Palliative day care: what do services do? Palliative Day Care Project Group

Consensus-based recommendations for the development and expansion of palliative day care clinics in Germany: results of a Delphi study

BACKGROUND

Needs-based, patient-oriented palliative care includes palliative day care clinics as a specialized semi-inpatient care offer. However, the establishment and development of these facilities has been unsystematic. Research is needed to strengthen their transparency and ensure their accessibility, quality, and structural adequacy. A national Delphi study was conducted to generate appropriate recommendations for the establishment and development of palliative day care clinics in Germany.

METHODS

Recommendations were formulated from focus group data on the development and expansion of palliative day care clinics in Germany. Experts on in- and outpatient palliative care rated 28 recommendations for relevance and feasibility, respectively, using a 4-point Likert-type scale. Suggestions for improvement were captured via free text comments. Items were considered consented when more than 80% of the experts scored them 4 (strongly agree) or 3 (somewhat agree), regarding both relevance and feasibility.

RESULTS

A total of 23 experts (32% response rate) completed three Delphi rounds. Following the first round, 10 of 28 recommendations were revised according to participants' comments; 1 recommendation was rejected. After the second round, 3 of these 10 recommendations were revised, while 3 were rejected. Consensus was achieved after the third round for 22 of the initial recommendations.

CONCLUSIONS

The Delphi-consented recommendations provide a basis for the targeted evidence- and needs-based development of palliative day care clinics. The findings show a need for standards setting and the meaningful integration of these clinics into existing structures.

TRIAL REGISTRATION

The present study was prospectively registered on April 20, 2020, with the German Clinical Trials Register (DRKS00021446).

[Empirically derived recommendations for the development and expansion of day hospices in Germany - Results of a Delphi expert panel]

INTRODUCTION

A needs-based and patient-oriented hospice and palliative care also includes day hospices as a specialised semi-inpatient care offer. The establishment and development of these facilities in Germany has been rather unsystematic. In order to ensure quality and adequacy of these structures, research is needed.

METHODS

A Delphi consensus study was conducted online from November 2022 to February 2023 aiming at generating recommendations for the development and expansion of day hospices in Germany. For each recommendation, the participants indicated on a four-point verbal rating scale how much they agreed upon a) the relevance and b) the feasibility of the recommendation. Items were considered consented when 80% of the participants (strongly) agreed with the recommendation regarding both criteria. If no consensus was reached, the recommendations were revised according to the participants' free text comments and presented in the next Delphi round. Descriptive analyses were applied.

RESULTS

A total of 64 experts participated in the first Delphi round and 44 in the second. In round 1, 34 recommendations and in round 2 six recommendations were consented. The final set contains a total of 40 recommendations: 18 on the tasks of day hospices, 13 on cooperation, 7 on funding, and 2 on public relations.

DISCUSSION

Recommendations for the development and expansion of day hospices in Germany were developed. Due to their highly rated feasibility, the recommendations should be directly transferable into care practice. It remains to be seen to what extent they will be taken into account in the renegotiation of the framework agreement for day hospices.

CONCLUSION

The Delphi-consented recommendations provide a basis to guide action in the currently very dynamic development of hospice work and palliative care in Germany.

Live Well, Die Well: The Development of an Online, Arts-Based Palliative Care Programme in the Shadow of the COVID-19 Pandemic

The Covid-19 crisis led to an increase in the 'total pain' of many terminally ill patients who faced a reduction in support, due to the temporary closure of front-line palliative day therapy services. A hospice volunteer, I instigated an online day therapy programme for patients previously attending face-to-face day therapy. Participant feedback revealed the importance of providing a space for ongoing peer support for participants' changing sense of identity, an issue for time-limited day therapy programmes. An exploration of key concepts associated with palliative care established the multiple connections between such changing identity and arts-based approaches to living well. This article charts how I used this understanding to develop an alternative, online arts-based support programme, Live well, die well. It explores the links between ongoing mutual support, arts-based activity and the reactions to a shifting identity in patients with a life-limiting illness.

