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Spelten ER, van Vuuren J, Naess K, Timmis J, Hardman R, Duijts S. Making community palliative and end-of-life care sustainable; investigating the adaptability of rural Australian service provision. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:1998-2007. [PMID: 33729632 DOI: 10.1111/hsc.13344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 12/01/2020] [Accepted: 02/11/2021] [Indexed: 06/12/2023]
Abstract
With the increased attention and demand on community-based palliative and end-of-life (EOL) care services comes the question of how to ensure their sustainability. Sustainability has three key attributes: acceptability, affordability and adaptability. Having established the acceptability and affordability of the community-based service, this paper focussed on adaptability, as the remaining issue affecting long-term sustainability. The aim of this study was to identify components of the palliative and EOL service which require adaptability to ensure long-term sustainability for the service. A mixed methods approach was used for this study. Semi-structured interviews were conducted with family members. Semi-structured focus groups and interviews were held with health professionals. Patient data were included to describe frequency and nature of contacts. The results were analysed using descriptive analysis. The setting was a rural town in Victoria, Australia. Nine family members were interviewed, and 16 health professionals were interviewed or took part in a focus group. Patient data included 121 participants. Four themes were identified: the uniqueness of the patient, workforce issues, collaboration between services and symptom and pain management. All themes indicated that the palliative and EOL service faces challenges which may threaten the sustainability of the service and require adaptability. Families regard palliative and EOL care as special and valued, and appreciate the endeavour, care and support taken to assist their loved one to die with dignity regardless of the location and setting. With sufficient attention paid to the adaptability of the service, community palliative and EOL care service can become more sustainable, thus offering choice and dignity for people approaching the end of life.
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Affiliation(s)
- Evelien R Spelten
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, VIC, Australia
| | - Julia van Vuuren
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, VIC, Australia
| | - Kelly Naess
- Sunraysia Community Health Services, Mildura, VIC, Australia
| | - Jennifer Timmis
- School of Rural Health, Monash University, Mildura, VIC, Australia
| | - Ruth Hardman
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, VIC, Australia
- Sunraysia Community Health Services, Mildura, VIC, Australia
| | - Saskia Duijts
- The Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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2
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Stajduhar KI. Examining the Perspectives of Family Members Involved in the Delivery of Palliative Care at Home. J Palliat Care 2019. [DOI: 10.1177/082585970301900106] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This ethnographic study examined the social context of home-based palliative caregiving. Data were composed of observation field notes, interviews, and textual documents, and were analyzed using constant comparative methods. Findings show that home-based palliative caregiving resulted in life-enriching experiences for many caregivers. However, assumptions about dying at home and health care reforms resulted in some caregivers feeling “pressured” to provide home care, and consequently, left them feeling their obligations to care were exploited by the health care system. Shifts toward providing care closer to home not only changed caregivers, but also changed the home setting where palliative care was provided. Findings indicate a need for interventions designed to improve support for caregivers at home, and to explore how assumptions influence and sometimes drive the provision of home health care.
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Affiliation(s)
- Kelli I. Stajduhar
- Centre on Aging, University of Victoria, and Vancouver Island Health Authority, Victoria, British Columbia, Canada
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Heyland DK, Lavery JV, Tranmer JE, Shortt S, Taylor SJ. Dying in Canada: Is It an Institutionalized, Technologically Supported Experience? J Palliat Care 2019. [DOI: 10.1177/082585970001601s04] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although preliminary evidence shows that people generally prefer to die at home, very little is known about where Canadians die. Understanding the epidemiology of dying in Canada may illuminate opportunities to improve quality of end-of-life care and related health policy. We conducted a cross-sectional analysis of death records in Canada to determine the proportions of deaths occurring in hospitals and special care units. Our analysis found that deaths in Canada occur in hospitals with provincial and territorial proportions ranging from 87% in Quebec to 52% in the Northwest Territories. In hospitals recording deaths in special care units, 18.64% of all deaths occurred in special care units. The proportion of deaths in special care units ranged from 25% in Manitoba to 7% in the Northwest Territories. The proportion of deaths in special care units varied by size and nature (teaching vs. non-teaching) of hospitals. It increased with the size of the hospital from 8% in hospitals with 1–49 beds, to 23% for hospitals with 400 or more beds. In teaching hospitals, 27% of deaths occurred in special care units, and in non-teaching hospitals the proportion was 15%. In conclusion, the majority of deaths in Canada occur in hospitals and a substantial proportion occur in special care units, raising questions about the appropriateness and quality of current end-of-life care practices in Canada.
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Affiliation(s)
- Daren K. Heyland
- Department of Medicine, Kingston General Hospital, and Department of Community Health and Epidemiology, Queen's University
| | - James V. Lavery
- Department of Community Health and Epidemiology and Queen's Health Policy Research Unit, Queen's University
| | - Joan E. Tranmer
- Department of Nursing, Kingston General Hospital, and School of Nursing, Queen's University
| | - S.E.D. Shortt
- Department of Community Health and Epidemiology and Queen's Health Policy Research Unit, Queen's University
| | - Sandra J. Taylor
- Department of Medicine, Kingston General Hospital, and School of Nursing and Department of Philosophy, Queen's University, Kingston, Ontario, Canada
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Brenneis C, Bruera E. The Interaction between Family Physicians and Palliative Care Consultants in the Delivery of Palliative Care: Clinical and Educational Issues. J Palliat Care 2019. [DOI: 10.1177/082585979801400312] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Carleen Brenneis
- Regional Palliative Care Program and Capital Health Authority, Edmonton, Alberta, Canada
| | - Eduardo Bruera
- Regional Palliative Care Program and Capital Health Authority, Edmonton, Alberta, Canada
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Cantwell P, Turco S, Brenneis C, Hanson J, Neumann CM, Bruera E. Predictors of Home Death in Palliative Care Cancer Patients. J Palliat Care 2019. [DOI: 10.1177/082585970001600105] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
With recent changes in health care there is greater emphasis on providing care at home, including the support of families to enable more home deaths. Since a home death may not be practical or desirable in every family situation, there is a need for an objective way to assess the viability of a home death in each individual family situation. The purpose of this study was to describe the relative role of predictors of home death in a cohort of palliative care patients with advanced cancer. A questionnaire was created as a means of assessing the viability of a home death. Five questions were included. Ninety questionnaires were administered by home care coordinators. A follow-up questionnaire was administered to record the place of death. Of the 73 evaluable patients, 34 (47%) died at home and 39 (53%) died in hospital or hospice. The desire for a home death by both the patient and the caregiver, support of a family physician, and presence of more than one caregiver were all significantly associated with a home death. Logistic regression identified a desire for home death by both the patient and the caregiver as the main predictive factor for a home death. The presence of more than one caregiver was also predictive of home death. The questionnaire is simple and, if our results are confirmed, it can be used for predicting those who will not have a home death.
