Death from cancer at home: the carers' perspective

What do patients and oncologists think about the evaluation and management of cancer-related anorexia-cachexia? The Quasar_SEOM study

INTRODUCTION

Cancer patients often suffer from malnutrition and early detection and raising awareness of nutritional issues is crucial in this population.

METHODS

The Spanish Oncology Society (SEOM) conducted the Quasar_SEOM study to investigate the current impact of the Anorexia-Cachexia Syndrome (ACS). The study employed questionnaires and the Delphi method to gather input from both cancer patients and oncologists on key issues related to early detection and treatment of ACS. A total of 134 patients and 34 medical oncologists were surveyed about their experiences with ACS. The Delphi methodology was used to evaluate oncologists' perspectives of ACS management, ultimately leading to a consensus on the most critical issues.

RESULTS

Despite widespread acknowledgement of malnutrition in cancer as a significant issue by 94% of oncologists, the study revealed deficiencies in knowledge and protocol implementation. A mere 65% of physicians reported being trained to identify and treat these patients, with 53% failing to address ACS in a timely manner, 30% not monitoring weight, and 59% not adhering to any clinical guidelines. The lack of experience was identified as the primary hindrance to the use of orexigens in 18% of cases. Furthermore, patients reported concerns and a perception of inadequate attention to malnutrition-related issues from their physicians.

CONCLUSION

The results of this study point to a gap in the care of this syndrome and a need to improve education and follow-up of cancer patients with anorexia-cachexia.

Palliative care utilisation: family carers' behaviours and determinants-a qualitative interview study

OBJECTIVES

Most research on starting palliative care focuses on the role of healthcare services and professional carers. However, patients and their family carers may also play a role. Especially opportunities for starting palliative care might exist among family carers. This study focused on family carers by identifying their behaviours and underlying determinants that might contribute to starting palliative care.

METHODS

A qualitative study with 16 family carers of deceased persons who used palliative care was conducted using semistructured, face-to-face interviews. Constant comparison analysis was used to identify groups of behaviours that influenced starting palliative care and related determinants. The behavioural determinants were matched with concepts in existing behavioural theories. A preliminary behavioural model was developed.

RESULTS

Most reported behaviours regarding starting palliative care were related to communicating with the seriously ill person, other family members and professional carers; seeking information and helping the seriously ill person process information from professional carers; and organising and coordinating care. Determinants facilitating and hindering these behaviours included awareness (eg, of poor health), knowledge (eg, concerning palliative care), attitudes (eg, negative connotations of palliative care) and social influences (eg, important others' opinions about palliative care).

CONCLUSIONS

This study identified relevant family carers' behaviours and related determinants that can contribute to starting palliative care. As these determinants are changeable, the palliative care behavioural model that resulted from this study can serve as a basis for the development of behavioural interventions aiming at supporting family carers in performing behaviours that might contribute to starting palliative care.

The Management of Terminal Illness: Opinions of the Medical and Nursing Staff in a Paris University Hospital

The views of French physicians and nurses of the organization of palliative care have not been previously analyzed. We surveyed opinion on the care of the terminally ill in a 1000-bed Paris university hospital. Data were obtained in 1992 by non-directed interviews of leading physicians and semi-directed interviews of nurses. Most physicians wished to manage terminal care in their departments. Patient and family preferences were considered in choosing the place for care. Treatment of hospitalized patients should be limited to relieving symptoms. Department heads and senior nurses agreed on most problems encountered in the management of care. The psychological burden borne by nurses was emphasized. Terminal care training and the possibility of consulting experts in palliative care were the main suggestions for improvement cited by both department heads and senior nurses. Integrating this knowledge into the planning process should result in improved care and in increased satisfaction for the care providers.

An Evaluation of Systematic Reviews of Palliative Care Services

This review aimed to identify and appraise all systematic reviews of palliative care services, to examine their findings in relation to methods used, and to explore whether further methods such as meta-analysis and meta-regression may be worthwhile. Ten databases were searched and augmented by hand searching specific journals, contacting authors, and examining the reference lists of all papers retrieved. Five systematic reviews met the inclusion criteria, and the update electronic search identified a further systematic review which found similar studies. A total of 39 studies were identified by the five systematic reviews. Of the 39 studies, 15 were RCTS, and 12 of those were North American. In comparison, the majority of U.K. studies were retrospective. Each review concluded similarly that there was a lack of good quality evidence on which to base conclusions. The more recent reviews were more rigorous, but none used a quantitative analysis. Despite the difficulties in combining heterogeneous interventions and outcomes in meta-analysis or meta-regression, such techniques may be valuable. More high quality evidence is needed to compare the relative merits of the differences in models of palliative care services, so that countries can learn from other appropriate systems of care at end of life.

Receiving Bad News: Experiences of Family Members

Little is known about how next-of-kin experience receiving bad news. The aim of this study was to explore the experiences of family members when receiving information about ending tumour treatment, with a focus on their role in this context.

Methods

Semi-structured interviews were performed and analyzed using a qualitative phenomenographic method.

Results

Twenty family members of patients with incurable progressive cancer admitted to hospital-based home care were included in the study. Data showed that family members want to protect, represent, or act on behalf of the patient. Some described themselves as assuming prominent roles: the demander-of-truth role, the secret-keeper role, and the controller role. Others assumed more passive roles: the surrendering role, the considerate listener role, and the excluded outsider role.

Conclusion

This study has revealed possible explanations as to why family members are dissatisfied with information. The results of this study may help doctors in clinical practice recognize the different types of behaviour family members exhibit when receiving bad news.

Dying of Non-Malignant Diseases in General Practice

Recent policy changes within the British National Health Service have encouraged the provision of care within the community. The objective of this study was to explore the needs of informal caregivers of people with non-malignant diseases who wished to remain in their own homes until death. Semi-structured interviews with a non-random sample of 20 bereaved carers from 14 surgeries, their general practitioners, and district nurses were analyzed to discover the extent and quality of the care provided by the primary care team. One quarter of the doctors considered that palliative care applied exclusively to people with cancer. One half of the doctors felt that palliative care was primarily concerned with pain relief. Both doctors and nurses believed that their role was that of coordinating care for the patient. Carers were reluctant to criticize professional caregivers, but the results of this study suggest that carers need help with the burden of caring, including emotional support, advice and information regarding social services and financial benefits, and recognition of their caring role. Palliative care is not exclusive to people with cancer but should be extended to people with non-malignant diseases, encompassing not only symptom relief but also explicitly including emotional or spiritual support, care of the family, and support in preparing for the end of life.