A survey of hospice day services in the United Kingdom & Republic of Ireland : how did hospices offer social support to palliative care patients, pre-pandemic?

INTRODUCTION

Social support is described by patients and other stakeholders to be a valuable component of palliative day care. Less is known about the range of hospice services that have been used in practice that facilitate social support. An online survey aimed to gain an overview of all hospice day services that facilitated social support for adults outside of their own homes.

METHODS

An online survey was distributed via email to people involved in managing hospice day services. Questions were asked on hospice characteristics, including staff and volunteer roles. Respondents were asked to identify services they felt offered social support to patients. Data collection took place between August 2017 and May 2018.

RESULTS

Responses were received from 103 hospices in the UK and ROI (response rate 49.5%). Results provide an overview of hospice day and outpatient services that offer social support to patients. These are: multi-component interventions, activity groups, formal support groups, befriending, and informal social activities. Multi-component interventions, such as palliative day care, were the most commonly reported. Their stated aims tend to focus on clinical aspects, but many survey respondents considered these multicomponent interventions to be the 'most social' service at their hospice. The survey also identified a huge variety of activity groups, as well as formal therapeutic support groups. Informal 'social-only' activities were present, but less common. Over a third of all the services were described as 'drop in'. Most responding hospices did not routinely use patient reported outcome measures in their 'most social' services.

CONCLUSIONS

The survey documents hospice activity in facilitating social support to be diverse and evolving. At the time of data collection, many hospices offered multiple different services by which a patient might obtain social support outside of their own home and in the presence of other patients.

Status, demand and practice models of palliative day-care clinics and day hospices: a scoping review

BACKGROUND

Little is known about the structure, accessibility, service provision and needs of palliative and hospice day-care in Germany and abroad. Researchers, healthcare providers and policy makers would benefit from a systematic overview.

AIM

The aim was to identify, describe and summarise available evidence on status, demand and practice models of palliative day-care clinics and day hospices. A secondary aim was to disclose research gaps and present recommendations for clinical practice and future research.

DESIGN

The scoping review followed the methodological framework of Arksey and O'Malley. The analysed publications included studies of varying kinds to describe the current state of the art.

DATA SOURCES

Using a highly sensitive search strategy, the authors searched PubMed, Web of Science Core Collection, CINAHL and Google Scholar within the publication window of inception to 12 June 2020. An additional hand search of the reference lists of the identified review articles was conducted.

RESULTS

The authors screened the titles and abstracts of 2643 studies, retrieved 197 full texts and included 32 articles in the review. The review identified nine major themes: (1) the referral process, (2) models of care, (3) patient characteristics, (4) demand, (5) the discharge process, (6) perceptions of services, (7) funding and costs, (8) outcome measurement and (9) education.

CONCLUSIONS

There is a need for further research to identify groups of patients who would receive the most benefit from palliative and hospice day-care and to determine any necessary revisions in admission criteria.

Status quo palliativmedizinischer Tageskliniken und Tageshospize in Deutschland: Ergebnisse einer gemischt-methodischen Studie

Ziel der Studie Der Bestand von Tageshospizen und palliativmedizinischen Tageskliniken in Deutschland soll erstmals systematisch erhoben und analysiert werden.

Methodik In dieser gemischt-methodischen Studie wurden Einrichtungsleitungen in leitfadengestützten Interviews (06.–07.2020) und standardisierter Fragebogenerhebung (08.–10.2020) zu einrichtungsbezogenen Kriterien befragt. Interviewdaten wurden qualitativ inhaltsanalytisch, quantitative Daten deskriptiv ausgewertet.

Ergebnisse Die Interviews (n = 7) liefern einen Überblick über Organisation und Versorgungsangebot hospizlich-palliativer Tageseinrichtungen. Von 28 standardisiert befragten Einrichtungen waren 13 bereits in Betrieb. Die zumeist an andere Versorger angebundenen Einrichtungen bieten in der Regel zwischen 2 und 8 Tagesplätze an.