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Affiliation(s)
- Patricia Cantwell
- Edmonton Regional Palliative Care Program, Edmonton, Alberta, Canada
| | - Sally Turco
- Edmonton Regional Palliative Care Program, Edmonton, Alberta, Canada
| | - Carleen Brenneis
- Edmonton Regional Palliative Care Program, Edmonton, Alberta, Canada
| | - John Hanson
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Catherine M. Neumann
- Division of Palliative Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Eduardo Bruera
- University of Texas, Anderson Cancer Center, Houston, Texas, USA
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Affiliation(s)
- Christopher Frank
- Palliative Care, St. Mary's of the Lake Hospital, Kingston, Ontario, Canada
| | - Neil R. Hobbs
- Palliative Care, St. Mary's of the Lake Hospital, Kingston, Ontario, Canada
| | - G. Ivan Stewart
- Palliative Care, St. Mary's of the Lake Hospital, Kingston, Ontario, Canada
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Fainsinger RL, Demoissac D, Cole J, Mead-Wood K, Lee E. Home versus Hospice Inpatient Care: Discharge Characteristics of Palliative Care Patients in an Acute Care Hospital. J Palliat Care 2019. [DOI: 10.1177/082585970001600106] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This prospective survey was initiated to identify factors that helped and hindered home discharge for 100 consecutive patients who did not require further specialist palliative or acute care. Information was collected on demographics, functional ability (using the Palliative Performance Scale [PPS] and Kamofsky Performance Scale [KPS]), cognitive function at discharge as measured by the Mini-Mental State Examination (MMSE), home support circumstances, and patient and family preference for discharge. 59 patients were discharged home and 41 were transferred to a hospice. Younger patients with younger caregivers were discharged home more often. Patients with better MMSE and better functional ability (PPS and KPS) were also more likely to go home. Patients going home were more likely to be married. Preference for site of discharge was met for 76% of patients and 90% of families. Of the patients going to a hospice, 24% of patients and 7% of families preferred a home discharge. More physical support at home could have facilitated a home discharge for 13 patients. Functionally dependent and cognitively impaired patients were generally unable to return home. To support patients and their families in an environment of their choice, access to increased physical support in the home must be addressed.
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Affiliation(s)
- Robin L Fainsinger
- Division of Palliative Medicine, Department of Oncology, University of Alberta
| | - Donna Demoissac
- Palliative Care Program, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Janet Cole
- Palliative Care Program, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Kathy Mead-Wood
- Palliative Care Program, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Ellen Lee
- Palliative Care Program, Royal Alexandra Hospital, Edmonton, Alberta, Canada
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9
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Chan A, Woodruff RK. Comparison of Palliative Care Needs of English- and Non-English-Speaking Patients. J Palliat Care 2019. [DOI: 10.1177/082585979901500104] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Arlene Chan
- Department of Medical Oncology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Roger K. Woodruff
- Department of Medical Oncology, Austin Hospital, Heidelberg, Victoria, Australia
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Stajduhar KI, Davies B. Death at Home: Challenges for Families and Directions for the Future. J Palliat Care 2019. [DOI: 10.1177/082585979801400304] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kelli I. Stajduhar
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Betty Davies
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
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11
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Daneault S, Labadie JF. Terminal HIV Disease and Extreme Poverty: A Review of 307 Home Care Files. J Palliat Care 2019. [DOI: 10.1177/082585979901500102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Serge Daneault
- Public Health Department, Montreal Centre Region and CLSC des Faubourgs, Montreal
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Nissmark S, Malmgren Fänge A. Occupational balance among family members of people in palliative care. Scand J Occup Ther 2018; 27:500-506. [PMID: 30001672 DOI: 10.1080/11038128.2018.1483421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Today people can live a long time with a chronic cancer diagnosis, and it affects the entire family. Family members to patients in palliative care often have to leave valued occupations due to lack of time and energy, while new roles are forced upon them, potentially affecting their health.Objective: To explore occupational balance, needs and roles among family members to persons in palliative care.Methods: Six semi-structured interviews were conducted with family members to terminally ill persons enrolled to specialized palliative care. A qualitative content analysis guided the data collection and analysis.Result: An overarching theme Striving for control while being in the disease, and two categories Changing roles and occupations in the family; and Handling emotions in the end of life emerged from the data.Conclusion: The findings suggest that family members could benefit from strategies to maintain valued roles and occupations, and that palliative care provision need to develop new ways to take family members needs into consideration.
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Affiliation(s)
- Sofia Nissmark
- Neurology and Rehabilitation Medicine, Lund University Hospital, Lund, Sweden
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Electronic patient-reported symptom assessment in palliative end-of-life home care. Health Syst (Basingstoke) 2017. [DOI: 10.1057/hs.2013.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
Hospice and palliative care philosophy is becoming increasingly incorporated into medical practice, education, and research. However, this process of integration may be hindered by continued adherence to several perceived conceptual dichotomies: natural and medicalized death, research and clinical care, and acceptance and denial of dying. These dichotomies were perhaps essential for the initial development of palliative care but could undermine the continuing evolution of care for the terminally ill. In this article, the authors deconstruct these dichotomies and advocate for a fully integrated model of palliative care.
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Woodman C, Baillie J, Sivell S. The preferences and perspectives of family caregivers towards place of care for their relatives at the end-of-life. A systematic review and thematic synthesis of the qualitative evidence. BMJ Support Palliat Care 2015; 6:418-429. [PMID: 25991565 PMCID: PMC5256384 DOI: 10.1136/bmjspcare-2014-000794] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 02/19/2015] [Accepted: 03/11/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Home is often reported as the preferred place of care for patients at the end-of-life. The support of family caregivers is crucial if this is to be realised. However, little is known about their preferences; a greater understanding would identify how best to support families at the end-of-life, ensuring more patients are cared for in their preferred location. OBJECTIVES To systematically search and synthesise the qualitative literature exploring the preferences and perspectives of family caregivers towards place of care for their relatives at the end-of-life. METHODS Ten databases (MEDLINE, PsycINFO, EMBASE, AMED, ASSIA, CINAHL, Social Care Online, Cochrane Database, Scopus, Web of Science) and reference lists of key journals were searched up to January 2014. Included studies were appraised for quality and data thematically synthesised. RESULTS Eighteen studies were included; all were of moderate or high quality. Two main themes were identified: (1) Preferences and perspectives: most family caregivers preferred home care, although a range of perspectives were reported. Both positive and negative perspectives of home, hospices and hospitals emerged. At times, family caregivers reported feeling obligated to provide home care. (2) Impact of facilitating home care; both positive and negative effects on family caregivers were reported. CONCLUSIONS Many family caregivers reported home as the preferred place of care; other places of care were infrequently considered. Healthcare professionals and service providers should be aware of these preferences and provide support where needed to enable family caregivers to successfully care at home, thus improving end-of-life experiences for families as a whole.