Helping lay carers of people with advanced cancer and their GPs to talk: an exploration of Australian users' views of a simple carer health checklist

The lay caregiving role is integral to advanced cancer care but places carers' health at risk. A supportive General Practitioner (GP) can help primary lay carers manage their health, if they disclose their concerns. A Needs Assessment Tool for Caregivers (NAT-C) was developed for carers to self-complete and use as the basis of a GP consultation, then tested in a randomised controlled trial. This paper reports a qualitative research study to determine the usefulness and acceptability of the NAT-C in the Australian primary care setting. Convenience samples of 11 carers and 5 GPs were interviewed between September 2010 and December 2011 regarding their experiences with and perceptions of the NAT-C. Open-ended questions were used, and the transcripts were analysed qualitatively to identify themes and patterns. Three major themes were identified: (a) Acceptability of the intervention; (b) Impact of the intervention on the GP-patient relationship; and (c) Place of the intervention in advanced cancer care. This simple checklist was acceptable to carers, although some were uncertain about the legitimacy of discussing their own needs with their GP. Carer-patients could not be certain whether a GP would be willing or equipped to conduct a NAT-C-based consultation. Such consultations were acceptable to most GPs, although some already used a holistic approach while others preferred brief symptom-based consultations. Although the NAT-C was acceptable to most carers and GPs, supportive consultations take time. This raises organisational issues to be addressed so carers can seek and benefit from their GP's support.

Development of an Assessment to Examine Training of the Hospice Primary Caregiver

BACKGROUND

Key to high-quality care of dying hospice patients at home is whether the hospice provides adequate training so the caregiver can safely care for the patient.

OBJECTIVE

The study objective was to develop and validate a survey of hospice training for caregivers to ensure safe, high-quality care in the home setting.

DESIGN

Our survey design was cross-sectional. Bereaved respondents of individuals who died at home under the care of hospice were surveyed three to six months postdeath.

MEASUREMENTS

Items were developed based on advice of an expert panel, focus groups of hospice caregivers, and literature review, with 12 items developed for testing and examining 8 key processes of care. We examined the validity and reliability of the assessment using factor analysis, correlational analyses, and multivariable modeling.

RESULTS

Our sample consisted of 262 primary caregivers (mean age 62.4, 76.7% female, 58.8% non-Hispanic white). Six questions focused on providing the caregiver with information, while another six focused on the training that hospice provided. Based on model fit and Cronbach's alpha, we dropped the information items. The items that examined hospice training demonstrated a one-factor solution and a Cronbach's of 0.90. We examined correlations of the multi-item composite with overall rating of quality of care (0.53), overall distress (0.31), and whether the respondent would recommend this hospice to others (0.49). There were no significant sociodemographic correlates of concerns with training.

CONCLUSIONS

Sufficient preliminary reliability and validity warrants further testing of this composite to examine the adequacy of training provided to family members to care safely for the patient.

Psychosocial Interventions for Patients With Advanced Cancer and Their Families

Few randomized controlled trials of family-based psychosocial interventions involving patients and at least one other family member have been conducted in the context of advanced cancer. Moreover, existing interventions have largely been stand-alone programs that have not been well integrated into routine palliative and clinical care. Programs that address this gap may not only improve patient and caregiver quality of life (QOL) but also the quality of palliative and supportive care services. The aim of this narrative review is to describe published interventions that have attempted to improve the QOL of advanced cancer patients and their family caregivers (eg, spouses, partners, and other family members) and to describe some of the challenges that make it difficult to implement such programs in clinical settings. Toward that end, the added value that family-based psychosocial interventions can bring to advanced cancer care is first described. Next, the literature on family-based interventions in advanced cancer is reviewed, and different theoretical approaches and outcomes are highlighted. This is followed by a description of some of the health system barriers to supportive family care in advanced cancer care. The article concludes with a synthesis of research findings and proposes directions for future research.

Delivery strategies to optimize resource utilization and performance status for patients with advanced life-limiting illness: results from the "palliative care trial" [ISRCTN 81117481]

CONTEXT

Evidence-based approaches are needed to improve the delivery of specialized palliative care.

OBJECTIVES

The aim of this trial was to improve on current models of service provision.

METHODS

This 2×2×2 factorial cluster randomized controlled trial was conducted at an Australian community-based palliative care service, allowing three simultaneous comparative effectiveness studies. Participating patients were newly referred adults, experiencing pain, and who were expected to live >48 hours. Patients enrolled with their general practitioners (GPs) and were randomized three times: 1) individualized interdisciplinary case conference including their GP vs. control, 2) educational outreach visiting for GPs about pain management vs. control, and 3) structured educational visiting for patients/caregivers about pain management vs. control. The control condition was current palliative care. Outcomes included Australia-modified Karnofsky Performance Status (AKPS) and pain from 60 days after randomization and hospitalizations.

RESULTS

There were 461 participants: mean age 71 years, 50% male, 91% with cancer, median survival 179 days, and median baseline AKPS 60. Only 47% of individuals randomized to the case conferencing intervention received it; based on a priori-defined analyses, 32% of participants were included in final analyses. Case conferencing reduced hospitalizations by 26% (least squares means hospitalizations per patient: case conference 1.26 [SE 0.10] vs. control 1.70 [SE 0.13], P=0.0069) and better maintained performance status (AKPS case conferences 57.3 [SE 1.5] vs. control 51.7 [SE 2.3], P=0.0368). Among patients with declining function (AKPS <70), case conferencing and patient/caregiver education better maintained performance status (AKPS case conferences 55.0 [SE 2.1] vs. control 46.5 [SE 2.9], P=0.0143; patient/caregiver education 54.7 [SE 2.8] vs. control 46.8 [SE 2.1], P=0.0206). Pain was unchanged. GP education did not change outcomes.

CONCLUSION

A single case conference added to current specialized community-based palliative care reduced hospitalizations and better maintained performance status. Comparatively, patient/caregiver education was less effective; GP education was not effective.

Consultation etiquette in general practice: a qualitative study of what makes it different for lay cancer caregivers

Background

It is commonplace for lay caregivers to overlook their own health concerns when supporting someone with advanced cancer. During this time, caregivers' needs as patients are often marginalised by health professionals, including General Practitioners (GPs), who may miss the breadth of caregivers' needs by focusing on the practicalities of caregiving. GPs traditionally rely on patients to raise their concerns, and then respond to these concerns, but caregivers as patients may be disinclined to cue their GP. The norms of engagement when caregivers consult their GP are less defined, and how they interact with their GP regarding their own health is under-explored. This sub-study investigates the norms, assumptions and subtleties which govern caregiver-GP consultations, and explores factors affecting their interaction regarding caregivers' own health concerns.