Schlussfolgerung Aufgrund der gezeigten Entstehungsdynamik scheint eine systematische Integration der neuen Strukturen in die bestehende Hospiz- und Palliativversorgung sinnvoll.

Challenges for palliative care day services: a focus group study

BACKGROUND

Palliative care day services provide a safe environment for people with palliative care needs, enabling them to access a range of services while acting as a respite services for family caregivers. Viewed as marginal services, they are often under resourced and under researched. The aim of this study was to understand how palliative day care services contribute to client care from the perspective of management and hospice multidisciplinary teams.

METHODS

A descriptive qualitative study, using six focus groups conducted with staff at three United Kingdom hospices in England, Scotland and Northern Ireland. Thirty-five participants were recruited, including management and staff. Discussions were transcribed and analysed thematically.

RESULTS

Four key themes emerged: (1) variations of care, beyond heterogeneity of patients; (2) unclear referrals and inconsistent patient population; (3) recognising strengths and challenges and (4) an uncertain future. A major focus of group discussions was the model of care and the benefits of the service, however the importance of demonstrating services' effectiveness and value for money was highlighted.

CONCLUSIONS

Management and hospice staff believed day-services to be a helpful introduction to palliative care, providing both social and medical support. Economic pressures and patient demand were influencing them to move from a social model to a hybrid model. Further research is needed to understand the effectiveness of the service.

The Strengths and Challenges of Palliative Day-Care Centers

Background:

Palliative day-care centers are a marginal service within the palliative care landscape. Relevant research on the potential and added value of this service model is lacking, and it may therefore be underappreciated.

Aim:

To examine how representatives of Belgian palliative day-care centers perceive their strengths and added value, as well as the biggest challenges to their survival.

Design:

Qualitative study of individual interviews and an overarching focus group. Data collection was performed from December 2014 to April 2015. Inductive coding was used to extract relevant themes from the verbatim transcripts.

Setting/Participants:

Participants were professional representatives of all 5 Flemish palliative day-care centers: 7 participants for the individual interviews and 6 participants for the focus group.

Results:

Five strengths were identified: (1) unique care model, (2) contact with peers in a nonclinical environment, (3) a reliable and competent multiprofessional team, (4) care tailored to the individual, and (5) respite for family caregivers. The most significant challenges were (1) optimizing government funding and (2) achieving sufficiently high occupancy and referral. According to interviewees, this latter challenge was due to the low visibility of the service to professionals and the public, unclear referral criteria, and the psychological threshold for referral among patients and professionals.

Conclusions:

Palliative day-care centers strive to provide unique services for patients with advanced illness. However, negotiating adequate funding and raising referral by changing current perceptions are paramount to unlocking their potential. Scientific analysis of cost utility and patient outcomes associated with their use is necessary.

Patients' perceptions of palliative care quality in hospice inpatient care, hospice day care, palliative units in nursing homes, and home care: a cross-sectional study

Background

Patients’ perceptions of care quality within and across settings are important for the further development of palliative care. The aim was to investigate patients’ perceptions of palliative care quality within settings, including perceptions of care received and their subjective importance, and contrast palliative care quality across settings.

Method

A cross-sectional study including 191 patients in late palliative phase (73 % response rate) admitted to hospice inpatient care, hospice day care, palliative units in nursing homes, and home care was conducted, using the Quality from the Patients’ Perspective instrument-palliative care (QPP-PC). QPP-PC comprises four dimensions and 12 factors; “medical–technical competence” (MT) (2 factors), “physical–technical conditions” (PT) (one factor), “identity–orientation approach” (ID) (4 factors), “sociocultural atmosphere” (SC) (5 factors), and three single items (S); medical care, personal hygiene and atmosphere. Data were analysed using paired-samples t-test and analysis of covariance while controlling for differences in patient characteristics.