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Affiliation(s)
| | - Jessica Baillie
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Stephanie Sivell
- Marie Curie Palliative Care Research Centre, Institute of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK
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Reyniers T, Deliens L, Pasman HR, Morin L, Addington-Hall J, Frova L, Cardenas-Turanzas M, Onwuteaka-Philipsen B, Naylor W, Ruiz-Ramos M, Wilson DM, Loucka M, Csikos A, Rhee YJ, Teno J, Cohen J, Houttekier D. International Variation in Place of Death of Older People Who Died From Dementia in 14 European and non-European Countries. J Am Med Dir Assoc 2015; 16:165-71. [DOI: 10.1016/j.jamda.2014.11.003] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 11/25/2022]
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Reyniers T, Houttekier D, Pasman HR, Stichele RV, Cohen J, Deliens L. The family physician's perceived role in preventing and guiding hospital admissions at the end of life: a focus group study. Ann Fam Med 2014; 12:441-6. [PMID: 25354408 PMCID: PMC4157981 DOI: 10.1370/afm.1666] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Family physicians play a pivotal role in providing end-of-life care and in enabling terminally ill patients to die in familiar surroundings. The purpose of this study was to explore the family physicians' perceptions of their role and the difficulties they have in preventing and guiding hospital admissions at the end of life. METHODS Five focus groups were held with family physicians (N= 39) in Belgium. Discussions were transcribed verbatim and analyzed using a constant comparative approach. RESULTS Five key roles in preventing and guiding hospital admissions at the end of life were identified: as a care planner, anticipating future scenarios; as an initiator of decisions in acute situations, mostly in an advisory manner; as a provider of end-of-life care, in which competency and attitude is considered important; as a provider of support, particularly by being available during acute situations; and as a decision maker, taking overall responsibility. CONCLUSIONS Family physicians face many different and complex roles and difficulties in preventing and guiding hospital admissions at the end of life. Enhancing the family physician's role as a gatekeeper to hospital services, offering the physicians more end-of-life care training, and developing or expanding initiatives to support them could contribute to a lower proportion of hospital admissions at the end of life.
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Affiliation(s)
- Thijs Reyniers
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - H Roeline Pasman
- EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
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Affiliation(s)
- Bridget Johnston
- Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, School of Health Sciences, The University of Nottingham, Nottingham, UK
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Hunt KJ, Shlomo N, Addington-Hall J. End-of-life care and achieving preferences for place of death in England: results of a population-based survey using the VOICES-SF questionnaire. Palliat Med 2014; 28:412-21. [PMID: 24292157 DOI: 10.1177/0269216313512012] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIM Health policy places emphasis on enabling patients to die in their place of choice, and increasing the proportion of home deaths. In this article, we seek to explore reported preferences for place of death and experiences of care in a population-based sample of deaths from all causes. DESIGN Self-completion post-bereavement survey. SETTING/PARTICIPANTS Census of deaths registered in two health districts between October 2009 and April 2010. Views of Informal Carers - Evaluation of Services Short Form was sent to each informant (n = 1422; usually bereaved relative) 6-12 months post-bereavement. RESULTS Response was 33%. In all, 35.7% of respondents reported that the deceased said where they wanted to die, and 49.3% of these were reported to achieve this. Whilist 73.9% of those who were reported to have a preference cited home as the preferred place, only 13.3% of the sample died at home. Cancer patients were more likely to be reported to achieve preferences than patients with other conditions (p < .01). Being reported to have a record of preferences for place of death increased the likelihood of dying at home (odds ratio = 22.10). When rating care in the last 2 days, respondents were more likely to rate 'excellent' or 'good' for nursing care (p < .01), relief of pain (p < .01) and other symptoms (p < .01), emotional support (p < .01) and privacy of patient's environment (p < .01) if their relative died in their preferred place. CONCLUSIONS More work is needed to encourage people to talk about their preferences at the end of life: this should not be restricted to those known to be dying. Increasing knowledge and achievement of preferences for place of death may also improve end-of-life care.
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Affiliation(s)
- Katherine J Hunt
- 1Faculty of Health Sciences, University of Southampton, Southampton, UK
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Holt V, Bernstein D, Jones A, Millington-Sanders C, Ormerod G. Out-of-hours special patient notes. LONDON JOURNAL OF PRIMARY CARE 2013; 5:102-105. [PMID: 25949699 PMCID: PMC3960641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In 2011, an out-of-hours service in central London reviewed its system for special patient notes (SPNs) - a main mechanism to communicate valuable information about patients to the clinicians who cover two-thirds of the week when day-time general practices are closed. This revealed that: half of frequent callers did not have an SPNabout half of existing SPNs were out of dateday-time general practitioners (GPs) respond well to requests by out-of-hours doctors to provide an SPNproviding SPNs was low on the list of priorities of day-time GPs who were too busy reacting to everyday problems.
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Affiliation(s)
- Victoria Holt
- London Central & West Unscheduled Care Collaborative, St Charles Centre for Health and Wellbeing, London, UK
| | - Dan Bernstein
- London Central & West Unscheduled Care Collaborative, St Charles Centre for Health and Wellbeing, London, UK
| | - Adam Jones
- London Central & West Unscheduled Care Collaborative, St Charles Centre for Health and Wellbeing, London, UK
| | | | - Georgina Ormerod
- London Central & West Unscheduled Care Collaborative, St Charles Centre for Health and Wellbeing, London, UK
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Howell DM, Abernathy T, Cockerill R, Brazil K, Wagner F, Librach L. Predictors of home care expenditures and death at home for cancer patients in an integrated comprehensive palliative home care pilot program. ACTA ACUST UNITED AC 2012; 6:e73-92. [PMID: 22294993 DOI: 10.12927/hcpol.2011.22179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Empirical understanding of predictors for home care service use and death at home is important for healthcare planning. Few studies have examined these predictors in the context of the publicly funded Canadian home care system. This study examined predictors for home care use and home death in the context of a "gold standard" comprehensive palliative home care program pilot in Ontario where patients had equal access to home care services. METHODS Secondary clinical and administrative data sources were linked using a unique identifier to examine multivariate factors (predisposing, enabling, need) on total home care expenditures and home death for a cohort of cancer patients enrolled in the HPCNet pilot. RESULTS SUBJECTS WITH GASTROINTESTINAL SYMPTOMS (OR: 1.64; p=0.03) and those with higher income had increased odds of dying at home (OR: 1.14; p<0.001), whereas age, number of GP visits, gastrointestinal symptoms (i.e., nausea, vomiting, bowel obstruction) and eating problems (i.e., anorexia/cachexia) predicted home care expenditures. CONCLUSIONS Predictors of home death found in earlier studies appeared less important in this comprehensive palliative home care pilot. An income effect for home death observed in this study requires examination in future controlled studies. RELEVANCE Access to palliative home care that is adequately resourced and organized to address the multiple domains of issues that patients/families experience at the end of life has the potential to enable home death and shift care appropriately from limited acute care resources.