Methods

We conducted semi-structured interviews with six lay caregivers and 19 health professionals in Brisbane, Australia, and analyzed the interview transcripts thematically.

Results

Traditional norms of engagement are subjected to assumptions and expectations which caregivers and GPs bring to the consultation. Practice pressures also influence both parties' capacity and willingness to discuss caregivers' health. Nonetheless, some GPs monitor caregivers' health opportunistically. Their interaction is enhanced by the quality of the caregiver-GP relationship and by the GP's skills.

Conclusions

Caregivers are caught in a paradox whereby their health needs may become subsumed by the care recipient's needs in a setting where patient needs are normally scrutinised and supported. Caregivers may not raise their health concerns with their GP, who instead may need to cue them that it is timely and safe to do so. The routine use of a prompt may help to address caregivers' needs systematically, but it needs to be complemented by GPs' desire and capacity to engage with patients in a caregiving role. The potential difference GPs can make to the health of these patients is substantial.

The meaning of being in transition to end-of-life care for female partners of spouses with cancer

Objective:

Female partners of cancer patients are at high risk for psychological distress. However, the majority of studies have focused on measurement of female partners' psychological distress during diagnosis and early treatment. There is a gap in the literature with regard to qualitative studies that examine the experiences of female partners of spouses with cancer during the transition to end-of-life care. The purpose of this qualitative study was to explore the meaning of being in transition to end-of-life care among female partners of spouses with cancer.

Methods:

An interpretive phenomenological approach based on Gadamer's (1960/1975) philosophy was used to gain a deeper understanding of the phenomenon of end-of-life transition. Eight female partners from two in-patient hospices and a community-based palliative care service were interviewed using a semistructured approach.

Results:

Three major themes and associated subthemes were identified that outlined female partners' experiences. One major theme, Meaning of Our Lives, included the subthemes Our Relationship, Significance of His Life, and Searching for Understanding. In another theme, Dying with Cancer, partners undertook the Burden of Caring, experienced an Uncertain Path and were Looking for Hope. In the last theme, Glimpses of the Future, participants Faced Tomorrow and confirmed their Capacity to Survive.

Significance of results:

The results centered on three major concepts: meaning making, anticipatory mourning, and hope. Although meaning making has been identified as a fundamental way in which bereaved individuals cope with loss, results of this study suggested that female partners made meaning of their situations before their spouses' deaths. Participants also spontaneously described aspects of anticipatory mourning, thus, validating a concept that has been widely accepted despite limited research. Another finding was that participants shouldered the responsibility of adjusting spouses' hopes in order to help them to cope. Implications for practice and research are drawn from these findings.

Associations between home death and GP involvement in palliative cancer care

BACKGROUND

Most cancer patients die at institutions despite their wish for home death. GP-related factors may be crucial in attaining home death.

AIM

To describe cancer patients in palliative care at home and examine associations between home death and GP involvement in the palliative pathway.

DESIGN OF STUDY

Population-based, combined register and questionnaire study.

SETTING

Aarhus County, Denmark.

METHOD

Patient-specific questionnaires were sent to GPs of 599 cancer patients who died during a 9-month period in 2006. The 333 cases that were included comprised information on sociodemography and GP-related issues; for example knowledge of the patient, unplanned home visits, GPs providing their private phone number, and contact with relatives. Register data were collected on patients' age, sex, cancer diagnosis, place of death, and number of GP home visits. Associations with home death were analysed in a multivariable regression model with prevalence ratios (PR) as a measure of association.

RESULTS

There was a strong association between facilitating home death and GPs making home visits (PR = 4.3, 95% confidence interval [CI] = 1.2 to 14.9) and involvement of community nurses (PR = 1.4, 95% CI = 1.0 to 1.9). No other GP-related variables were statistically significantly associated with home death.

CONCLUSION

Active involvement of GPs providing home visits and the use of home nurses were independently associated with a higher likelihood of facilitating home death for cancer patients. The primary care team may facilitate home death, accommodating patients' wishes. Future research should examine the precise mechanisms of their involvement.

A systematic review of informal caregivers' needs in providing home-based end-of-life care to people with cancer

AIMS

This paper presents the results of a systematic review examining the practical information needs of informal caregivers providing home-based palliative and end-of-life care to people with advanced cancer.

BACKGROUND

Modern hospice care has led to increases in home-based palliative care services, with informal caregivers assuming responsibility for the majority of care. In response, health policy emphasises the provision of palliative care services in which both the patient and carer receive adequate support throughout illness and death. While the emotional needs of carers have been extensively researched, their practical needs with respect to the provision of physical care are yet to receive systematic attention.

DESIGN

Systematic review.

METHODS

Eligible articles were identified via electronic searches of research and evidence-based databases, hand-searching of academic journals and searches of non-academic grey literature websites. Quality of research was assessed via accepted guidelines for reviewing non-randomised, observational and qualitative literature. Data were synthesised by comparing and contrasting the findings to identify prominent themes.

RESULTS

Research consistently highlights this lack of practical support, often related to inadequate information exchange. These deficits typically manifest in relatives adopting a 'trial and error' approach to palliative care. Informal carers request a greater quantity of practically-focussed information, improvements in quality and increased methods of dissemination.

CONCLUSION

Synthesis of the literature suggests that home-based palliative care services have been insufficiently focussed on assisting informal caregivers acquire practical nursing skills.

RELEVANCE TO CLINICAL PRACTICE

Enhanced access to professional advice represents a potentially effective method of increasing carers' confidence in their ability to undertake practical aspects of home-based care. Evidence suggests that nurses and other health providers may better assist home-based carers by providing the information and skills-training necessary to facilitate this. This may necessitate the involvement of carers in the design and testing of new educational interventions.

Pilot Testing of a Question Prompt Sheet to Encourage Family Caregivers of Cancer Patients and Physicians to Discuss End-of-life Issues

Family members of patients with advanced illness have many questions. Unfortunately, several barriers prevent caregivers from discussing their questions with the physicians caring for the patient. Although question prompt sheets can be helpful in overcoming barriers to communication, few have been developed for family caregivers. The goal of this study, therefore, was to develop and test the acceptability and feasibility of a short question prompt sheet designed to encourage discussions about end-of-life concerns in an outpatient palliative care clinic. Our results demonstrated that caregivers wanted to discuss a variety of questions, primarily questions about medications, symptoms, support services, and what to expect. All caregivers thought that the question prompt sheets was easy to understand and felt comfortable completing it in clinic and the majority reported that the question prompt sheets made it easier for them to ask questions.