Results

Patients’ perceptions of care received within settings showed high scores for the factors and single items “honesty” (ID) and “atmosphere” (S) in all settings and low scores for “exhaustion” (MT) in three out of four settings. Patients’ perceptions of importance scored high for “medical care” (S), “honesty” (ID), “respect and empathy” (ID) and “atmosphere” (S) in all settings. No aspects of care scored low in all settings. Importance scored higher than perceptions of care received, in particular for receiving information. Patients’ perceptions of care across settings differed, with highest scores in hospice inpatient care for the dimensions; ID, SC, and “medical care” (S), the SC and “atmosphere” (S) for hospice day care, and “medical care” (S) for palliative units in nursing homes. There were no differences in subjective importance across settings.

Conclusion

Strengths of services related to identity–orientation approach and a pleasant and safe atmosphere. Key areas for improvement related to receiving information. Perceptions of subjective importance did not differ across settings, but perceptions of care received scored higher in more care areas for hospice inpatient care, than in other settings. Further studies are needed to support these findings, to investigate why perceptions of care differ across settings and to highlight what can be learned from settings receiving high scores.

Music Therapy References Relating to Cancer and Palliative Care

Hospitals and clinics worldwide have incorporated music therapy in their work with cancer patients and in palliative care. As the music therapy profession has developed internationally, so has its role in palliative care. The arts and creative arts therapies are being seen as a form of spiritual care in healthcare settings, particularly where individuals are confronting life-threatening illnesses. By offering opportunities to engage in the arts and develop creative expression, people with cancer can be enabled to mourn, grieve, celebrate life, be empowered to endure their situation, and find healing and meaning. In many studies we find that music therapy is not simply used with the identified patients but also with their families and carers. As well as noting the importance of work with patients and their families, music therapists also emphasise the importance of music for their own healing. This is necessary to meet personal needs when working with the dying and in the context of a broader hospital milieu of colleagues and friends.

The World Health Organisation's recommendations for cancer relief and palliative care are to affirm life and regard dying as a normal process, to provide relief from pain and distressing symptoms, to integrate the psychological and spiritual aspects of patient care, to offer a support system to help patients as actively as possible until death, and to offer a support system to help the family cope during the illness and in their own bereavement. Music therapy has the potential to meet all of these recommendations.

Implementing Outcome Measures Within an Enhanced Palliative Care Day Care Model

BACKGROUND

Specialist palliative care day care (SPDC) units provide an array of services to patients and their families and can increase continuity of care between inpatient and homecare settings. A multidisciplinary teamwork approach is emphasized, and different models of day care exist. Depending on the emphasis of care, the models can be social, medical, therapeutic, or mixed. We describe our experience of introducing an enhanced therapeutic specialist day care model and using both patient- and carer-rated tools to monitor patient outcomes.

MEASURES

Validated tools used to monitor patients' progress were the Edmonton Symptom Assessment System, the Edmonton Functional Assessment Tool, Part A of the McGill Quality of Life (QoL) Index, and the Palliative Care Problem Severity Scale.

INTERVENTION

Participating patients received multidisciplinary teamwork input over eight-week cycles of care and completed the validated tools.

OUTCOMES

A total of 70.6% of patients showed an improvement in their Edmonton Symptom Assessment System Symptom Distress Scores after one eight-week cycle. An improvement in Edmonton Functional Assessment Tool scores occurred in 53% and remained unchanged in 13% of patients. On a scale of 0-10, overall QoL improved in 56% of patients, remained unchanged in 18%, and worsened in 26%. Palliative Care Problem Severity Scale scores after an eight-week cycle improved in 58%.

CONCLUSIONS/LESSONS LEARNED

This enhanced therapeutic model of SPDC allows for the tracking of progress toward specific goals and monitoring of patients' symptoms, functional status, QoL, and complexity. Retrospective analyses of validated tools show SPDC results in both maintenance and improvement of all parameters.

