Transforming end-of-life care for the 21st century: the hospice vision

The expression of 'policy' in palliative care: A critical review

The importance of 'policy' within palliative care has steadily increased over the past 25 years. Whilst this has been welcomed within the palliative care field and seen as a route to greater recognition, we focus here on a more critical perspective that challenge the effectiveness of a 'policy turn' in palliative care. Applying Bacchi's "What's the Problem Represented to Be?" (WPR) framework to data from a systematic search, we address the research question, "in what ways has 'policy' been articulated in palliative care literature?". The paper describes the construction of 'the problem' context and reflects critically on the robustness and pragmatic utility of such representations. In particular, we identify five elements as prominent and problematic: (1) a lack of empirical evidence that connects policy to practice; (2) the dominance of 'Global North' approaches; (3) the use of a policy narrative based on 'catastrophe' in justifying the need for palliative care; (4) the use of idealistic and aspirational 'calls to action'; and (5) a disengaged and antagonistic orientation to existing health systems. We conclude by suggesting that the efficacy of palliative care policy could be enhanced via greater emphases on 'Global South' perspectives, 'assets-based' approaches and attention to pragmatic implementation.

End-of-life Care for Hematological Malignancies: The ‘Technological Imperative’ and Palliative Care

Recent research indicates that hospice/ palliative care practices have not yet been integrated into the care of patients with hematological malignancies. As research in relation to palliative care and hematological malignancies is in its infancy, many of the end-of-life care practices with these diagnostic groups are based on unexamined ideas. The findings presented in this article, which are taken from recent post-doctoral research on hematological malignancies and palliative care, make a contribution to documenting information on what is happening to patients and their families in this area. In particular, the findings provide insights on issues associated with the patient and carer awareness that the patient is dying, understanding of prognosis, and the desire to die at home. Such insights are placed in the context of descriptions of the patients’ experience with treatment during the terminal stage.

Impact of Home Hospice Care on Patients with Advanced Lung Cancer: A Longitudinal Population-Based Study in Taiwan

BACKGROUND

The effectiveness of home hospice care was helping patients to die at home, and reducing symptom burden.

OBJECTIVE

The study objective was to explore the impact of home hospice care on death at home, end-of-life (EOL) care, and health care costs among patients with advanced lung cancer in their last month of life.

METHODS

Using Taiwan's National Health Insurance Claims Database, we analyzed factors associated with home hospice care using logistic regression analysis.

RESULTS

We enrolled 568 patients with advanced lung cancer under hospice care who died during 1997-2011, of which 238 (41.9%) received home hospice care. Compared with the inpatient hospice (IH) group, the home hospice (HH) group had a larger portion die at home (55.5% versus 22.1%, p < 0.001), but a smaller portion stayed in hospital more than 14 days in their last month of life (67.3% versus 40.8%, p < 0.001). The mean health care cost was less in the HH group than in the IH group (US $1,385.00 ± $1,370.00 and US $2,155.00 ± $1,739.00 [p < 0.001], respectively). Female patients' (p = 0.001) decreased hospital stay in the last month of life (p < 0.001) and longer hospice care duration (p = 0.003) were predictors of receiving home hospice care in advanced lung patients.

CONCLUSION

Home hospice care enables patients with advanced lung cancer to increase the 33.4% chance of dying at home, to spend an average of eight-days less in hospital stay, and to save 35.7% health care costs in the last month of life, compared with their counterparts with only inpatient hospice care. Female patients' decreased hospital stay and longer hospice care duration were the predictors of receiving home hospice care.

Hospice care and survival among elderly patients with lung cancer

BACKGROUND

Recently observed trends toward increasingly aggressive end-of-life care may reflect providers' concerns that hospice may hasten death.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 7879 patients aged 65 years or older who died of advanced non-small-cell lung cancer from 1991 through 1999 after surviving for at least 3 months from their cancer diagnoses. Length of hospice admission post-cancer diagnosis and indicators of aggressive end-of-life care were ascertained based on claims data. We evaluated overall survival and care near death after controlling for baseline characteristics by using propensity score (PS) and instrumental variable analyses (IVA).