Evaluation of End-of-Life Cancer Care From the Perspective of Bereaved Family Members: The Japanese Experience

Surveying bereaved family members could enhance the quality of end-of-life cancer care in inpatient palliative care units (PCUs). We systematically reviewed nationwide postbereavement studies of PCUs in Japan and attempts to develop measures for evaluating end-of-life care from the perspective of bereaved family members. The Care Evaluation Scale (CES) for evaluating the structures and processes of care, and the Good Death Inventory (GDI) for evaluating the outcomes of care were considered suitable methods. We applied a shortened version of the CES to three nationwide surveys from 2002 to 2007. We developed the CES as an instrument to measure the structures and processes of care and the GDI as an outcomes measure for end-of-life cancer care from the perspective of bereaved family members. We conducted three nationwide surveys in 1997, 2001, and 2007 (n = 850, 853, and 5,301, respectively). Although six of the 10 areas of the CES showed significant improvements between the two time points investigated, we identified considerable potential for further progress. Feedback from surveys of bereaved family members might help to improve the quality of end-of-life cancer care in inpatient PCUs. However, the effectiveness of feedback procedures remains to be confirmed. Furthermore, there is a need to extend the ongoing evaluation process to home care hospices and general hospitals, including cancer centers, identify the limitations of end-of-life care in all settings, and develop strategies to overcome them.

Financial stress and strain associated with terminal cancer--a review of the evidence

Financial circumstances are a significant influence on the quality of life for older people and may be important to health and wellbeing at the end of life. The aim of this study is to review the evidence for the existence and consequences of financial stress and strain at the end of life for people dying with cancer. We conducted a systematic search of four electronic databases for studies, providing data on illness-related financial burden (stress), or perception of financial hardship (strain), from patients with terminal cancer or their caregivers. Twenty-four papers were identified from 21 studies published in English between 1980 and 2006, the majority (14) of cross-sectional design. Financial stress was reported in all 13 studies from the USA (median 33%, range 10-66%), but only four sought measures of financial strain. In the USA, specific social consequences, such as moving house or change in employment to cope with caregiving, were reported in four of these studies; one of these also noted changes in treatment choices and avoidance of care for other family members. In studies from outside the USA, there is a dearth of data on financial stresses and the consequences of this for the household, despite widespread reporting of financial strain. To fill a gap in our understanding and improve holistic palliative care, researchers need to ask the questions about the consequences of financial stresses and strain for the health and wellbeing of the household.

Randomized controlled trial of a prompt list to help advanced cancer patients and their caregivers to ask questions about prognosis and end-of-life care

PURPOSE

To determine whether provision of a question prompt list (QPL) influences advanced cancer patients'/caregivers' questions and discussion of topics relevant to end-of-life care during consultations with a palliative care (PC) physician.

PATIENTS AND METHODS

This randomized controlled trial included patients randomly assigned to standard consultation or provision of QPL before consultation, with endorsement of the QPL by the physician during the consultation. Consecutive eligible patients with advanced cancer referred to 15 PC physicians from nine Australian PC services were invited to participate. Consultations were audiotaped, transcribed, and analyzed by blinded coders; patients completed questionnaires before, within 24 hours, and 3 weeks after the consultation.

RESULTS

A total of 174 patients participated (92 QPL, 82 control). Compared with controls, QPL patients and caregivers asked twice as many questions (for patients, ratio, 2.3; 95% CI, 1.7 to 3.2; P < .0001), and patients discussed 23% more issues covered by the QPL (95% CI, 11% to 37%; P < .0001). QPL patients asked more prognostic questions (ratio, 2.3; 95% CI, 1.3 to 4.0; P = .004) and discussed more prognostic (ratio, 1.43; 95% CI, 1.1 to 1.8, P = .003) and end-of-life issues (30% v 10%; P = .001). Fewer QPL patients had unmet information needs about the future (21 = 4.14; P = .04), which was the area of greatest unmet information need. QPL consultations (average, 38 minutes) were longer (P = .002) than controls (average, 31 minutes). No differences between groups were observed in anxiety or patient/physician satisfaction.

CONCLUSION

Providing a QPL and physician endorsement of its use assists terminally ill cancer patients and their caregivers to ask questions and promotes discussion about prognosis and end-of-life issues, without creating patient anxiety or impairing satisfaction.

Problems experienced by the informal caregivers of cancer patients and their needs for support

Informal caregivers experience problems of their own for which they need support, but despite the efforts of the World Health Organization to include the well-being of family members and caregivers in the concept of palliative care, their needs are rarely assessed systematically. This report explores caregivers' problems and their needs for professional support. Seventy-six caregivers of cancer patients with advanced disease completed a comprehensive needs assessment questionnaire, the Problems and Needs in Palliative Care questionnaire-caregiver form, listing 67 potential problems in their quality of life and their role of caregiver and 9 items concerning informational needs. The results of this study reveal that the "Top 20" list of the problems and needs reported by caregivers includes fears and emotional burdens; for the most part, caregivers did not need any more professional attention than they were already receiving. Many, however, needed support for managing patients' symptoms and wanted professional attention for the availability and coordination of services. Despite communalities, there was diversity in caregivers' individual needs. Personal needs could be identified with the Problems and Needs in Palliative Care questionnaire-caregiver form checklist. Although only a few caregivers were affected by some issues, such as financial problems, help for them was often needed. In conclusion, most caregivers would like more professional attention for 4 or 5 specific issues, often related to their competence as caregivers for their patients. Using structured needs assessments with the Problems and Needs in Palliative Care questionnaire-caregiver form seems a feasible method to identify the needs of individual caregivers in palliative care.

Hospice at home service: the carer's perspective

GOALS OF THE WORK

The aim of this study was to explore the bereaved caregivers' experience of the Hospice at Home service delivered in one region of the UK.

MATERIALS AND METHODS

Three hundred and ten bereaved caregivers identified by the Community Specialist Palliative Care Team or Hospice at Home nurse, who met inclusion criteria, were sent a postal questionnaire to explore their views and experiences of the Hospice at Home service. Data were collected during 2002.

MAIN RESULTS

In total, 128 caregivers responded, providing a 41% response rate. Most caregivers believed that the Hospice at Home service enabled their loved one's wish to be cared for and to die at home to be fulfilled. A number of suggestions were made relating to increased awareness of the service, training for staff, coordination of service delivery and bereavement support.