Connectedness at the End of Life Among People Admitted to Inpatient Palliative Care

The significance of connectedness for well-being is well known. At the end of life however, illness and body decline may challenge a person’s ability of staying and feeling connected. The aim of this phenomenological study was to interpret meanings of connectedness, through narrative interviews with persons admitted to inpatient palliative care in Sweden. Results involving connectedness through the body, connectedness to, and uncanniness toward other patients, and connectedness to significant others and society are discussed. The study underscores the importance of connectedness until death. However, in inpatient palliative care this is complex. Patients can cocreate or challenge each other’s sense of connectedness through the symbolism of illness and diseased bodies. Moreover, the capability of connectedness is influenced by illness, spatiality, atmosphere, activities, and resources in the care place.

Findings from a nursing scholarship study tour to inform a proposal for a day hospice model in South Australia

South Australia releases national and international travel scholarships every year to the nursing and midwifery workforce to enable them to undertake observational site visits to inform the development of service models that can be introduced into care practices back in South Australia. Ten sites across New Zealand, Canada, and the UK agreed to host a site visit as part of a scholarship to look at day hospice (DH) programmes. The author undertook an observational study that included participation in DH programmes and discussions with staff and patients. There were many similarities across the three countries, in particular in the structure of the programmes, the staff makeup, and the support of the volunteer workforce. Two distinct models were observed: social and medical. Each has its value and both need to be incorporated to ensure services and participants have their needs met. Based on the site visits and other research, the author devised a proposal for South Australia to commence with a time-limited sessional group DH programme with a focus on maintenance of function for participants coupled with caregiver education and information provision.

Setting priorities in and for end-of-life care: challenges in the application of economic evaluation

Health technology assessment processes aim to provide evidence on the effectiveness and cost-effectiveness of different elements of health care to assist setting priorities. There is a risk that services that are difficult to evaluate, and for which there is limited evidence on cost-effectiveness, may lose out in the competition for resources to those with better evidence. It is argued here that end-of-life care provides particular challenges for evaluation. Outcomes are difficult to measure, can take place over short time scales, and services can be difficult to characterise as they are tailored to the specific needs of individuals. Tools commonly used to measure health care outcomes do not appear to discriminate well in the end-of-life care context. It is argued that the assumption that units of time of different quality of life can simply be added to assess the overall experience at the end of life may not apply, and that alternative perspectives, such as the Peak and End Rule, might offer useful perspectives.

Evaluation of an admission and discharge programme at a UK specialist palliative day hospice

This paper reports on a system of managing admissions and discharges from a specialist palliative day hospice (SPDH) in the south of England. SPDH is a well established component of palliative care provision in the UK, but studies have rarely addressed issues around admission and discharge. Case study methodology was used to evaluate the programme. Interviews were conducted with five patients who had attended the day hospice, taken a break or been discharged and returned; their carer(s); the key worker from the day hospice; and any other health professional who was involved in the patient's care during the admission. Communication issues were found within the team regarding referral and discharge processes, documentation of care, decision making, and information giving. Family members did not feel involved in decision making in relation to the programme. The most significant finding was the emotional and psychological impact on the patients of taking the break. Discharge from SPDH is known to be a difficult and sensitive issue, especially when patients are living with life-limiting illnesses that can change quickly. The patients in this study all had some form of dependency on the service and four of the five would have chosen to continue attending if they could. They experienced deterioration in psychological and physical wellbeing during the period in which they did not attend.

Negotiating the boundary between paid and unpaid hospice workers: a qualitative study of how hospice volunteers understand their work

OBJECTIVE

To explore the nurse-volunteer relationship in a day hospice.

METHOD

Underpinned by an interpretive approach, face-to-face semistructured interviews were conducted with 12 day hospice volunteers.

FINDINGS

The nature and dynamics of the relationship between nursing staff and volunteers within the day hospice were characterized by increasing formality and changes in the division of labor, which challenged smooth working relationships.

CONCLUSIONS

Volunteers see their role as becoming increasingly formalized partly as a response to increasing administrative demands on hospice nurses. The willingness of volunteers to take on new roles is variable. For volunteers to feel secure and valued and working relationships to remain strong, the process of how boundaries between paid and unpaid workers are negotiated needs to be transparent.

