A preliminary study of the utility of the brief hospice inventory

Role of Occupational Therapy in Pain Management

This new position statement from the American Occupational Therapy Association (AOTA) describes occupational therapy's role in pain management. AOTA asserts that occupational therapy practitioners are distinctly prepared to work independently and to contribute to interprofessional teams in the treatment of pain. Practitioners strive to ensure active engagement in meaningful occupations for clients at risk for and affected by pain.

Role of Occupational Therapy in Pain Management

The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, collectively referred to as occupational therapy practitioners (AOTA, 2020b), are distinctly prepared to work independently and to contribute to interprofessional teams in the treatment of pain. Occupational therapy practitioners work to ensure active engagement in meaningful occupations for "persons, groups, or populations (i.e., the client)" (AOTA, 2020b, p. 1) at risk for and affected by pain.

Feasibility and validity of a tool for identification of people with intellectual disabilities in need of palliative care (PALLI)

BACKGROUND

There is a need for a specific tool that supports healthcare professionals in timely identifying people with intellectual disabilities (ID) in need of palliative care. Therefore, we developed PALLI: a tool for screening deteriorating health, indicative of a limited life expectancy.

AIMS

We evaluated feasibility, construct validity and predictive validity of PALLI.

METHODS

190 people with ID likely to be in need of palliative care were included. Physicians and daily care professionals (DCPs) completed PALLI and provided information on health outcomes at baseline, after 5-6 months and after 10-12 months. Linear Mixed Models and Generalized Linear Mixed Models were used to test validity.

RESULTS

Feasibility was adequate: physicians and DCPs were able to answer most items with 'yes' or 'no' and within a short amount of time. Construct validity was promising: a higher PALLI score at baseline was related to a higher level of decline in health, a higher symptom burden, a lower quality of life and more ADL-dependency at baseline. Predictive validity: only a higher physician-reported PALLI score at baseline significantly increased risk of death within 12 months.

CONCLUSIONS

PALLI shows promising feasibility and validity and has potential as a tool for timely identifying people with ID who may benefit from palliative care.

Patient- and Caregiver-Reported Assessment Tools for Palliative Care: Summary of the 2017 Agency for Healthcare Research and Quality Technical Brief

CONTEXT

Assessment tools are data collection instruments that are completed by or with patients or caregivers and which collect data at the individual patient or caregiver level.

OBJECTIVES

The objectives of this study are to 1) summarize palliative care assessment tools completed by or with patients or caregivers and 2) identify needs for future tool development and evaluation.

METHODS

We completed 1) a systematic review of systematic reviews; 2) a supplemental search of previous reviews and Web sites, and/or 3) a targeted search for primary articles when no tools existed in a domain. Paired investigators screened search results, assessed risk of bias, and abstracted data. We organized tools by domains from the National Consensus Project Clinical Practice Guidelines for Palliative Care and selected the most relevant, recent, and highest quality systematic review for each domain.

RESULTS

We included 10 systematic reviews and identified 152 tools (97 from systematic reviews and 55 from supplemental sources). Key gaps included no systematic review for pain and few tools assessing structural, cultural, spiritual, or ethical/legal domains, or patient-reported experience with end-of-life care. Psychometric information was available for many tools, but few studies evaluated responsiveness (sensitivity to change) and no studies compared tools.

CONCLUSION

Few to no tools address the spiritual, ethical, or cultural domains or patient-reported experience with end-of-life care. While some data exist on psychometric properties of tools, the responsiveness of different tools to change and/or comparisons between tools have not been evaluated. Future research should focus on developing or testing tools that address domains for which few tools exist, evaluating responsiveness, and comparing tools.

Patient reported outcome measures of quality of end-of-life care: A systematic review

End-of-life (EoL) care¹ is increasingly used as a generic term in preference to palliative care or terminal care, particularly with reference to individuals with chronic disease, who are resident in community and long-term care (LTC) settings. This review evaluates studies based on patient reported outcome measures (PROMS) of quality of EoL care across all health-care settings. From 1041 citations, 12 studies were extracted by searches conducted in EBSCO, Scopus, Web of Science, PubMed, Cochrane, Open Grey and Google Scholar databases. At present, the evidence base for EoL care is founded on cancer care. This review highlights the paucity of studies that evaluate quality of EoL care for patients with chronic disease outside the established cancer-acute care paradigm, particularly in LTC. This review highlights the absence of any PROMs for the estimated 60% of patients in LTC with cognitive impairment. Patient-reported outcomes (PROs) are critical to understanding how EoL care services and practices affect patients' health and EoL experience. PROMs describe the quality of care from the patient's perspective and add balance to existing clinical or proxy-derived knowledge on the quality of care and services provided.