CONCLUSIONS

The bereaved caregivers were thankful for the Hospice at Home service; however, the need for practical support, increased awareness of the Hospice at Home service and bereavement support were also identified. Although the bereaved caregivers provided a valuable insight in evaluating service provision, it is acknowledged that some caregivers are often so grateful for the treatment and care received that they tend to forget or ignore their less pleasant experiences. Further research is therefore required using an in-depth qualitative approach investigating on the carers' views and experiences of accessing the Hospice at Home service.

A comprehensive picture of palliative care at home from the people involved

The purpose of this study was to identify the comprehensive picture of palliative care in the home, as experienced by the people involved. The study is a secondary analysis of three phenomenological studies including six cancer patients, six next of kin and six district nurses. Data were collected in qualitative interviews using an interview guide. The interviews were tape-recorded and transcribed verbatim. In this secondary analysis, data were analysed by hermeneutic analysis guided by Gadamer. The guiding questions during the reading were: Is there an advantage receiving palliative care at home? Is there a disadvantage receiving palliative care at home? The findings indicate that the advantages of palliative care at home is; striving for normal life, including the care in the home composed of physical care and emotional/mental care. Striving for normal life also includes emotional feelings, safety and resources and policies which regulates this activity. Disadvantages of palliative care at home are commitment, composed of adaptation and extra work, and demands, composed of frustration and uncertainty. If the people involved are to be able to manage the situation and optimize living while dying, there must be support and resources facilitating the situation.

A pragmatic 2×2×2 factorial cluster randomized controlled trial of educational outreach visiting and case conferencing in palliative care—methodology of the Palliative Care Trial [ISRCTN 81117481]

The demand for palliative care is increasing, yet there are few data on the best models of care nor well-validated interventions that translate current evidence into clinical practice. Supporting multidisciplinary patient-centered palliative care while successfully conducting a large clinical trial is a challenge. The Palliative Care Trial (PCT) is a pragmatic 2 x 2 x 2 factorial cluster randomized controlled trial that tests the ability of educational outreach visiting and case conferencing to improve patient-based outcomes such as performance status and pain intensity. Four hundred sixty-one consenting patients and their general practitioners (GPs) were randomized to the following: (1) GP educational outreach visiting versus usual care, (2) Structured patient and caregiver educational outreach visiting versus usual care and (3) A coordinated palliative care model of case conferencing versus the standard model of palliative care in Adelaide, South Australia (3:1 randomization). Main outcome measures included patient functional status over time, pain intensity, and resource utilization. Participants were followed longitudinally until death or November 30, 2004. The interventions are aimed at translating current evidence into clinical practice and there was particular attention in the trial's design to addressing common pitfalls for clinical studies in palliative care. Given the need for evidence about optimal interventions and service delivery models that improve the care of people with life-limiting illness, the results of this rigorous, high quality clinical trial will inform practice. Initial results are expected in mid 2005.

Palliative care in primary care: a study to determine whether patients and professionals agree on symptoms

BACKGROUND

Difficulties in managing symptoms of palliative care patients at home have been identified, yet there has been no investigation of agreement on symptom assessment in primary care. Lack of agreement between patients' and primary care professionals' symptom assessments may be contributing to difficulties in symptom control.

AIM

To investigate agreement on symptom assessments between patients at home and GPs and district nurses.

DESIGN OF STUDY

Prospective, self-completed, structured symptom assessments.

SETTING

Routine contacts with adult palliative care patients estimated to be in their last year of life.

METHOD

Patient and professional symptom assessments were obtained using CAMPAS-R, a comprehensive and reliable measure validated for palliative care in the community. Prevalence of reported symptoms was calculated in patient-professional pairs. Intraclass correlation techniques (ICCs) and percentage agreement were used to determine how well symptom assessments of patients and professionals agreed.

RESULTS

Anxiety and depression were significantly more likely to be reported by professionals, and GPs over-identified nausea, vomiting and constipation. Professionals assessed emotional symptoms as more severe than patients. Agreement on scoring of physical symptoms was better, although this was at least partially due to agreement on absence of symptoms. Unlike previous reports, pain scores recorded by doctors in this study, were not significantly different from patients.

CONCLUSION

This quick and easy to complete assessment tool, CAMPAS-R, has potential for monitoring quality of palliative care symptom control at home.

Home death--the caregivers' experiences

The objectives of this study were to evaluate caregivers' experiences concerning the care of a terminally ill loved one at home, and to compare the death experiences of caregivers with and without access to homecare programs. The primary caregivers of all the patients who died of cancer 6-18 months before the study period (1999-2001) in the Negev area were contacted. This group included 240 caregivers of patients who died in the home palliative care program and 404 caregivers of patients who died with no access to a home palliative care program. A total of 159 caregivers were interviewed, 76 from the home palliative program and 83 who had no access to a palliative care program. Death at home occurred for 80.3% of patients with access to homecare and 20.5% of those without access. Despite the fact that caring for a loved one at home was a greater financial and emotional burden, there was a greater overall satisfaction with the caring experience of those whose loved ones died at home and had access to the homecare program. Given appropriate professional support systems, home-based care at the end of life is preferable to most caregivers.

The needs of terminally ill cancer patients versus those of caregivers for information regarding prognosis and end-of-life issues

BACKGROUND

The difficulty of negotiating the concerns of family members while also respecting the needs of the patient adds complexity to the task of discussing prognosis and end-of-life (EOL) issues with terminally ill cancer patients. The informational needs of caregivers may be different from those of the patients themselves with regard to these topics. However, to the authors' knowledge, this issue has received relatively little research attention.

METHODS

The authors conducted focus groups and individual interviews with 19 patients with far advanced cancer and 24 caregivers from 3 palliative care (PC) services in Sydney and 22 PC health professionals (HPs) from around Australia. The focus groups and individual interviews were audiotaped and fully transcribed. Additional focus groups or individual interviews were conducted until no additional topics were raised. The participants' narratives were analyzed using qualitative methodology.

RESULTS

The participants had varying views regarding whether patients and caregivers should be told different information concerning prognosis and EOL issues. Three themes were identified from the transcripts regarding meeting the informational needs of both the patients and caregivers: 1) the importance of consistency and openness, 2) the specific information needed to care for the patient, and 3) the value of having separate discussions with the patient and caregiver. A desire to restrict the patient's access to information by the caregiver or vice versa was reported by the HPs to be one of the most challenging issues when discussing prognosis and EOL issues. Three themes were identified with regard to this issue: 1) autonomy versus protection, 2) negotiating family dynamics, and 3) difficulty using interpreters.