Patients' psychosocial experiences of attending Specialist Palliative Day Care: a systematic review

Recent reviews conclude that the benefits of attending Specialist Palliative Day Care (SPDC) are likely to be in social, psychological and spiritual domains. However, these areas are not easily identified, leaving researchers and practitioners unclear as to what aspects of these domains patients most need and desire. The objective of this review was to systematically evaluate literature on patient-perceived psychosocial experiences of attendance at SPDC. Twelve studies were included. Evidence showed that patients value a person-centred approach that reduces isolation, increases social support, encourages communication and provides activities. Future research could focus on investigating why patients value the psychosocial experiences reported and how these experiences can be defined in a way that would be meaningful to clinical service commissioners. Once this has been done, clinicians can start to measure more effectively clinical effectiveness and devise justifiable interventions to help this patient group.

‘If I look old, I will be treated old’: hair and later-life image dilemmas

This paper considers the social symbolism of hair, how it is managed and styled in later life, and what attitudes to appearance in general and hairstyling in particular reveal about ageism in contemporary culture. The paper draws on findings from a two-year, nationwide, participative study of age discrimination in the United Kingdom, the Research on Age Discrimination (RoAD) project. Using data collected by qualitative methods, including participant diaries and interviews undertaken by older field-workers, the paper explores narratives of image and appearance related to hair and associated social responses. The paper focuses on older people's accounts of the dual processes of the production of an image and consumption of a service with reference to hairdressing – and the dilemmas these pose in later life. The findings are considered in the context of the emerging debate on the ageing body. The discussion underlines how the bodies of older people are central to their experience of discrimination and social marginalisation, and examines the relevance of the body and embodiment to the debate on discrimination. A case is made for further scrutiny of the significance of hairdressing to the lives of older people and for the need to challenge the assumption that everyday aspects of daily life are irrelevant to the policies and interventions that counter age discrimination and promote equality.

Can observational studies provide a realistic alternative to randomized controlled trials in palliative care?

Evidence-based medicine demands 'gold standard' randomized controlled trials (RCTs). If strict criteria of quality, validity, and size are met, observational studies give the same result. Given the dearth of RCTs in palliative care, our aim was to identify good observational studies using PubMed searches and e-mail letters to experts in palliative care. The prior intention was provide the most comprehensive description possible to date of observational studies in palliative care, rather than to perform any statistical analyses. Three hundred and forty abstracts of study reports were identified, of which 27% (91) included > or = 200 subjects and 8% (27) > or = 1000 subjects. In reports with > or = 200 subjects, 51% included only cancer patients, and 42% included heterogeneous 'palliative care' patients. Prospective and retrospective studies accounted for 38% and 32% of all reports with > or = 200 subjects. In reports with > or = 1000 subjects, 59% were retrospective and 19% prospective. Patients had some input in 26% of studies with > or = 200 subjects, and 15% with > or = 1000 subjects. Only 12 prospective reports had one specific intervention. We found that palliative care is deficient not only in RCTs, but also good quality observational studies. Those that exist are extremely heterogeneous in subject, design, outcome reporting, and intervention.

Palliative day care--a study of well-being and health-related quality of life

AIM

The aim of the study was to study the outcomes of palliative day care, in terms of health-related quality of life and the emotional well-being of cancer patients participating in a palliative day care programme for a period of five weeks, compared with a group of palliative cancer patients not participating in day-care.

METHODS

The day care sample comprised of patients in a palliative day care programme delivered in two different day care facilities. Participants in the comparison group were recruited from a palliative home care service facility. All patients had a cancer diagnosis. The participants were invited to respond to two questionnaires once a week for a period of five weeks; the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30) and the Mood Adjective List (MACL).

RESULTS

The participants in the day care group and the comparison group reported similar levels of perceived functioning and symptoms, as measured by the EORTC QLQ-30, with no significant differences between the groups. However, the day care group reported higher levels of emotional well-being as measured by the MACL than the comparison group reported, although these differences were not statistically significant.