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Affiliation(s)
- Doris M Howell
- Princess Margaret Hospital, University Health Network, Toronto, ON
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Tellett L, Pyle L, Coombs M. End of life in intensive care: Is transfer home an alternative? Intensive Crit Care Nurs 2012; 28:234-41. [DOI: 10.1016/j.iccn.2012.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 01/10/2012] [Accepted: 01/20/2012] [Indexed: 11/17/2022]
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Zimmermann C. Acceptance of dying: a discourse analysis of palliative care literature. Soc Sci Med 2012; 75:217-24. [PMID: 22513246 DOI: 10.1016/j.socscimed.2012.02.047] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 02/15/2012] [Accepted: 02/21/2012] [Indexed: 11/19/2022]
Abstract
The subject of death denial in the West has been examined extensively in the sociological literature. However, there has not been a similar examination of its "opposite", the acceptance of death. In this study, I use the qualitative method of discourse analysis to examine the use of the term "acceptance" of dying in the palliative care literature from 1970 to 2001. A Medline search was performed by combining the text words "accept or acceptance" with the subject headings "terminal care or palliative care or hospice care", and restricting the search to English language articles in clinical journals discussing acceptance of death in adults. The 40 articles were coded and analysed using a critical discourse analysis method. This paper focuses on the theme of acceptance as integral to palliative care, which had subthemes of acceptance as a goal of care, personal acceptance of healthcare workers, and acceptance as a facilitator of care. For patients and families, death acceptance is a goal that they can be helped to attain; for palliative care staff, acceptance of dying is a personal quality that is a precondition for effective practice. Acceptance not only facilitates the dying process for the patient and family, but also renders care easier. The analysis investigates the intertextuality of these themes with each other and with previous texts. From a Foucauldian perspective, I suggest that the discourse on acceptance of dying represents a productive power, which disciplines patients through apparent psychological and spiritual gratification, and encourages participation in a certain way to die.
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Affiliation(s)
- Camilla Zimmermann
- University of Toronto, 610 University Ave., 16-712, Toronto, Ontario, Canada M5G 2M9.
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O'Brien M, Jack B. Barriers to dying at home: the impact of poor co-ordination of community service provision for patients with cancer. HEALTH & SOCIAL CARE IN THE COMMUNITY 2010; 18:337-345. [PMID: 20039968 DOI: 10.1111/j.1365-2524.2009.00897.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
For patients dying of cancer, there is an emphasis on giving choice regarding preferred location for care, with the option of dying at home, which is integral to UK government health initiatives such as the End of Life Care Programme. However, patients continue to be admitted to hospital in the terminal phase of their illness when they have expressed a desire to die at home. A qualitative study, using two audio tape-recorded focus group interviews, with a purposive sample of district nurses and community specialist palliative care nurses (19) was undertaken across two primary care trusts in the north west of England. Data were analysed using a thematic analysis approach. From a service provision perspective, the results reveal that poor discharge planning and co-ordination, difficulty in establishing additional equipment and services together with inadequate out of hours medical provision were all factors contributing to hospital admissions for patients with cancer in the last hours and days of life, and thus were barriers to dying at home.
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Affiliation(s)
- Mary O'Brien
- Evidence-based Research Centre, Faculty of Health, Edge Hill University, St Helen's Road, Ormskirk, Lancashire, UK.
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26
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Momm F, Lingg S, Xander C, Adebahr S, Grosu AL, Becker G. Die Situation der Angehörigen von Strahlentherapiepatienten. Strahlenther Onkol 2010; 186:344-50. [DOI: 10.1007/s00066-010-2111-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 02/24/2010] [Indexed: 10/19/2022]
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JACK B, O'BRIEN M. Dying at home: community nurses' views on the impact of informal carers on cancer patients' place of death. Eur J Cancer Care (Engl) 2009; 19:636-42. [DOI: 10.1111/j.1365-2354.2009.01103.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Iecovich E, Carmel S, Bachner YG. Where they want to die: correlates of elderly persons' preferences for death site. SOCIAL WORK IN PUBLIC HEALTH 2009; 24:527-542. [PMID: 19821191 DOI: 10.1080/19371910802679341] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The purpose of this study is to characterize older people who prefer dying at home versus those who prefer dying elsewhere. Data were drawn from a longitudinal study that was conducted of 1138 elderly persons in Israel. The results showed that the vast majority of the respondents preferred to die in their homes. Those who preferred to die at home did not differ significantly in most sociodemographic characteristics from those who preferred to die elsewhere except for marital status, economic status, living arrangements, and place of residence. The preference for the death site showed that those who lived with somebody, had trust in the family, and had frequent social contacts preferred to die at home.
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Affiliation(s)
- Esther Iecovich
- Master's Program in Gerontology, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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29
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Wowchuk SM, Wilson EA, Embleton L, Garcia M, Harlos M, Chochinov HM. The Palliative Medication Kit: An Effective Way of Extending Care in the Home for Patients Nearing Death. J Palliat Med 2009; 12:797-803. [DOI: 10.1089/jpm.2009.0048] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - E. Adriana Wilson
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia
| | - Lori Embleton
- Winnipeg Regional Health Authority (WRHA) Palliative Care Program, Winnipeg, Canada
| | - Marcelo Garcia
- Winnipeg Regional Health Authority (WRHA) Palliative Care Program, Winnipeg, Canada
| | - Mike Harlos
- Winnipeg Regional Health Authority (WRHA) Palliative Care Program, Winnipeg, Canada
| | - Harvey Max Chochinov
- Winnipeg Regional Health Authority (WRHA) Palliative Care Program, Winnipeg, Canada
- Department of Psychiatry, Family Medicine, University of Manitoba, Winnipeg, Canada
- Manitoba Palliative Care Research Unit, CancerCare Manitoba, Winnipeg, Canada
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Lind L, Karlsson D. A system for symptom assessment in advanced palliative home healthcare using digital pens. ACTA ACUST UNITED AC 2009; 29:199-210. [PMID: 15742987 DOI: 10.1080/14639230400005966] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Symptom control is one of the most important components of delivering effective palliative care, and adequate symptom assessment is a prerequisite for good symptom control. Patients receiving treatment in palliative home healthcare is geographically separated from the caregivers making symptom control a challenge, a challenge that could be met by the use of information and communication technology. Technologies of today offer different ways for patients to assess their symptoms at home and send the assessments to the healthcare provider. Examples are the use of a PC, a touch-tone telephone, and a digital pen, which require different kinds of infrastructure in the patient's home, and which differ in strengths and weaknesses. As part of an ongoing quality assurance work within the hospital-based home care clinic at Linköping University Hospital, the project has designed, developed and implemented an IT-support system for pain assessments for patients at home using digital pen and mobile Internet technology. A questionnaire study indicated that pain assessment using digital pens was accepted by patients and that problems mainly arose from the use of the visual-analogue scale.
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Affiliation(s)
- Leili Lind
- Department of Biomedical Engineering/Medical Informatics, Linköpings universitet, Sweden.
