 questions. Response rate did not differ significantly between postal and interview groups (interview; 56% (69 of 123), postal: 52% (161 of 308). Responders in the two groups did not differ in terms of their sociodemographic characteristics. Postal questionnaires had significantly more missing data, particularly on questions about service provision and satisfaction with services. Responses to questions differed between the groups on 11 of 158 questions. Interview group respondents were more likely to give top ranking responses to questions on service satisfaction and symptom control.

CONCLUSIONS

Postal questionnaires are an acceptable alternative to interviews in retrospective post-bereavement surveys of care for the dying, at least in terms of response rate and response bias. However, the increased costs of interview surveys need to be balanced against the fact that postal questionnaires result in more missing data, and possibly less reliable answers to some questions. Caution is needed in combining results from the two data collection methods as interview respondents gave more positive answers to some questions.

Specialist palliative care in nonmalignant disease

The objective of this study was to investigate how many patients who die from causes other than cancer might benefit from specialist palliative care. This was achieved by secondary analysis of data from the Regional Study of Care for the Dying, a retrospective national population-based interview survey. The investigation involved 20 self-selected English health districts, nationally representative in terms of social deprivation and most aspects of health services provision. A total of 3696 patients were randomly selected from death registrations in the last quarter of 1990; an interview concerning the patient was completed 10 months after the death by bereaved family, friends or officials. The results show that a third (243/720) of cancer patients who were admitted to hospices or had domiciliary palliative care scored at or above the median on three measures of reported symptom experience in the last year of life. That is the number of symptoms (eight or more), the number of distressing symptoms (three or more) and the number of symptoms lasting more than six months (three or more). A total of 269 out of 1605 noncancer patients (16.8%) fulfilled these criteria. On this basis, it is estimated that 71,744 people who die from nonmalignant disease in England and Wales each year may require specialist palliative care. An increase of at least 79% in caseload would, therefore, be expected if specialist palliative care services were made fully available to noncancer patients. This is a conservative estimate, as non-cancer patients were matched to only one-third of cancer patients who had specialist palliative care. It is concluded that clinicians and patient groups caring for patients with advanced nonmalignant disease must work together with specialist palliative care services and with health commissioners to develop, fund and evaluate appropriate, cost-effective services which meet patient and family needs for symptom control and psychosocial support.

How do cancer patients who die at home differ from those who die elsewhere?

Our objective was to investigate how cancer patients who die at home differ from those who do not. A postbereavement survey of 229 people who registered the death of a random sample of cancer deaths in an inner London health authority was conducted. It was found that a fifth of patients (21%) died in their own home. Overall, 38% were reported to have expressed a preference for place of death, 73% of whom wanted to die at home. Only 58% achieved this. Having special equipment and stating a preference for place of death was associated with an increased likelihood of dying at home; using social and health services for social care was associated with a decreased likelihood of so doing. It was concluded that, as in previous studies, most patients who expressed a preference wanted a home death, but nearly half did not achieve this. Recognition of a preference for home death, providing the motivation to 'stick it out' at home, and adequate community support to provide the practical means to fulfil the preference, appear to be crucial in the achievement of a home death for all who desire it.

Which terminally ill cancer patients receive hospice in-patient care?

The objective of this study was to investigate which terminally ill cancer patients receive in-patient care in hospices and other specialist palliative care in-patient units. An interview survey was made of family or others who knew about the last year of life of a random sample of people who died in 1990. Twenty district health authorities from a range of inner city, outer urban and rural settings took part. Although self-selected, districts were nationally representative in terms of social characteristics and on many indicators of health service provision and usage. Interviews were obtained for 2074 cancer deaths out of a random sample of 2915, a 71% response rate. 342 had been admitted to a total of 31 different hospices. Using logistic regression analysis five factors were found to independently predict hospice in-patient care: having pain in the last year of life, having constipation, being dependent on others for help with activities of daily living for between one and six months before death, having breast cancer, and being under the age of 85 years. A third of patients with all five factors were admitted, compared with no patients with none of these factors. It was found that symptom severity, age, dependency level and site of cancer played a role in determining hospice admission but have limited predictive value. Admission seems to be governed more by chance than by need. Further research is needed to identify which patients benefit most from in-patient care in hospices and other specialist palliative care units as the present arrangements appear to be both inequitable and insupportable.

Variations by age in symptoms and dependency levels experienced by people in the last year of life, as reported by surviving family, friends and officials

OBJECTIVE

To explore the relationships between age, reported symptoms and dependency in the last year of life in those dying from cancer and in those dying from other causes.

DESIGN

Secondary analysis of data from the Regional Study of Care for the Dying, a retrospective interview survey of deaths in 1990 in 20 nationally representative English health districts. There were 2061 cancer deaths and 1469 non-cancer deaths (sudden deaths were excluded).

MAIN RESULTS

In cancer patients, the mean number of symptoms reported to have been experienced in the last year of life decreased with age (from 8.29 in those aged <65 to 7.79 in those aged 65 -74, 7.37 in those aged 75-84 and 7.42 in those aged 85 and older), while the number of symptoms reported to have lasted more than 6 months increased (2.93, 3.15, 3.24 and 3.52). In both cancer and non-cancer patients the proportion of symptoms reported to have been 'very distressing' decreased with age (cancer, 45, 43, 40 and 35%; non-cancer, 39, 38, 34 and 27%). In non-cancer patients the mean number of self-care tasks the deceased had needed help with increased substantially with age (2.23, 2.50, 3.04 and 3.95); in cancer patients the mean level was higher and there was no age gradient (3.89, 3.94, 3.83 and 4.1). The prevalence of dependency on most of the seven self-care tasks in cancer patients was comparable with or higher than that in the older and most restricted non-cancer patients.

CONCLUSION

Younger cancer patients are more likely than older cancer patients to need help with relieving distressing symptoms. However, some elderly patients were reported to have had very distressing symptoms, and these patients should not be excluded from specialist palliative care services on the basis of their age. Cancer patients did not show increased dependency with age, indicating the importance of community health and social services being appropriate for and accessible by cancer patients of all ages.

Carers' health status: is it associated with their evaluation of the quality of palliative care?

The associations between measures assessing bereaved carers' health status and their perceptions of the quality of palliative care delivered by community nurses, general practitioners and hospital doctors to cancer patients in their last year of life are investigated in this paper. Analysis was conducted on a sub-sample from the Regional Study of Care for the Dying (RSCD), a survey in which relatives or friends of a random sample of deaths in 1990 in 20 health districts in England were interviewed some 10 months after the death. The sub-sample consisted of 1858 carers of people who died from cancer. The results showed statistically significant associations between bereaved carers' self-rating of health status, their psychological functioning, their experience of bereavement-related health problems, and their satisfaction with services delivered by the different providers. Further research is needed, however, to explore in-depth the nature of these associations.