CONCLUSIONS

The results of the current study emphasized the importance of considering the distinct informational needs of caregivers, as well as those of the patient, when discussing prognosis and EOL issues.

Social class and access to specialist palliative care services

OBJECTIVE

To determine any social class differences in place of death of cancer patients in South Bristol; to explore the experience of carers; and to identify inequalities in access to palliative care.

DESIGN

Two-part study: (1) A cross-sectional survey of all 960 cancer deaths in South Bristol between September 1999 and December 2002. (2) A qualitative in-depth interview study of 18 carers of patients who died of cancer during the same period in South Bristol. Fourteen of those who died were from social class IIIM (manual), IV and V (i.e. lower social classes).

MAIN OUTCOMES

Place of death of patients according to social class and geographical distance from the hospice. Carers' accounts of the way in which illness and death were conducted, and their response to the management of death and dying.

RESULTS

The cross sectional survey showed that patients from social class V were less likely to die in the hospice. This finding was independent of geographical proximity. In the qualitative study, no class specific beliefs about death and dying were identified. Attitudes to the way dying should be conducted were common across the classes. Families expected to be present and centre stage at the time of death and for it to be conducted in a dignified and personal manner. Health care staff in all settings supported them in this aim. No one in this study died without a family member present. Some elderly carers were less open than younger carers in the way they talked about death and did not wish to be present at the death. Some carers from social class IV and V were less active in seeking information or asking for hospice admission than carers from other classes. Unrealistic expectations about the availability of hospice beds were common to all carers. Anxiety was common among carers. It was reduced by the provision of reliable and consistent healthcare support, by information provided in a timely and sensitive way, and by open and shared decision making between carer and patient. Most important in reducing anxiety was the support of a second carer who lived locally and was reliable. Carers from social classes IIIM (manual), IV and V were more likely to have this kind of support than carers from social classes I, II and IIIN (non-manual).

CONCLUSION

Although cancer patients from social class V were less likely than others to die in the hospice, social inequality in access to or utilisation of healthcare in terminal illness was not prominent in carers' accounts. When it did arise, it was associated with passivity in seeking information and support on the part of some carers from social classes IV and V. Carers from social classes IIIM-V received more regular and reliable support from their families than those from social classes I-IIIN.

A qualitative study of the experience of caring for a person with bulimia nervosa. Part 2: Carers' needs and experiences of services and other support

OBJECTIVE

Family carers of people with mental disorders have specific needs to safeguard their own mental health. The needs of carers of individuals with eating disorders have received little attention. A focus group with carers of people with anorexia nervosa identified a number of specific needs (Haigh & Treasure [2003]. European Eating Disorders Review, 11(2), 125-141). However, there has been no published research into the needs of carers of individuals with bulimia nervosa (BN).

METHOD

Twenty carers of individuals with BN were interviewed using a semistructured interview schedule. Interviews were transcribed and the texts were analyzed using a content analysis approach to identify themes.

RESULTS

Carers expressed the need for more information, practical advice, guidance, and the need to talk to others about their experiences.

DISCUSSION

Further research is recommended to explore how the needs expressed by carers may best be translated into services that effectively meet the requirements of both patients and carers and reduce the risk to carers' mental health.

Valued aspects of primary palliative care: content analysis of bereaved carers' descriptions

BACKGROUND

Informal carers provide the bulk of palliative home care. They largely rely on general practitioners (GPs) and district nurses to support them in this role, yet little is known about what carers themselves consider important in this support.

AIM

To identify what informal carers valued in the palliative support provided by GPs and district nurses by using carers' own descriptions of such support.

DESIGN OF STUDY

Retrospective interviews.

SETTING

Primary care in Cambridgeshire.

METHOD

Semi-structured interviews with bereaved carers of 48 patients with cancer and 12 patients with non-cancer diagnoses. Content analysis of carers' evaluative descriptions of GP and district nurse support.

RESULTS

The accessibility of the GP and district nurse emerged as the most important aspect of support. Enlistment of help from other agencies was also extensively mentioned, together with provision of equipment. Attitude or approach during interactions, and relationship with the professional were important, particularly regarding GP support, whereas support for the carer, information, and symptom control were mentioned less often. Data suggested that support was not as good for older patients (> or =75 years), but this finding requires further investigation.

CONCLUSION

Results largely confirmed findings of previous, quantitative research and the importance of a patient-centred approach. What emerged most strongly, however, was the central importance of accessibility of support services for lay carers responsible for end-of-life home care. This mainly concerned GP and district nurse support, but accessibility of additional care and equipment were also important. In short, carers' main focus was the basic support that enabled them to sustain care in the home.

Guidelines on the role of the specialist nurse in supporting patients with lung cancer

Recently, there has been a significant increase in the number of nurse specialist posts working with patients with lung cancer in the UK. This has been in response to a recognized need to improve lung cancer services. However, there is concern that these posts have been developed quickly with little strategic planning or evaluation. This paper is a collaborative project by the members of The London and South East Lung Cancer Forum for Nurses and aims to offer guidelines to managers and practitioners on areas where improvements may be made in the care of patients with lung cancer. Recommendations are based on Government guidelines, evidence from recent research studies and the experience of the members of the Forum.

The experience of family members caring for a dying loved one

Qualitative nursing research into the experience of family members caring for a dying loved one has been limited. This study used a phenomenological approach to explore this experience. The pattern of caring for a dying loved one and its intertwined dimensions were described. Caregivers felt a sense of helplessness that was associated with illness progression, their inability to relieve pain and discomfort, and decision-making related to patient admission to a palliative care unit. Lack of support from health professionals and having to face personal limits were found to accelerate the decision to admit a patient. The role of a support person involved with the caregiver was also considered and found to be an area worthy of further investigation. Health professionals must provide information and support tailored to the caregivers' needs as they change along a patient's illness trajectory.

Meeting the supportive needs of family caregivers in palliative care: challenges for health professionals

Caring for a dying relative is demanding, and family caregivers have acknowledged many unmet needs associated with their caregiver role. Consistently, caregivers of dying patients with cancer have reported that they need more support and information from health care professionals. Moreover, a number of palliative care clinicians and researchers have called for interventions to enhance the support offered to family caregivers. However, before researchers can develop and test palliative care interventions directed to families, it is important to identify barriers that may confront health care professionals with regard to the provision of supportive family care. For new interventions to be feasible they must be applicable within the constraints of current palliative care service delivery environments. This paper provides an account of issues that may impinge on optimal transference of supportive strategies from health care professionals to family caregivers of patients receiving palliative care. By acknowledging these barriers to supportive care, researchers and health care professionals can begin to design and implement interventions that are clinically relevant and more likely to be effective.