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Schiessl C, Bidmon J, Sittl R, Griessinger N, Schüttler J. [Patient-controlled analgesia (PCA) in outpatients with cancer pain. Analysis of 1,692 treatment days]. Schmerz 2008; 21:35-8, 40-2. [PMID: 16955293 DOI: 10.1007/s00482-006-0500-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In the home-care setting, cancer pain patients in need of parenteral analgesia have to be switched to patient-controlled analgesia using portable pumps. But there is a paucity on data on the logistic requirements or the success rate of such a cost-intensive therapy performed by specialized home-care services. METHODS In a retrospective study we analyzed data on care intensity, logistics and outcome of 46 consecutive palliative cancer patients with patient-controlled analgesia (PCA) in a home-care setting. RESULTS On days 1, 2, and 3 of PCA the switch to parenteral analgesia resulted in a significant increase of the median daily opioid dose in comparison to the dose just prior to PCA. Concurrently, pain scores were significantly reduced. The median duration of PCA was 25 days (range 2-189 days). On average, each patient was seen by the home-care team every 7.4 days. The median duration of the home visits was 60 min (range, 10-190 min). Of the visits 20% were unscheduled, most of these visits being due to problems regarding analgesia. Most patients died at home. Insufficient analgesia required prefinal hospitalization in only a single case. CONCLUSION If the indications are correct, intravenous PCA for palliative cancer pain patients results in higher opioid consumption and better pain control. Home-care PCA requires a lot of human and financial resources, but pain-related hospitalization can be prevented.
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Affiliation(s)
- C Schiessl
- Schmerzambulanz der Anästhesiologischen Klinik, Universitätsklinikum, Erlangen.
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32
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Abstract
Palliative medicine provides end-of-life care to terminally ill patients with a focus on pain and symptom management, psychosocial and spiritual support and bereavement follow-up. This article reviews some of the more recent literature on the subject of palliative care focusing on educational barriers to quality palliative care, advances in quality assessment, and advances in pain and symptom management.
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Affiliation(s)
- S J McGarrity
- Department of Anaesthesia, M.S. Hershey Medical Centre, Penn State Geisinger Health System, Hershey, Pennsylvania 17033, USA.
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33
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Thomas K, Noble B. Improving the delivery of palliative care in general practice: an evaluation of the first phase of the Gold Standards Framework. Palliat Med 2007; 21:49-53. [PMID: 17169960 DOI: 10.1177/0269216306072501] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Gold Standards Framework (GSF) was developed to improve the delivery of palliative care in general practice. AIM The aim of the study was to evaluate the first phase of GSF in terms of its acceptability to primary care teams, effectiveness in changing practice and professionals' views on the consequences for patient care. METHODS A prospective longitudinal comparative survey of 12 participating, 12 matched and 18 other practices included focus groups and questionnaires. RESULTS Participating practices reported that the GSF was acceptable. They also reported more standards successfully achieved than matched practices. Registers, team meetings and co-ordinated care were thought to have improved communication, teamwork, patient identification, assessment and care planning. CONCLUSIONS This small study suggests that the GSF appears to be acceptable and its early introduction to a few teams appears to have changed practice. Participants were positive about the effect on care. An evaluation of national uptake and further research into clinical outcomes is required.
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Affiliation(s)
- Keri Thomas
- John Taylor Hospice, Birmingham and School of Health Sciences, University of Birmingham, Birmingham, UK
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Aabom B, Kragstrup J, Vondeling H, Bakketeig LS, Stovring H. Does persistent involvement by the GP improve palliative care at home for end-stage cancer patients? Palliat Med 2006; 20:507-12. [PMID: 16903404 DOI: 10.1191/0269216306pm1169oa] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To analyse the effect of GP home visits on the granting of a terminal declaration (TD) and on place of death. PARTICIPANTS AND DESIGN A total of 2025 patients with cancer as the primary cause of death in the period 1997-1998, were investigated in a mortality follow-back design using the Danish Cancer Register and four administrative registers. The Danish TD can be issued by a physician for patients with an estimated prognosis of six months or less. The TD gives the right to economic benefits and increased care for the dying patient. SETTING The island of Funen/Denmark. MAIN OUTCOME MEASURES Main outcome--hospital death. Intermediate outcome--TD. RESULTS A total of 38% of patients received a TD and 56% died in hospital. GP home visits in the week before TD (odds ratio (OR): 16.8; 95% CI: 8.2-34.4), as well as four weeks before TD (OR: 6.4; 95% CI: 4.5-9.2) were associated with an increased likelihood of receiving a TD. GP home visits in the group with TD (OR: 0.18; 95% CI: 0.11-0.29) and the group without TD (OR: 0.08; 95% CI: 0.05-0.13) was inversely associated with hospital death. A dose-response relationship was found in both groups. CONCLUSION Persistent involvement by the GP is associated with improved end-of-life care for cancer patients. Provided that temporal relations are taken into account, the mortality follow-back design can be a suitable and ethical research method to highlight and monitor end-of-life cancer care.
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Affiliation(s)
- Birgit Aabom
- Research Unit for General Practice, University of Southern Denmark, J.B. Winsloøws Vej 9A, 5000 Odense C, Denmark.
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35
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Gómez-Batiste X, Tuca A, Corrales E, Porta-Sales J, Amor M, Espinosa J, Borràs JMA, de la Mata I, Castellsagué X. Resource consumption and costs of palliative care services in Spain: a multicenter prospective study. J Pain Symptom Manage 2006; 31:522-32. [PMID: 16793492 DOI: 10.1016/j.jpainsymman.2005.11.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2005] [Indexed: 11/25/2022]
Abstract
Patients (n=395) with terminal-stage cancer receiving attention from palliative care services (PCSs) were recruited over a period of 15 consecutive days from 171 participating PCS units. Resource consumption and costs were evaluated for 16 weeks of follow-up, and the findings were compared with a study conducted in 1992 so as to assess change over time. The most frequent health care interventions were homecare visits, hospital admissions, and patient-consultant phone calls. PCS provided 67% of all services and consultation interventions in 91% of patients. Compared with the historical data, there was a significant shift from the use of conventional hospital beds toward palliative care beds, a reduced hospital stay (25.5-19.2 days; P=0.002), an increase in the death-at-home option (31%-42%), a lower use of hospital emergency rooms (52%-30.6%; P=0.001), and an increase in programmed care. Compared to the previous resource consumption and expenditure study in 1992, the current PCS policy implies a cost saving of 61%, with greater efficiency and no compromise of patient care.
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Affiliation(s)
- Xavier Gómez-Batiste
- Palliative Care Service (X.G.-B., A.T., E.C., J.P.-S., J.E.), and Cancer Epidemiology Unit (X.C.), Institut Català d'Oncologia, Barcelona, Spain.
