Palliative medicine

Assessing the Need for and Potential Role of a Day Hospice: A Qualitative Study

We conducted a qualitative case study as part of a needs assessment for a day hospice in a small Ontario city. Data were gathered from semi-structured interviews with 28 stakeholders: nine health care administrators, 11 health care providers, and eight lay people (terminally ill adults and informal caregivers). Respondents described support, counselling, social activities, and respite as key day hospice services. They also described several barriers to accessing services, including location, transportation, admission criteria, referrals, and fees. For most respondents, the ideal staff mix includes both volunteers and paid professionals in either a free-standing organization or institutionally linked hospice. Although the vast majority of participants were reluctant to impose admission criteria or other limitations on hospice clientele, they expressed the need to ensure equitable access to this scarce resource. Opinions varied greatly across stakeholder groups, highlighting the need to collect information from all relevant stakeholder groups when planning hospices.

Patientsʼ Experiences of Palliative Care in the Home

In recent times the rapid expansion of interest in palliative care has become a significant feature of health care development. Caring in the palliative way means simultaneous attention to the medical, nursing, spiritual, emotional, and social needs of the patient. The main purpose of the present study has been to obtain an understanding of patients' experiences of palliative care at home with service from district nurses. The research design is influenced by Giorgi's phenomenology. Six patients diagnosed with cancer and receiving palliative care at home were interviewed and the transcribed interviews were analyzed. Interviews were conducted in the patients' homes. The findings show that the essential meaning of the patients' experiences of palliative home care can be described as "uncertain safety." This meaning of essence is explicated by 4 themes, which are labeled "Safe but unsafe at home," "A sense of powerlessness," "Change of everyday life," and "Hope and belief in the future." The findings of the study point out the importance of well functioning teamwork and resources to facilitate patient's experiences of safety in their own homes. It should be noted that the patient and their next of kin are members of the team.

Family experiences of palliative care in the acute hospital setting

The study described in this article sought to gain understanding and insights into the lived experience of families who journeyed with their loved one through the palliative phase of illness as inpatients in the acute hospital setting. The study was carried out in a district general hospital which did not have the services of a palliative care team. A descriptive phenomenological approach was used as the researcher wanted the participants to describe their experience of palliative care in the acute hospital setting as they experienced it. This approach is described in detail. A purposive sample of eight family members was interviewed and data were analysed using Colaizzi's (1978) seven stages of data analysis. The results showed that the acute hospital environment had many shortcomings as a place to deliver palliative care and family members were at times left feeling isolated and helpless. The limitations of the study are discussed along with recommendations that could enhance outcomes of care for family members during this difficult period in their loved one's illness.

HIV infection: the spectrum of symptoms and disease in male and female patients attending a London hospice

To delineate the demographic features and clinical profile of male and female individuals utilizing a respite, rehabilitation and hospice centre in London, a retrospective study of patient notes was undertaken. The subjects were 59 male and 59 female HIV patients at first admission to the hospice. The study revealed clinically important differences between men and women and also identified special problems for African women and intravenous drug users. Women experienced more constipation, headache and musculoskeletal pain than men. Men suffered more neuropathic pain and visual loss. Lower respiratory tract infections were more common in women, especially in those with a history of injection drug use. Gynaecological morbidity was common. There was no difference in AIDS diagnoses between men and women. HIV encephalopathy developed in 23% of the cohort during the follow-up period which has implications for provider units. There are increasing numbers of HIV-positive women and injection drug users being referred for palliative care services. Multidisciplinary teams should be aware of the particular symptom profile of these groups.

Hospice and palliative care

The emergence of AIDS and the aging of the population, with the numerous malignant and debilitating maladies associated with growing older, have focused attention on the provision of cost-effective quality care by hospice and palliative care programs. Hospice and palliative care is a venerated system of care, which uses an interdisciplinary approach to address the medical, psychosocial, and spiritual issues that arise in the treatment of terminally ill patients. This interdisciplinary stratagem for symptom control is necessary to ensure that dying patients and their families are afforded dignity and quality of life through death and the period of familial bereavement. Although death is dominant in palliative situations, terminal care requires an affirmation of life and a recognition that dying is not an aberration of medical care but a natural and normal process. Palliative care, however, also requires a personal acceptance of death and an acknowledgment that dying does not denote a failure to provide good medical care but, rather, calls for an acquiescence that curative treatment is no longer feasible. Accordingly, the terminal state is an integral process and a time to reconcile differences so that patient and family may accept death with a minimum of physical, spiritual, and psychosocial anguish. This article discusses the various precepts cardinal to hospice and palliative care, including the philosophy of terminal care, the management of pain, the adverse effects of analgesic medications, the management of nonpain symptoms, the use of terminal sedation, and the stages of familial bereavement.

Dying from cancer: results of a national population-based investigation

OBJECTIVE

To describe the quality of care received in the last year of life by people who die from cancer, focusing particularly on symptom control, communication with health professionals, and care in the community.

DESIGN

Interview survey of family members or others who knew about the last year of life of a random sample of people who died in the UK in 1990, based upon methods used in nationally representative surveys by Cartwright in 1969, and Cartwright and Seale in 1987.

SETTING

Twenty district health authorities from a range of inner city, outer urban and rural settings. Although self-selected, districts were nationally representative in terms of social characteristics and on many indicators of health service provision and usage.

PARTICIPANTS

Interviews were obtained for 2074 cancer deaths out of a random sample of 2915, a 71% response rate.

MAIN RESULTS

At some stage in the last year of life, 88% were reported to have been in pain, 66% were said to have found it to be 'very distressing', and 61% to have experienced it in their last week. Treatment that only partially controlled the pain, if at all, was said to have been received by 47% of those treated for pain by their GPs and by 35% of hospital patients. Other common symptoms experienced by more than half the sample in their last year were loss of appetite, constipation, dry mouth or thirst, vomiting or nausea, breathlessness, low mood, and sleeplessness. Half of the respondents (51%) were unable to get all the information they wanted about the patient's medical condition when they wanted it. Relatives bore the brunt of caring for 81% of the sample. Of respondents who had helped to care for the deceased, 65% said that their activities had been at least fairly restricted, but 53% had found it rewarding. District nurses had helped 60% of the deceased, 20% had had a home help, and 9% had received 'meals on wheels'. More help with activities of daily living was reported to have been needed by 31%; 24% were reported to have needed more help with domestic chores; 25% were reported to have needed more financial help, and 29% were reported to have needed either more care from district nurses (if had some) or some care (if had none).

CONCLUSION

There is still some way to go before all dying cancer patients receive high quality care. Education in the principles of palliative care is needed at all levels of the NHS if high standards are to be reached. In addition, adequate resources are required to meet the social and health care needs of cancer patients at home. There is, as yet, no room for complacency about the care of dying cancer patients.

Appropriate palliative care: when does it begin?

The transition between a curative and a palliative approach to the care of a patient with cancer may be filled with uncertainty for patients, their families and health care professionals. A conventional model of treating the patient with cancer through curative, palliative and terminal phases is examined. The boundaries between the phases of care are blurred. A model of care based on respect for patient autonomy ensures that the timing of the switch from curative to palliative care is appropriate.