Measuring outcomes in palliative care: limitations of QALYs and the road to PalYs

Tools for measuring outcomes in health and social care have become key parts of the processes of evaluation and setting priorities. Measures of output that can be used in all settings and specialties have the advantage that they facilitate comparisons and choices between and within patient groups. However, the most commonly used composite measure of outcomes, the quality-adjusted life year (QALY) appears not to work well in complex interventions, such as palliative care, leading to the paradox that there is evidence that people would give priority to interventions and services that would be shown not to be cost-effective, using QALYs as an outcome measure. This article explores the possible reasons for this paradox, and looks at alternative approaches that may provide better tools for setting priorities within palliative care and for comparison of palliative and other care services.

“I Come Because I Can”: Stories of Hope from the Cancer Drop in

Hospices are now the established institutionalized home of specialist palliative care practice in the United Kingdom. Despite attempts to widen access, the dominant patient group continues to be cancer sufferers. A multidisciplinary approach to the support of patients characterizes this field of health care, with both skilled professionals and volunteers attending to patients' physical, emotional, and spiritual needs. Day care, as one type of provision within hospice services, has its own practice territory with wide variations now well documented in the literature. This article reports on a participant observation study that explored the day care provision of a community hospice trust located in southern England. Drawing on the concepts of palliative care and hope in the lives of terminally ill people, findings suggest that this facility helps to counter the isolating effects of cancer and that self-comparison acts as motivation to attend day care, contributing to hope for continued survival.

Palliative Medicine in Britain

In Britain, Palliative Medicine was recognized as a subspecialty of Internal Medicine exactly 20 years after Cicely Saunders founded St Christopher's, at exactly the same time that government was at last recognizing the worth and the needs of general practice. Both had far-reaching effects and implications for patients, doctors, and the future of medicine. For Palliative Medicine it meant units wishing to train specialists going through a rigorous selection process; the development of an equally rigorous training program for the doctors who had already gained a higher qualification before starting Palliative Medicine, demonstrating the need for and benefits of palliative medicine to the sceptics in the profession and, now, continuing to recruit the staff for the steadily increasing number of new services. Today there are more Palliative Medicine consultants/specialists than there are oncologists and neurologists combined, with Hospital Palliative Care Teams in every major hospital and cancer center. With nine Chairs in Palliative Medicine, there is now a drive for research and professional education. The specialty faces major challenges, however, ranging from training to care for patients with non-malignant disease to enabling patients to die in the place of their choice—something that rarely happens today; from defining what is distinctive or unique about palliative medicine to clarifying the respective place of general practice and the specialty. Most would agree that the biggest challenge for the young, thriving specialty is how to share its principles with other doctors wherever they work.

Patient demographics and centre description in European palliative care units

Patients in palliative care are elderly, frail and in decline with multisystem disease. These and other factors make palliative care research particularly challenging, and has been one of several reasons why relatively little systematic research has been performed. The European Association for Palliative Care (EAPC) is seeking to emphasise the importance of research. The present project is the first empirical multicentre study organised by the EAPC Research Network, with the aim of identifying the patient population using specialised palliative care, and identifying a network of palliative care services across Europe, able to participate in a multicentre collaboration for research. During a designated week in the autumn of 2000, data on patients were recorded from 143 centres. The survey was carried out by means of two questionnaires, one centre questionnaire and one patient questionnaire. Data were submitted on 3013 patients from 22 different European countries. Almost all patients had cancer (94%), while some had neurological disease (3%). The majority (75%) had been referred to a palliative care service during the six to seven months before the survey was performed. Very few patients had less than one week of expected survival (6%), the majority were expected to live one to six months, while as many as 16% were expected to live more than one year. The majority of the patients (27%) were fully ambulatory--the ability to walk independently without any assistance. The majority of the patients (60%) received care as an outpatient, either at a traditional clinic in an outpatient cancer hospital (12%), in home-care programs from a specialised advisory service (24%), or external nursing care (24%). The population of patients included in this survey was not a sample of dying patients. There were a substantial number of patients with an anticipated life expectancy of more than six months. The study demonstrated a considerable enthusiasm for research in the palliative care community across Europe. The heterogeneity of the sample is evident, and this will need careful consideration for future clinical trials. This calls for an international consensus on how to report on patient characteristics within palliative care research. This is necessary in order to be able to evaluate the representativity of the study population, as well as to compare data between studies. The range of services encountered in the survey highlights the need for the organisational and clinical standards for palliative care, which can be audited.