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Yun YH, Lim MK, Choi KS, Rhee YS. Predictors associated with the place of death in a country with increasing hospital deaths. Palliat Med 2006; 20:455-61. [PMID: 16875117 DOI: 10.1191/0269216306pm1129oa] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate the contribution of type of illness, socio-demographic factors, and area of residence to the place of death in a country with increasing hospital deaths. DESIGN Descriptive study of hospital deaths using a 10-year death registration database from the Korean National Statistical Office. SETTING AND PARTICIPANTS Through the National Vital Statistics System, 2,402,259 deaths were registered in Korea from 1992 to 2001. MEASUREMENT AND MAIN RESULTS There was a significant trend toward an increase in the proportion of hospital deaths, from 16.6% in 1992 to 39.9% in 2001. The proportion of deaths at home decreased over that period, from 72.9 to 49.2%. The risk of hospital death versus home death was lower for those aged 75 years and over (adjusted odds ratio: 0.212; 95% confidence interval: 0.210-0.214) compared with those <55 years, and for people who were highly educated (2.04; 2.02-2.06), had white-collar jobs (1.55; 1.54-1.57), and resided in areas with more available hospital beds (2.46; 2.42-2.51). Compared with other causes of death, the risk of dying in hospital was higher for patients with ischaemic heart disease (1.83; 1.79-1.86), cancer (1.25; 1.23-1.26) and chronic lower respiratory disease (1.21; 1.18-1.23). CONCLUSIONS Trends in place of death are influenced by available hospital beds, socio-demographic factors and the nature of the terminal disease, in a country with increasing hospital deaths. These associations should be viewed within the context of culture and local health care systems.
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Affiliation(s)
- Young Ho Yun
- Quality of Cancer Care Branch, Research Institute and Hospital, National Cancer Center 809, Madu-dong, Ilsan-gu, Goyang-si, Gyeonggi-do, 411-769, Korea.
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Plummer S, Hearnshaw C. Reviewing a new model for delivering short-term specialist palliative care at home. Int J Palliat Nurs 2006; 12:183-8. [PMID: 16723964 DOI: 10.12968/ijpn.2006.12.4.21016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The transition period between inpatient and community care is often a time of anxiety for patients receiving palliative care and their families. The team at Michael Sobell House designed and implemented a new community palliative care nursing service in order to ease the difficulties associated with moving between these settings. The new model offered short-term support for nurses trained in specialist palliative care who provide hands-on care, psychological support, night nursing or advice and support. The service supplemented existing community teams in order to offer a quick response to patient need. The service was evaluated at the end of the first year using two methods: an audit examining the first year's activity; and a questionnaire to health professionals who had used the service. Insight into the origins of referrals, the tasks performed by the outreach nurses and the aims of each patient episode were gained. Healthcare professionals' feedback was positive and gave some areas for suggested improvement. Reflections included issues relating to collaborative working between services, gaining a greater understanding of the problems associated with facilitating a home death and exploring potential areas of service expansion.
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Affiliation(s)
- Sue Plummer
- East and North Hertfordshire NHS Trust, Lister Hospital, Coreys Mill Lane, Stevenage, Hertfordshire.
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38
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Worth A, Boyd K, Kendall M, Heaney D, Macleod U, Cormie P, Hockley J, Murray S. Out-of-hours palliative care: a qualitative study of cancer patients, carers and professionals. Br J Gen Pract 2006; 56:6-13. [PMID: 16438809 PMCID: PMC1821404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND New out-of-hours healthcare services in the UK are intended to offer simple, convenient access and effective triage. They may be unsatisfactory for patients with complex needs, where continuity of care is important. AIM To explore the experiences and perceptions of out-of-hours care of patients with advanced cancer, and with their informal and professional carers. DESIGN OF STUDY Qualitative, community-based study using in-depth interviews, focus groups and telephone interviews. SETTING Urban, semi-urban and rural communities in three areas of Scotland. METHOD Interviews with 36 patients with advanced cancer who had recently used out-of-hours services, and/or their carers, with eight focus groups with patients and carers and 50 telephone interviews with the patient's GP and other key professionals. RESULTS Patients and carers had difficulty deciding whether to call out-of-hours services, due to anxiety about the legitimacy of need, reluctance to bother the doctor, and perceptions of triage as blocking access to care and out-of-hours care as impersonal. Positive experiences related to effective planning, particularly transfer of information, and empathic responses from staff. Professionals expressed concern about delivering good palliative care within the constraints of a generic acute service, and problems accessing other health and social care services. CONCLUSIONS Service configuration and access to care is based predominantly on acute illness situations and biomedical criteria. These do not take account of the complex needs associated with palliative and end-of-life care. Specific arrangements are needed to ensure that appropriately resourced and integrated out-of-hours care is made accessible to such patient groups.
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Affiliation(s)
- Allison Worth
- Cancer Care Research Centre, University of Stirling, Stirling, Scotland FK9 4LA, UK.
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Harding R, Leam C. Clinical notes for informal carers in palliative care: recommendations from a random patient file audit. Palliat Med 2005; 19:639-42. [PMID: 16450881 DOI: 10.1191/0269216305pm1092oa] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although palliative care aims to support family members and informal carers, current evidence suggests that high levels of unmet need persist, and that this population is challenging to work with. This study aimed to 1) measure the proportion of patients that have an informal carer, 2) describe the clinical notes data on existing needs and coping, 3) measure the completeness of assessment data recording, 4) appraise the utility of existing informal carers' sections in the patient files, and 5) make recommendations for improvement. An audit was conducted reviewing 145 closed patient files. Of these, 100 had identifiable informal carers (69.9%). Although patient data was complete, data was severely lacking on their informal carer. Diverse coping strategies were described, and the primary need was for finance and advice about state welfare payments (n=64). The findings suggest a need for files to identify and record informal carers as potentially distinct from family members, promote assessment data completion for informal carers on a par with that of patients, and to develop systematic approaches to systems that maximize utility and incorporate multiprofessional input into the development of clinical notes.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care, Policy and Rehabilitation, Guy's King's & St Thomas' School of Medicine, King's College London, London, UK.
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40
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King N, Thomas K, Martin N, Bell D, Farrell S. 'Now nobody falls through the net': practitioners' perspectives on the Gold Standards Framework for community palliative care. Palliat Med 2005; 19:619-27. [PMID: 16450879 DOI: 10.1191/0269216305pm1084oa] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Gold Standards Framework (GSF) seeks to facilitate consistent and high quality community palliative care through a set of guidelines, mechanisms and assessment tools. The present study set out to examine practitioners' perspectives on the GSF during its first national roll-out. Two general practices that had adopted the GSF were recruited in each of four geographical areas, and each matched as closely as possible with a non-GSF practice. Sixty-eight semi-structured telephone interviews were carried out with general practitioners and district nurses in 16 selected practices, along with the GSF facilitator and up to four other 'stakeholders' in each area. Analysis revealed that the majority of GSF participants felt that the framework had strengthened their provision of community palliative care. In particular, communication within primary health care teams and co-ordination of services improved, aspects which were better in the GSF practices than in the matched non-GSF practices. Practitioners felt there was more consistency of care, with a reduced likelihood that individual patients would 'slip through the net'. The most common areas of concern were in relation to the workload associated with the role of the GSF co-ordinator. Implications for the development and effective implementation of the framework and for further research are discussed.