A critical analysis of test-retest reliability in instrument validation studies of cancer patients under palliative care: a systematic review

BACKGROUND

Patient-reported outcome validation needs to achieve validity and reliability standards. Among reliability analysis parameters, test-retest reliability is an important psychometric property. Retested patients must be in a clinically stable condition. This is particularly problematic in palliative care (PC) settings because advanced cancer patients are prone to a faster rate of clinical deterioration. The aim of this study was to evaluate the methods by which multi-symptom and health-related qualities of life (HRQoL) based on patient-reported outcomes (PROs) have been validated in oncological PC settings with regards to test-retest reliability.

METHODS

A systematic search of PubMed (1966 to June 2013), EMBASE (1980 to June 2013), PsychInfo (1806 to June 2013), CINAHL (1980 to June 2013), and SCIELO (1998 to June 2013), and specific PRO databases was performed. Studies were included if they described a set of validation studies. Studies were included if they described a set of validation studies for an instrument developed to measure multi-symptom or multidimensional HRQoL in advanced cancer patients under PC. The COSMIN checklist was used to rate the methodological quality of the study designs.

RESULTS

We identified 89 validation studies from 746 potentially relevant articles. From those 89 articles, 31 measured test-retest reliability and were included in this review. Upon critical analysis of the overall quality of the criteria used to determine the test-retest reliability, 6 (19.4%), 17 (54.8%), and 8 (25.8%) of these articles were rated as good, fair, or poor, respectively, and no article was classified as excellent. Multi-symptom instruments were retested over a shortened interval when compared to the HRQoL instruments (median values 24 hours and 168 hours, respectively; p = 0.001). Validation studies that included objective confirmation of clinical stability in their design yielded better results for the test-retest analysis with regard to both pain and global HRQoL scores (p < 0.05). The quality of the statistical analysis and its description were of great concern.

CONCLUSION

Test-retest reliability has been infrequently and poorly evaluated. The confirmation of clinical stability was an important factor in our analysis, and we suggest that special attention be focused on clinical stability when designing a PRO validation study that includes advanced cancer patients under PC.

Initial Assessment of Patients Without Cognitive Failure Admitted in Palliative Care

Aim:

To develop a screening tool that was short, not time consuming but able to detect the patients’ main problems at admission.

Methods:

A list of 106 symptoms/problems derived from a review of the literature was created and shortened using a Delphi process.

Results:

Thirteen experts scored each item with a numeric rating scale of 0 to 10 for relevance. After 3 rounds, the list was shortened to 14 items: general question—what bothers you the most? symptoms/problems—pain, lack of appetite, vomiting, tiredness/fatigue, nausea, constipation, shortness of breath, depression, anxiety, difficulty sleeping; activity (dressing, washing, etc); support from family/friends; and well-being.

Conclusion:

The final tool is short and seems to include the relevant items that would make it useful for clinical practice.

An examination of adherence to pain medication plans in older cancer patients in hospice care

CONTEXT

Timely and appropriate management of pain is essential to promote comfort at the end of life.

OBJECTIVES

To determine if pain-related factors and nonpharmacologic interventions affect medication adherence in older cancer patients in community-based hospices.

METHODS

The study involved cancer patients aged 55 years and older, newly admitted to one of the 13 community-based hospices in the midwestern U.S. A descriptive design with patients or their proxies providing information during two telephonic interviews and review of their hospice medical records were used.

RESULTS

A total sample of 65 patients was obtained, with data directly from 32 patients during Interview 1 (T(1)), 25 during Interview 2 (T(2)), and proxy reports for 33 (T(1)) and 30 (T(2)) patients. The overall mean pain medication adherence scores (maximum 9) for all patients were 8.43 (T(1)) and 8.38 (T(2)). For component analysis (three components; maximum of three points each), patients were the least adherent with opioid orders at both time points (2.65). Patients were the most adherent to nonsteroidal anti-inflammatory/acetaminophen orders at T(1) (2.91) and medications for neuropathic pain at T(2) (2.89). Data provided statistical evidence that patients with more hours of controlled pain in the past 24 hours were more likely to have had better adherence, whereas patients with higher levels of comfort over the last few days were more likely to have had worse adherence.