RESULTS

Hospice patients were older, more likely to be non-Hispanic white and female, more likely to reside in urban areas with high hospice availability and higher socioeconomic status, more likely to be treated in a teaching hospital, and received less aggressive end-of-life care compared to nonhospice patients. Among hospice patients, those experiencing short-term hospice admissions within 3 days of death were more likely to be male, reside in urban areas, be treated in a teaching hospital, and receive more aggressive end-of-life care. PS analysis found that survival favored hospice patients slightly relative to nonhospice patients by 5.0 percentage points (25.7% versus 20.7%) at 1 year and 1.4 percentage points (6.9% versus 5.5%) at 2 years postdiagnosis (p < 0.001), while there was no significant difference between those with short- and longer duration hospice stays (p = 1.00). IVA confirmed these findings.

CONCLUSIONS

Hospice enrollment did not compromise length of survival following advanced lung cancer diagnosis.

Another form to fill in! Clients’ reflections on the hospice use of questionnaires

GOALS OF WORK

The use of validated tools is increasingly accepted as an unqualified good that is viewed as best practice in supportive care. This article begins to explore the impact of standardized questionnaire use in supportive care by presenting findings from recent qualitative research on clients' perceptions of the use of standardized assessment tools during their hospice experience.

PATIENTS AND METHODS

There were two arms to this phenomenological descriptive study: A. Interviews with hospice patients and their carers; B. Interviews with hospice staff. The results from arm A are reported in this article. This involved interviews with ten families (available patient and carer) who had hospice experience with questionnaires and ten families who were cared for without questionnaires. The interviews were audiorecorded, transcribed verbatim, and thematically analysed.

MAIN RESULTS

The research presented in this article is seminal work in the area which affirms significant concerns about the use of questionnaires in hospice practice. The evidence indicates the majority of clients dislike the use of questionnaires and points to questionnaire use being a practice built around staff, rather than client, needs. The findings also provide insight into the process of collusion by which hospice workers who are enthusiastic about the use of questionnaires can be led to believe, because of client gratitude, that the process is positive.

CONCLUSIONS

Questionnaires should not be seen as an unqualified good, and thus should not be automatically accepted as best practice within hospice or palliative care service provision.

Are we making progress? Not in haematology!

It will be shown, through the presentation of recent research findings, that haematology is a neglected area in terms of sensitive care of the dying. The Australian evidence indicates that scant progress has been made in relation to even the most basic palliative care practices such as sensitive, honest information giving or appropriate referral to the palliative system. Rather, the data show that during terminal trajectory, patients from these diagnostic groups and their families remain trapped in processes within the high-tech, curative system that are not responsive to the needs of the dying.

Qualitative findings on the experience of end-of-life care for hematological malignancies

There is a loud silence in the literature on the issues related to palliative care for hematological malignancies. This article presents information that begins to address that silence. The limited research that is available indicates that, to date, patients with a hematological malignancy and their families received scant attention with regards to the provision of palliative care. The findings presented in this article demonstrates that families are enduring considerable hardship and are left with much emotional pain and many unresolved issues when such care is not offered. It is hoped that the findings presented in this article will be used for developing effective strategies to ensure that patients with hematological malignancies and their families, no less than any others, can be afforded the dignity and respect that the appropriate provision of palliative services ensures.

Caregivers' insights on the dying trajectory in hematology oncology

It is increasingly acknowledged in the research literature that palliative care is not offered to patients with a hematologic malignancy. The evidence indicates that patients are not dying at home or in the comfort of the hospice setting but are more likely to end up in the high-tech care of an intensive care unit. The holistic, compassionate care of the hospice/palliative care philosophy is not routinely made available to either these patients or the families who care for them. However, little is known about what the end-of-life experience is for such patients and their families and how they are managing to negotiate their dying experience in a system that is designed to cure not to palliate. In particular, there is a dearth of information on what happens to the caregivers during what is characteristically a prolonged and difficult period of sustained caring within the high-tech system. This discussion presents findings from recent research that is beginning to document the experience of the dying trajectory for patients from these diagnostic groups and their families. The hope and expectation from such research is that the information will make a contribution to building multidisciplinary plans of care for hematologic malignancies during the dying trajectory, to ensure that patients and their families are appropriately referred to the palliative system or, at least, are given sensitive palliative care within the curative system.