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Affiliation(s)
- Nigel King
- Primary Care Research Group, School of Human and Health Sciences, University of Huddersfield, Queensgate, UK.
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41
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Sullivan KA, McLaughlin D, Hasson F. Exploring district nurses' experience of a hospice at home service. Br J Community Nurs 2005; 10:496-502. [PMID: 16301923 DOI: 10.12968/bjcn.2005.10.11.19958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hospice at home (HAH) services complement the role of the district nursing team, providing 24-hour palliative home care. However, little is known about district nurses' experience or perceptions of working alongside the HAH service. This study surveyed a representative sample of district nurses (DNs) to ascertain their experience of working alongside an HAH service. A self-completed postal questionnaire comprised of 14 items was distributed to 128 DNs. The evaluation found significant levels of satisfaction. All respondents indicated that they would refer a patient to the service again. However, the need for improved communication and increased awareness among DNs about the HAH service were also identified. The findings support the idea that an HAH service can enable patients with advanced progressive disease to be cared for at home. While the findings of this study cannot be generalized, they add to the growing body of research about HAH services in palliative care.
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Affiliation(s)
- Kate A Sullivan
- School of Health and Social Care, North East Wales Institue of Higher Education, Wrexham, Wales
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42
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Sullivan KA, McLaughlin D, Hasson F. Exploring district nurses’ experience of a hospice at home service. Int J Palliat Nurs 2005; 11:458-66. [PMID: 16215523 DOI: 10.12968/ijpn.2005.11.9.19779] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM this study surveyed a representative sample of district nurses (DNs) to ascertain their experience of working alongside a HAH service. METHOD a self-completed postal questionnaire comprised of 14 items was distributed to 128 DNs. RESULTS the evaluation found significant levels of satisfaction. All respondents indicated that they would refer a patient to the service again. However, the need for improved communication and increased awareness among DNs about the HAH service were also identified. CONCLUSION the findings support the idea that a HAH service can enable patients with advanced progressive disease to be cared for at home. While the findings of this study cannot be generalized, they add to the growing body of research about HAH services in palliative care.
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Affiliation(s)
- Kate A Sullivan
- School of Health and Social Care, North East Wales Institute of Higher Education, Plas Coch Campus, Mold Road, Wrexham LL11 2AW, Wales, UK
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43
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Brazil K, Howell D, Bedard M, Krueger P, Heidebrecht C. Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med 2005; 19:492-9. [PMID: 16218162 DOI: 10.1191/0269216305pm1050oa] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES (1) To determine informal caregivers perceptions about place of care and place of death; and (2) to identify variables associated with a home death among terminally ill individuals who received in-home support services in a publicly funded home care system. PARTICIPANTS AND DESIGN A total of 216 informal caregivers participated in a bereavement interview. Data collection included care recipient and informal caregiver characteristics, the use of and satisfaction with community services, and preferences about place of death. RESULTS Most caregivers reported that they and the care recipient had a preferred place of death (77 and 68%, respectively) with over 63% reporting home as the preferred place of death. Caregivers had a greater preference for an institutional death (14%) than care recipients (4.7%). While 30% of care recipients did not die in their preferred location, most caregivers (92%) felt, in retrospect, that where the care recipient died was the appropriate place of death. Most caregivers reported being satisfied with the care that was provided. The odds of dying at home were greater when the care recipient stated a preference for place of death (OR: 2.92; 95% CI: 1.25, 6.85), and the family physician made home visits during the care recipients last month of life (Univariate odds ratios (OR): 4.42; 95% CI: 1.46, 13.36). DISCUSSION The ethic of self-control and choice for the care recipient must be balanced with consideration for the well being of the informal caregiver and responsiveness of the community service system.
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Affiliation(s)
- Kevin Brazil
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
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44
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Catt S, Blanchard M, Addington-Hall J, Zis M, Blizard R, King M. Older adults' attitudes to death, palliative treatment and hospice care. Palliat Med 2005; 19:402-10. [PMID: 16111064 DOI: 10.1191/0269216305pm1037oa] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cancer patients who receive care from specialist palliative care services in the UK are younger than those who do not receive this care. This may be explained by age-related differences in attitudes to end-of-life care. OBJECTIVE To determine the relationship between age and i) attitudes to death and preparation for death; and ii) knowledge about, and attitudes to, cancer and palliative care. DESIGN Interviews with older people, using a novel questionnaire developed using nominal groups. Main comparisons were made between people aged 55-74 with those aged 75 years and over. SETTING General practices in London. SUBJECTS 129 people aged 55-74 and 127 people aged 75 years or over on the lists of general practitioners. METHODS A cross-sectional survey to determine knowledge and experience of hospice care; preparation for end-of-life; and attitudes to end-of-life issues. RESULTS Participants were knowledgeable about specialist palliative care and almost half had some indirect contact with a hospice. People aged >74 were less likely than younger participants to want their doctor to end their life in a terminal illness. Although they believed death was easier to face for older people, they did not believe that younger people deserved more consideration than older people when dying, or that they should have priority for hospice care. Education, social class, hospice knowledge and anxiety about death had little influence on overall attitudes. CONCLUSIONS The relative under-utilization of hospice and specialist palliative care services by older people with cancer in the UK cannot be explained by their attitudes to end-of-life issues and palliative care.
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Affiliation(s)
- Susan Catt
- Department of Mental Health Sciences, Royal Free and University College Medical School (UCL), London, UK.
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45
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Abstract
The purpose of this paper is to describe the variations in and factors influencing family members' decisions to provide home-based palliative care. Findings were part of a larger ethnographic study examining the social context of home-based palliative caregiving. Data from participant observations and in-depth interviews with family members (n=13) providing care to a palliative patient at home, interviews with bereaved family members (n=47) and interviews with health care providers (n=25) were subjected to constant comparative analysis. Findings indicate decisions were characterized by three types. Some caregivers made uninformed decisions, giving little consideration to the implications of their decisions. Others made indifferent decisions, whereby they reluctantly agreed to provide care at home, and still others negotiated decisions for home care with the dying person. Decisions were influenced by three factors: fulfilling a promise to the patient to be cared for at home, desiring to maintain a 'normal family life' and having previous negative encounters with institutional care. Findings suggest interventions are needed to better prepare caregivers for their role, enhance caregivers' choice in the decision-making process, improve care for the dying in hospital, and consider the development of alternate options for care.
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Affiliation(s)
- Kelli I Stajduhar
- Centre on Aging, University of Victoria and Vancouver Island Health Authority, Victoria, BC, Canada.