CONCLUSION

This study identified that pain medication adherence among older adults with cancer receiving hospice care is high. However, hospices must be alert to the fact that even as patients become more comfortable, adherence must continue to be emphasized to ensure that pain does not redevelop or exacerbate, if pain relief is a patient priority.

The relationships among pain, nonpain symptoms, and quality of life measures in older adults with cancer receiving hospice care

OBJECTIVE

Gathering firsthand or reported information about patients in the final stages of terminal cancer is difficult due to patient frailty, cognitive impairment, excessive fatigue, and severity of illness, as well as gatekeeping by hospice providers and caregivers, and highly variable documentation practices. We sought to further understand and elucidate end-of-life experiences in older cancer patients through the application of validated tools employed in the hospice setting. This article summarizes data collected about pain, non-pain symptoms, and other aspects of quality of life (QOL) as reported by older hospice patients or by their caregivers during the 2 weeks of hospice care.

DESIGN

Data was collected from an ongoing Institutional Human Subjects Review Board-approved research project with 94 older adults with cancer or their caregivers receiving service in a home setting from 14 Midwestern hospices. Participants completed one or two telephone interviews. Instruments used to gather information include the Brief Pain Inventory and the Brief Hospice Inventory.

RESULTS

Data analysis showed mean "worst pain" ratings significantly decreased from Interview 1 to Interview 2, and pain reports were significantly correlated with fatigue, anxiety, appetite, comfort, symptom control, and overall QOL.

CONCLUSIONS

Our findings reinforce previously held views that older patients with cancer experience pain and non-pain symptoms. And both pain and non-pain symptoms can impact and confound the treatment of other symptoms and interfere with the patient's overall QOL. The results of this study support the assertion that hospice care can have a positive impact on pain severity and related suffering, as well as patient QOL as death approaches.

Development and initial validation of the Three-Levels-of-Needs Questionnaire for self-assessment of palliative needs in patients with cancer

CONTEXT

To improve palliative care, it is important that questionnaires accurately assess the needs of the patients. No questionnaire existed that combined three different and important approaches to needs assessment. We developed such a questionnaire, called the Three-Levels-of-Needs Questionnaire (3LNQ), based on literature searches. The 3LNQ measures 12 important needs with three different approaches when used as a supplement to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30): problem intensity, problem burden, and felt need.

OBJECTIVES

To investigate the initial validity of the 3LNQ.

METHODS

We used a relatively new method that investigates whether the questionnaire has the same meaning for the patients as for the researchers. To do this, 74 patients with advanced cancer filled out the questionnaire and participated in an open-ended interview. The patients' responses to the questionnaire before the interview were compared against the researchers' responses based on the interviews. Items showing substantial agreement were accepted as valid without further analysis. For the remaining items, reasons for disagreements were analyzed qualitatively.

RESULTS

All items on problem intensity, eight of 12 items on problem burden, and three of 12 items on felt need were accepted as valid because of high agreement. Analysis of the qualitative data concerning the remaining items showed that most disagreements did not indicate problems with the patients' self-assessment. Instead, different causes for disagreements were elucidated, but these did not interfere with validity.

CONCLUSION

The 3LNQ appears to measure palliative needs comprehensively, and this initial validation showed satisfactory results. The analysis gave important insights into the patients' perceptions of their own situations, into their expectations of the health care system, and into the complexity of needs assessment.

Palliative care symptom assessment for patients with cancer in the emergency department: validation of the Screen for Palliative and End-of-life care needs in the Emergency Department instrument

OBJECTIVE

We sought to develop and validate a novel palliative medicine needs assessment tool for patients with cancer in the emergency department.

METHODS

An expert panel trained in palliative medicine and emergency medicine reviewed and adapted a general palliative medicine symptom assessment tool, the Needs at the End-of-Life Screening Tool. From this adaptation a new 13-question instrument was derived, collectively referred to as the Screen for Palliative and End-of-life care needs in the Emergency Department (SPEED). A database of 86 validated symptom assessment tools available from the palliative medicine literature, totaling 3011 questions, were then reviewed to identify validated test items most similar to the 13 items of SPEED; a total of 107 related questions from the database were identified. Minor adaptations of questions were made for standardization to a uniform 10-point Likert scale. The 107 items, along with the 13 SPEED items were randomly ordered to create a single survey of 120 items. The 120-item survey was administered by trained staff to all patients with cancer who met inclusion criteria (age over 21 years, English-speaking, capacity to provide informed consent) who presented to a large urban academic emergency department between 8:00 am and 11:00 pm over a 10-week period. Data were analyzed to determine the degree of correlation between SPEED items and the related 107 selected items from previously validated tools.