Evaluation of a short-term group intervention for informal carers of patients attending a home palliative care service

Despite evidence of high psychological distress and unmet needs, evaluated interventions for informal caregivers in palliative care are few. This study involved an observational outcome evaluation of attendees, and a comparison group, in specialist home palliative care. The measures included carer psychological status and patient physical status at baseline, 8 weeks, and 20 weeks. Qualitative data were collected regarding content, satisfaction with, and impact of intervention. Process data described the uptake, resources, and group activity. The intervention combined informal multiprofessional teaching with facilitated peer exchange and support, and was delivered over 6 sessions of 90 minutes per week. The uptake rate was 25%; carers were less likely to accept if they were in paid employment (OR=0.26, P=0.06), and more likely to accept if they utilized avoidance coping (OR=1.13, P=0.04) or their patient had worse physical status (OR=2.1, P=0.03). Attendees described significant support and knowledge gains from the multiprofessional input and peer group. Most relied on social comparison processes to appraise their situation. Potential detection of significant effects on global psychological scores (i.e. anxiety, depression, and burden) using multivariate analysis was disallowed due to attrition. This acceptable and accessible intervention provided information and support; further outcome studies are needed for a range of interventions. Short-term interventions are unlikely to affect global psychological scores, and future evaluations should include additional time points of data collection to demonstrate support during attendance.

Validation of a symptom measure suitable for use among palliative care patients in the community: CAMPAS-R

The purpose of the study was to investigate psychometric properties of CAMPAS-R, an instrument for prospectively monitoring patients' symptoms and needs during palliative care at home. CAMPAS-R was piloted for face and content validity and then administered alongside criterion measures to a home care sample. Cronbach's alpha was used to test internal consistency and criterion-related validity was tested by non-parametric correlation with Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS) and EORTC QLQ-C30. Predictive validity was assessed by relating CAMPAS-R scores to survival. One hundred and nine patients were recruited to the study. Good reliability and high correlations between CAMPAS-R and criterion measures were found. Predictive validity was demonstrated by significant differences in symptom scores between groups differing in length of survival. CAMPAS-R is acceptable to patients, families and primary care professionals and is a valid, reliable instrument, which has the benefit of being easy to score.

Perceptions of nurses with regard to doctor-patient communication

The objective of this study was to evaluate nurses' perceptions of communication between doctors and patients with cancer, AIDS and rheumatoid arthritis. A cross-sectional study was conducted with 741 nurses in 12 hospitals. Nurses received a self-questionnaire that included questions on personal value and attitudes. The answers were used in constructing affective variables (religious beliefs, attitude towards death, paternalism). The prevalence of explicit communication in 'nurse perception of doctor-patient communication' in the case of cancer was 4.5%, with AIDS 30%, and with rheumatoid arthritis 41.8%. When the value of communication was evaluated, it became evident that the likelihood of a nurse perceiving explicit communication in reference to a diagnosis of cancer was 6.5 time greater when communication was considered to be of greater value (CI 95% 2.6-6.6). For nurses who accept the possibility of death, the likelihood of perceiving explicit communication in the case of AIDs was 7.4 times greater than for nurses who deny this possibility (CI 95% 3.7-14.7), and when nurses displayed a deeply religious attitude, the likelihood of perceiving explicit communication was 80% greater than for nurses without this attitude (CI 95% 1.1-2.9). Nurses participate actively in the process of attending to patients with cancer and other disabling illnesses. Thus, there is a need for health professionals who provide compassionate attention, which will improve the various interrelationships between nurses and patients.

How next of kin experience palliative care of relatives at home

Primary health care teams are the teams responsible nowadays in Sweden for the greater part of the home health care system, providing palliative care in the patient's home. If palliative care in the home is to be ethically defensible, it should be voluntary from the point of view of the next of kin and should be designed in such a way that he or she receives different forms of support during the care period. The purpose of this paper is to explore the meaning of palliative care in the home as experienced by the next of kin. The data consist of transcripts from interviews with the next of kin. Giorgi's phenomenological method was selected as the method/analysis for this study, because it focuses on uncovering the meaning of experiences of the participants by studying descriptions from their perspective. A feeling of insufficiency is the phenomenon, which permeates all the five themes: adjustment, awareness, being perceived as a person, emotional effects and feelings of uncertainty. Because the informal carer/next of kin is a significant contributor to palliative care in the home, it is important to promote feelings of control and also self-efficacy.

Building bridges in palliative care: evaluating a GP Facilitator programme

The objective of this study was to evaluate the impact of the Macmillan GP Facilitator Programme in Palliative Care on the knowledge, attitudes and confidence in symptom control of general practitioners (GPs), communication with patients and out-of-hours practice. GP Facilitators work on average for two sessions a week with practices in their locality. The design included a before and after study, with geographical controls matched on type of area (inner city, urban and rural) and broadly on Jarman scores using postal questionnaires sent to GPs. Scores measured change in GP awareness, attitudes and practice over two years of the intervention, derived from Likert scale responses to the postal questionnaires. Although overall few significant results were found, we did identify an increase in the use of palliative care guidelines in Facilitator districts, together with an increase in awareness of day care. The programme was associated with increased positive attitudes towards specialist palliative care services and results suggested increased satisfaction with out-of-hours services for patients. No change was found for confidence in symptom control and communication over diagnosis with cancer patients was less than in control districts. The design also incorporated a qualitative component, and from this we found the Facilitator programme to be popular with local GPs who valued the support of a colleague who knew the demands and constraints of general practice. In conclusion, we have demonstrated an impact of the GP Facilitator programme on GP awareness of, use and increased positive attitudes towards specialist palliative care services. By improving communication between primary and specialist palliative care, the programme should contribute substantially to improved care of the dying at home.

Dying at home: a care pathway for the last days of life in a community setting

The Cancer Nursing Strategy (Department of Health (DoH), 2000a) expects nurses at senior level to lead the way in improving the organization and delivery of cancer care. Lack of forward planning can be a feature of community palliative care, and may lead to inappropriate crisis admission in the last days despite patients and relatives expressing a wish to stay at home. This article attempt to demonstrate how, though collaboration and effective team working, issues and/or problems encountered in the last days of life were managed by developing and promoting a care pathway for the last days of life. Although based on Ellershaw's pioneering work, this pathway was developed specifically for use in the community to reflect and address the particular problems encountered in this setting when caring for dying patients.