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Thomas C. The place of death of cancer patients: can qualitative data add to known factors? Soc Sci Med 2004; 60:2597-607. [PMID: 15814184 DOI: 10.1016/j.socscimed.2004.10.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2003] [Accepted: 10/25/2004] [Indexed: 11/18/2022]
Abstract
Research on the distribution of cancer deaths by setting-hospital, hospice, home, other--is longstanding, but has been given fresh impetus in the UK by policy commitments to increase the proportion of deaths occurring in patients' homes. Studies of factors associated with the location of cancer deaths fall into two main categories: geo-epidemiological interrogations of routinely collected death registration data, and prospective and retrospective cohort studies of terminally ill cancer patients. This paper summarises the findings of these studies and considers the place of death factors that are generated in semi-structured interviews with 15 palliative care service providers working in the Morecambe Bay area of north-west England. These qualitative data are found not only to confirm and considerably enrich understanding of known factors, but also to bring new factors into view. New factors can be grouped under the headings: service infrastructure, patient and carer attitudes, and cultures of practice. Such an approach provides useful information for policy makers and practitioners in palliative care.
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Affiliation(s)
- Carol Thomas
- Institute for Health Research, Lancaster University, Alexander Square, Lancaster LA1 4YL, UK.
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Ahlner-Elmqvist M, Jordhøy MS, Jannert M, Fayers P, Kaasa S. Place of death: hospital-based advanced home care versus conventional care. A prospective study in palliative cancer care. Palliat Med 2004; 18:585-93. [PMID: 15540666 DOI: 10.1191/0269216304pm924oa] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this prospective nonrandomized study was to evaluate time spent at home, place of death and differences in sociodemographic and medical characteristics of patients, with cancer in palliative stage, receiving either hospital-based advanced home care (AHC), including 24-hour service by a multidisciplinary palliative care team or conventional hospital care (CC). Recruitment to the AHC group and to the study was a two-step procedure. The patients were assigned to either hospital-based AHC or CC according to their preferences. Following this, the patients were asked to participate in the study. Patients were eligible for the study if they had malignant disease, were older than 18 years and had a survival expectancy of 2-12 months. A total of 297 patients entered the study and 280 died during the study period of two and a half years, 117 in the AHC group and 163 in the CC group. Significantly more patients died at home in the AHC group (45%) compared with the CC group (10%). Preference for and referral to hospital-based AHC were not related to sociodemographic or medical characteristics. However, death at home was associated with living together with someone. Advanced hospital-based home care targeting seriously ill cancer patients with a wish to remain at home enable a substantial number of patients to die in the place they desire.
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48
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Abstract
It has become commonplace to say that contemporary western society is 'death-denying'. This characterization, which sociologists have termed the 'denial of death thesis', first arose in the social science, psychological and clinical medical literature in the period between 1955 and 1985. During the same time period, the hospice and palliative care movements were developing and in part directed themselves against the perceived cultural denial of death in western society. While the denial of death has been taken for granted by the lay public as well as by clinicians, in the sociological literature it has been increasingly questioned. In this paper we use sociological critiques of the denial of death thesis to raise critical questions about the theory and practice of contemporary palliative care. In particular, we argue that the emphasis of palliative care should not be on extinguishing the denial of death but on the relief of suffering.
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Affiliation(s)
- Camilla Zimmermann
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, University of Toronto, Ontario, Canada.
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Milberg A, Strang P, Carlsson M, Börjesson S. Advanced Palliative Home Care: Next-of-Kin's Perspective. J Palliat Med 2003; 6:749-56. [PMID: 14622454 DOI: 10.1089/109662103322515257] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
GOALS (1). To describe what aspects are important when next-of-kin evaluate advanced palliative home care (APHC) and (2). to compare the expressed aspects and describe eventual differences among the three settings, which differed in terms of length of services, geographic location, and population size. SUBJECTS AND METHODS Four to 7 months after the patient's death (87% from cancer), 217 consecutive next-of-kin from three different settings in Sweden responded (response rate 86%) to three open-ended questions via a postal questionnaire. Qualitative content analysis was performed. MAIN RESULTS Service aspects and comfort emerged as main categories. The staff's competence, attitude and communication, accessibility, and spectrum of services were valued service aspects. Comfort, such as feeling secure, was another important aspect and it concerned the next-of-kin themselves, the patients, and the families. Additionally, comfort was related to interactional issues such as being in the center and sharing caring with the staff. The actual place of care (i.e., being at home) added to the perceived comfort. Of the respondents, 87% described positive aspects of APHC and 28% negative aspects. No major differences were found among the different settings. CONCLUSIONS Next-of-kin incorporate service aspects and aspects relating to the patient's and family's comfort when evaluating APHC. The importance of these aspects is discussed in relation to the content of palliative care and potential goals.
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Affiliation(s)
- Anna Milberg
- Linköpings Universitet, Division of Geriatrics and Palliative Research Unit, Linköping, Sweden.
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Harding R, Higginson IJ, Donaldson N. The relationship between patient characteristics and carer psychological status in home palliative cancer care. Support Care Cancer 2003; 11:638-43. [PMID: 12905058 DOI: 10.1007/s00520-003-0500-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2003] [Accepted: 05/28/2003] [Indexed: 10/26/2022]
Abstract
GOALS Despite being both providers and intended recipients of care, informal carers in cancer palliative care report high levels of distress and unmet needs. In order to develop supportive care strategies, this analysis aimed to identify which patient characteristics contribute to carer psychological distress and which coping strategies carers employ. PATIENTS AND METHODS Informal carers attending two home palliative care services gave cross-sectional data regarding patient characteristics and their own psychological status using standardised measures. Multivariate analyses were performed for each dependent carer psychological measure, with patient characteristics as independent variables (adjusted for carer age and gender). MAIN RESULTS Forty-three carers participated. Greater patient distress was associated with carer anxiety (b value: magnitude of the effect) (b=0.31, p=0.07), and both patient psychological status (b=0.37, p=0.02) and pain (b=0.29, p=0.09) were associated with carer psychological morbidity. Carer burden was associated with patient psychological distress (b=0.35, p=0.03) and pain (b=0.29, p=0.08). Carer avoidance/emotion-focused cognitive coping strategies were associated with patient physical function (b=0.34, p=0.04), and cognitive problem-focused coping was associated with patient symptoms (b=0.28, p=0.06) and physical function (b=0.29, p=0.05). CONCLUSIONS Adequate provision of patient psychological interventions and effective pain education and control are needed in order to improve carers' psychological health. Patient characteristics are associated with apparently opposing forms of carers' coping (i.e. both avoidance and engagement), demonstrating the importance of interventions addressing a range of coping responses. Further research is needed to understand why carers employ problem-focused coping in response to symptoms but not to pain. Evidence-based interventions for informal carers are urgently needed but must be delivered in the context of optimal patient pain and symptom control.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care and Policy, Guy's King's and St Thomas' School of Medicine, King's College London, Weston Education Centre, Cutcombe Road, SE5 9PJ, London, UK.
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