RESULTS

A total of 53 subjects were enrolled, of which 49 (92%) completed the survey in its entirety. Fifty-three percent of subjects were male, age range was 24-88 years, and the most common cancer diagnoses were breast, colon, and lung. Cronbach coefficient α for the SPEED items ranged from 0.716 to 0.991, indicating their high scale reliability. Correlations between the SPEED scales and related assessment tools previously validated in other settings were high and statistically significant.

CONCLUSION

The SPEED instrument demonstrates reliability and validity for screening for palliative care needs of patients with cancer presenting to the emergency department.

The measurement of spirituality in palliative care and the content of tools validated cross-culturally: a systematic review

CONTEXT

Despite the need to assess spiritual outcomes in palliative care, little is known about the properties of the tools currently used to do so. In addition, measures of spirituality have been criticized in the literature for cultural bias, and it is unclear which tools have been validated cross-culturally.

OBJECTIVES

This systematic review aimed to identify and categorize spiritual outcome measures validated in advanced cancer, human immunodeficiency virus (HIV), or palliative care populations; to assess the tools' cross-cultural applicability; and for those measures validated cross-culturally, to determine and categorize the concepts used to measure spirituality.

METHODS

Eight databases were searched to identify relevant validation and research studies. An extensive search strategy included search terms in three categories: palliative care, spirituality, and outcome measurement. Tools were evaluated according to two criteria: 1) validation in advanced cancer, HIV, or palliative care and 2) validation in an ethnically diverse context. Tools that met Criterion 1 were categorized by type; tools that also met Criterion 2 were subjected to content analysis to identify and categorize the spiritual concepts they use.

RESULTS

One hundred ninety-one articles were identified, yielding 85 tools. Fifty different tools had been reported in research studies; however, 30 of these had not been validated in palliative care populations. Thirty-eight tools met Criterion 1: general multidimensional measures (n=21), functional measures (n=11), and substantive measures (n=6). Nine measures met Criterion 2; these used spiritual concepts relating to six themes: Beliefs, practices, and experiences; Relationships; Spiritual resources; Outlook on life/self; Outlook on death/dying; and Indicators of spiritual well-being. A conceptual model of spirituality is presented on the basis of the content analysis. Recommendations include consideration of both the clinical and cultural population in which spiritual instruments have been validated when selecting an appropriate measure for research purposes. Areas in need of further research are identified.

CONCLUSION

The nine tools identified in this review are those that have currently been validated in cross-cultural palliative care populations and, subject to appraisal of their psychometric properties, may be suitable for cross-cultural research.

Evaluation of quality-of-life measures for use in palliative care: a systematic review

PURPOSE

In this literature review we evaluated the feasibility and clinimetric quality of quality-of-life (QoL) measurement instruments suitable for use in palliative care.

METHODS

We conducted a systematic literature review to identify instruments measuring (at least one domain of) QoL. We selected articles that present data on patients receiving palliative care and at least one measurement property. A checklist was used to describe the characteristics of the instruments, and a widely accepted rating list was used to evaluate the clinimetric aspects.

RESULTS

29 instruments were identified and evaluated, most of which were targeted at palliative patients in general. None of the instruments demonstrated satisfactory results for all measurement properties. Fourteen instruments received positive ratings for construct validity. Thirteen instruments were tested for reliability, but only two were tested adequately and had positive results (ICC>0.70). Responsiveness was not tested adequately for any of the instruments. Very few of the studies provided information on the interpretation of the scores. Overall, the MQOL, followed by the QUAL-E and the QODD, received the best ratings for their measurement properties.

CONCLUSIONS

Many measurement instruments were identified, but most had not yet been adequately evaluated. The evaluation of existing instruments with good content validity should have priority over the development of new instruments.

Critical care nurses provide their perspectives of patients' symptoms in intensive care units

BACKGROUND

Patients in intensive care units (ICUs) can be adversely affected by distressing symptoms. When critically ill patients are unable to self-report symptoms, ICU nurses become proxy reporters.

OBJECTIVE

The purpose of this prospective, descriptive study was to explore how ICU nurses assess and treat distressing symptoms in critically ill patients at high risk of dying.

METHODS

Twenty-two nurses participated in this single-site, prospective, descriptive study and described their patients' symptoms and how the symptoms were being managed in response to interviews that used open-ended questions. Taped interviews were transcribed verbatim, and themes were identified.