Vulnerability of family caregivers in terminal palliative care at home; balancing between burden and capacity

This paper reports on a grounded theory interview-based study with 13 family members aged 28-80 years caring for terminally ill people at home (with a life expectancy of 3 months or less) in the Netherlands. The project was approved by the ethics committee of the Maastricht University Hospital. The aim of this study was to explore the experiences of family caregivers, their needs for home care, and which health services they receive. Data were analysed using the constant comparative method. 'Vulnerability' was identified as the core category. Caring for a terminally ill person at home requires continuous balancing between care burden and capacity to cope. Whether or not the carer will succeed in keeping in optimum balance is dependent on a number of factors impinging on the caregiver's vulnerability. Care burden, restricted activities, fear, insecurity, loneliness, facing death, lack of emotional, practical and information-related support were identified from the data as factors having the potential to increase the caregiver's vulnerability, and may be risk factors for fatigue and burnout. Continuing previous activities, hope, keeping control, satisfaction and good support are factors which may decrease the caregiver's vulnerability, and may protect against fatigue and burnout. The experiences of the caregivers in our study showed that the support from informal and professional caregivers was not sufficient. Education and practical tools may make professionals more sensitive for the vulnerable position of family caregivers, even when these caregivers do not show their vulnerability.

A comparison of patients dying at home and patients dying at a hospice: Sociodemographic factors and caregivers' experiences

Objective:The aim of this study was to investigate whether there were any differences between patients who died at home and patients who died at a hospice, that is, sociodemographic variables, the family caregivers' experiences of burden, and their opinion of reasons for hospice care.

Methods:The study comprises a consecutive sample of family caregivers to adult patients: (I) who were cared for by the advanced palliative home care team (APHCT) and died at home, (II) who were cared for by the APHCT and died at the Hospice, (III) who were cared for and died at the Hospice in Uppsala during a period of one year. A questionnaire was mailed to caregivers and the medical records of all the patients were analyzed.

Results:The place of death differed significantly and varied according to gender and cohabitation status. Men died to a greater degree at home compared with women. The family caregivers' experiences of burden were moderate. Caregivers of patients who died at home thought that this care form has a more positive influence on the patients' quality of life than was the case in the other groups. They were also more satisfied with their own achievement. The caregivers' opinion of why patients needed hospice care was nearly the same in groups II + III, acutely developing symptoms being the most common reason.

Significance of results:This study showed that women died to a lesser degree at home than men. The explanation for this is unknown and requires further investigation. It is important to establish whether female patients or male caregivers need another type of support than male patients or female caregivers, since the aim of palliative care is that every patient who wishes to die at home should have this wish fulfilled.

Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers?

Palliative care provision varies widely, and the effectiveness of palliative and hospice care teams (PCHCT) is unproven. To determine the effect of PCHCT, 10 electronic databases (to 2000), 4 relevant journals, associated reference lists, and the grey literature were searched. All PCHCT evaluations were included. Anecdotal and case reports were excluded. Forty-four studies evaluated PCHCT provision. Teams were home care (22), hospital-based (9), combined home/hospital care (4), inpatient units (3), and integrated teams (6). Studies were mostly Grade II or III quality. Funnel plots indicated slight publication bias. Meta-regression (26 studies) found slight positive effect, of approximately 0.1, of PCHCTs on patient outcomes, independent of team make-up, patient diagnosis, country, or study design. Meta-analysis (19 studies) demonstrated small benefit on patients' pain (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.23-0.64), other symptoms (OR: 0.51, CI: 0.30-0.88), and a non-significant trend towards benefits for satisfaction, and therapeutic interventions. Data regarding home deaths were equivocal. Meta-synthesis (all studies) found wide variations in the type of service delivered by each team; there was no discernible difference in outcomes between city, urban, and rural areas. Evidence of benefit was strongest for home care. Only one study provided full economic cost-benefit evaluation. This is the first study to quantitatively demonstrate benefit from PCHCTs. Such comparisons were limited by the quality of the research.

Loss of weight and loss of appetite in advanced cancer: a problem for the patient, the carer, or the health professional?

This paper aims to examine the loss of weight and loss of appetite as 'problems' experienced by patients with advanced cancer and those that care for them. It reports the results of a systematic search of the literature and presents the findings as a narrative review. Research to date has focused upon charting the prevalence and incidence of these symptoms, but little empirical work has been conducted to investigate how patients and carers experience these problems. There is some evidence to suggest that anorexia may be more distressing for those caring for the patient than the person suffering from the symptom itself. Understanding the reason for this anguish requires an appreciation of the meaning of food refusal and constitutes the first step towards informing the development of effective interventions. Such exploratory work is mandatory if health professionals wish to move beyond speculation and deliver interventions that provide meaningful benefits for the cancer patient and their family.

Caring for the terminally ill: the district nurse's perspective

This study aimed to explore the role of the district nurse in terminal care in order to understand and clarify the work that district nurses undertake in this area. District nurses view themselves as having a central and valued role in terminal care, yet studies have highlighted concerns that they may not have the necessary skills to provide effective terminal care. In order to target the educational and developmental needs of district nurses the role of the district nurse in terminal care was explored using a qualitative approach. Six semi-structured interviews, including the use of vignettes, were undertaken with district nurses from one community trust. Interviews were all taped and transcribed verbatim. Transcriptions were analysed using coding and categorizing with constant comparison of recurring themes. Common themes relating to how district nurses viewed their role in terminal care were then developed. The district nurses viewed their role as centring on the development of a relationship with the client and family. The relationship was a foundation to understanding and knowing the clients' and families' needs and was the medium through which all other care was given. The focus of care was determined by those needs identified through the relationship. Care needs identified within the study were complex and difficult to distinguish but fell within four themes: (1) emotional; (2) social; (3) physical; (4) informational. The importance of the relationship between the district nurse, the terminally ill client and the carer has not been clearly identified before and this study points towards the importance of formal structures to be put in place within palliative care and the provision of district nurse training to allow the opportunity and skills for this relationship to be fostered and developed.

Informal carers in cancer contexts

This paper considers some of the challenges involved in studying informal carers in cancer contexts. It reviews current knowledge by examining, first, the dominant psycho-oncological research tradition that focuses on psychological distress among carers and, second, the more recent sociologically informed body of work examining what carers actually do and the contribution that they make to patient care. The authors suggest that this second sociologically informed approach offers an important counter-weight to the psycho-oncological perspective. The developing research agenda for a sociology of cancer caring is briefly outlined.