RESULTS

Three major themes were derived from the data: 1) signs of symptoms, (2) treatment of symptoms, and (3) "symptoms" versus "signs." Most nurses did not make distinctions between the assessment of "signs" of disease and the assessment of "symptoms," and consequently, signs and symptoms were frequently inventoried collectively.

CONCLUSION

Critically ill patients experience a broad range of symptoms. Continued attempts to validate nonverbal measures of symptoms are warranted because lack of such measures may adversely affect symptom treatment for critically ill patients. Furthermore, heightened awareness and increased education of nurses to differentiate between signs and symptoms lay the foundation for increasing attention on symptoms, improving accuracy of symptom assessment, and guiding appropriate symptom management.

Assessing physical functioning: a systematic review of quality of life measures developed for use in palliative care

BACKGROUND

Physical decline is experienced by all palliative care patients and affects most aspects of life. Physical functioning (PF) is therefore a crucial domain for quality of life (Qol) assessments. The purpose of this study was to review how PF assessments are performed in Qol instruments developed for palliative care

METHODS

For identification of instruments, Medline searches up to April 2005 were performed using the terms (palliative care OR end of life care OR terminal care) AND quality of life AND (assessment OR instrument OR questionnaire). A total of 1326 hits were screened. Named QoL instruments were extracted from 240 abstracts and 46 relevant reports. Items assessing PF were then identified and classified according to activity domains as described by the WHO International Classification of Functioning Disability and Health.

RESULTS

Of 224 different instruments detected, 39 were identified as developed for palliative care. Of these, 11 included original PF assessments. Two were comprehensive performance status measures made for staff assessment, 9 were multidimensional tools including 2-7 PF items. The content and phrasing of items varied considerably. All instruments included some aspects of self-care, whereas the coverage of mobility, domestic, work--and leisure activities was inconsistent.

INTERPRETATION

Despite its importance, PF assessment seems to be a minor part of palliative care QoL instruments. Clear definitions and conceptualization of PF are needed, as well as a consensus on relevant aspects to include in improved instruments. Performance scales already developed should be further explored with regard to content, validity and psychometric properties.

A systematic review of measures of end-of-life care and its outcomes

OBJECTIVE

To identify psychometrically sound measures of outcomes in end-of-life care and to characterize their use in intervention studies.

DATA SOURCES

English language articles from 1990 to November 2005 describing measures with published psychometric data and intervention studies of end-of-life care.

STUDY DESIGN

Systematic review of end-of-life care literature.

EXTRACTION METHODS

Two reviewers organized identified measures into 10 major domains. Eight reviewers extracted and characterized measures from intervention studies.

PRINCIPAL FINDINGS

Of 24,423 citations, we extracted 200 articles that described 261 measures, accepting 99 measures. In addition to 35 measures recommended in a prior systematic review, we identified an additional 64 measures of the end-of-life experience. The most robust measures were in the areas of symptoms, quality of life, and satisfaction; significant gaps existed in continuity of care, advance care planning, spirituality, and caregiver well-being. We also reviewed 84 intervention studies in which 135 patient-centered outcomes were assessed by 97 separate measures. Of these, 80 were used only once and only eight measures were used in more than two studies.

CONCLUSIONS

In general, most measures have not undergone rigorous development and testing. Measure development in end-of-life care should focus on areas with identified gaps, and testing should be done to facilitate comparability across the care settings, populations, and clinical conditions. Intervention research should use robust measures that adhere to these standards.

How can occupational therapists measure outcomes in palliative care?

The objective of this paper is to identify an outcome measure for occupational therapy interventions with palliative clients, in particular Home Assessments. Several possibilities beyond traditional functional measures are considered, and the notion of quality of life (QoL) as a potential measure and routine part of assessment is discussed.A systematic literature search resulted in 45 QoL tools that might be suitable for palliative care. The validation or development papers for these tools were closely examined. Twenty-four instruments met the inclusion criteria for further consideration for use by occupational therapists. The research found that it may be feasible for occupational therapists to use a QoL tool as a routine part of assessing each palliative patient, with the objective of focusing interventions to priority areas identified by the patient. Further work in this area will identify a range of established and validated methods of assessing QoL, suitable for different stages within the palliative phase of illness for purposes including assessment, support and targeted interventions.

Toward evidence-based prescribing at end of life: a comparative analysis of sustained-release morphine, oxycodone, and transdermal fentanyl, with pain, constipation, and caregiver interaction outcomes in hospice patients

OBJECTIVE

The primary goal of this investigation was to examine selected outcomes in hospice patients who are prescribed one of three sustained-release opioid preparations. The outcomes examined include: pain score, constipation severity, and ability of the patient to communicate with caregivers.

PATIENTS AND SETTINGS

This study included 12,000 terminally ill patients consecutively admitted to hospices and receiving pharmaceutical care services between the period of July 1 and December 31, 2002.

DESIGN

We retrospectively examined prescribing patterns of sustained-release morphine, oxycodone, and transdermal fentanyl. We compared individual opioids on the aforementioned outcome markers, as well as patient gender, terminal diagnosis, and median length of stay.

RESULTS

Patients prescribed a sustained-release opioid had similar average ratings of pain and constipation severity, regardless of the agent chosen. Patients prescribed transdermal fentanyl were reported to have more difficulty communicating with friends and family when compared with patients prescribed either morphine or oxycodone. On average, patients prescribed transdermal fentanyl had a shorter length of stay on hospice as compared with those receiving morphine or oxycodone.

CONCLUSION

There was no difference in observed pain or constipation severity among patients prescribed sustained-release opioid preparations. Patients receiving fentanyl were likely to have been prescribed the medication due to advanced illness and associated dysphagia. Diminished ability to communicate with caregivers and a shorter hospice course would be consistent with this profile. Further investigation is warranted to examine the correlation between a patient's ability to interact with caregivers and pain control achieved.

Confirmation of the "disability paradox" among hospice patients: preservation of quality of life despite physical ailments and psychosocial concerns

OBJECTIVE

The purpose of this study was to describe quality of life (QOL) and psychosocial and spiritual issues among patients receiving hospice care.

METHODS

A questionnaire addressing QOL, spirituality, optimism, loss, fears about the terminal process and death anxiety was administered to 66 adults receiving care from 14 hospices. The physical components of QOL (physical symptoms and physical well-being) were rated lower than the psychosocial and spiritual aspects (support, existential well-being, psychological symptoms).

RESULTS

Respondents had a strong spiritual connection and a strong sense of hope. Although these individuals did not express anxiety or fear about death, there were concerns about the dying process itself. Also, although most felt at ease with their current situation, respondents were concerned about how their illness was affecting their family. Financial and legal issues did not concern most of these individuals.

SIGNIFICANCE OF RESULTS

There were few significant associations between patient characteristics and the QOL or other psychosocial or spiritual issues addressed. Among this older terminally ill population receiving hospice care, whose functional status was fair and for whom physical symptoms were troublesome, QOL persisted and a positive outlook prevailed.

Hospice: Comprehensive Care at the End of Life

Hospice is a health care service delivery system that provides palliative care for patients who have a limited life expectancy and require comprehensive biomedical, psychosocial, and spiritual support. This article reviews the indications and provisions for hospice care for all age groups, including issues of prognosis and the role of the physician on the hospice interdisciplinary team. Because most deaths in the United States result from chronic progressive illnesses (eg, cancer and cardiovascular, cerebrovascular, pulmonary, and neurodegenerative diseases) that affect older individuals, discussion focuses on the provisions of the Medicare Hospice Benefit, which has become an important entitlement in efforts to improve care of the dying in this country.

The Evolving and Important Role of Anesthesiology in Palliative Care

A small but clinically significant proportion of dying patients experience severe physically or psychologically distressing symptoms that are refractory to the usual first-line therapies. Anesthesiologists, currently poorly represented in the rapidly evolving specialties of hospice and palliative medicine, are uniquely qualified to contribute to the comprehensive care of patients who are in this category. Anesthesiologists' interpersonal capabilities in the management of patients and families under duress, their knowledge and comfort level with the application of potent analgesic and consciousness-altering pharmacology, and their titrating and monitoring skills would add a valuable dimension to palliative care teams. This article summarizes the state of the art and means by which anesthesiologists might contribute to improvements in the important end-of-life outcome of safe and comfortable dying.

Symptom control outcomes in a community palliative care nursing team

Measuring outcomes of care is an essential component of clinical governance. This article describes a pragmatic approach to auditing symptom control outcomes in a community specialist palliative care nursing team. Using a palliative care assessment tool, it demonstrates that the team make a positive difference to the patient's experience of most symptoms and a plan for further development of practice is formulated in response to the results of the audit. Unexpected outcomes reveal some of the realities of community specialist palliative care and demonstrate that audit is worthwhile despite some of the pitfalls in this area of practice.