Social objectives in cancer care: the example of palliative day care

Social objectives are poorly specified and evaluated in cancer care. Palliative day care is an example where social objectives are often identified but research has focused on health-care outcomes. A literature review identifies four types of social objective: emotional and spiritual care, general social care, services for families and carers and creative arts. Social objectives include: distinguishing between therapeutic work and leisure and supportive interventions, promoting service continuity, reducing social isolation, increasing social interaction, reassuring introduction to palliative care, rehearsal of reactions to illness with a sympathetic audience, integration of families and carers into care services, respite for carers and creative work for three separable objectives. It is argued that interventions to achieve social objectives may be defined and evaluated in a measurable way. Similarly, social objectives and interventions can be specified at other stages in the cancer journey.

Patient satisfaction with hospice day care

Day hospice allows patients to remain living at home while attending a specialist palliative care center. This paper describes patient feedback (n=26) on medical, social and therapeutic out-patient palliative care services provided at one such facility in Northern Ireland. Medical records of all attending patients (n=50) were reviewed, and patients completed a semi-structured questionnaire. Patients' comments on day hospice were largely positive. A number of suggestions for new service activities were made, and the need for education of multi-professional team members was recognized. Respondents recognized that day hospice allowed respite care for the family. Patients were very appreciative of the care that was offered--their concern for its continuance perhaps restraining any criticism they had. Such findings provide the opportunity for health professionals to gain further insights into day care to better meet patients' needs.

End-of-Life Care: Lessons from Other Nations

Palliative care and hospice services have evolved across the globe in different contexts and in different ways, although many of the challenges faced are similar. Comparison between countries helps to identify the best solutions for individual patients and their families, who have complex needs and problems. This paper describes the globally shared challenges and beginnings in hospice and palliative care. It reviews evolution of services and approaches. It compares the models of hospice and palliative care in the United States and the United Kingdom, where pioneer hospices were developed through the work of Dame Cicely Saunders, and then seeks to highlight ways to learn from the different approaches to address common questions. Several research recommendations result from this review. In many countries the research agenda in palliative and end-of-life care must move from describing need (where there are ample studies) to understanding how and determining whether services and interventions work, for whom, and when. Studies should consider the whole trajectory of illness, particularly in slowly progressive or relapsing conditions (including neurological conditions). Future studies should work toward the use of a similar set of core outcome measures, as well as take advantage of the opportunity to undertake "natural experiments" by comparing and contrasting care systems developed in different contexts around the world.

Palliative care of patients with a primary malignant brain tumour: case review of service use and support provided

Individuals with a primary malignant brain tumour require intensive palliative care services because of the symptoms and cognitive problems they experience. Many of these patients stay with their families at home, being supported by palliative care home teams rather than being admitted for hospice care. The provision of respite care and community services to support these families goes largely unreported. This study arises out of a need to review support services for patients and carers within one cancer and palliative care service. This retrospective case analysis identifies that there are a range of services used in the community to support patients with primary malignant brain tumours but that only a small proportion receive inpatient hospice care. District nursing services were extensively used but also a high number (74%) of patients were admitted to local hospitals for symptom management. This paper attempts to explore the services utilized but also questions the apparently limited provision of hospice care for supporting individuals in the palliative care stages of such an illness. This paper considers the illness trajectory, the complex symptoms experienced by patients and respite services utilized. Issues of those engaged in informal care giving and in the provision of support for those with a primary malignant glioma are also considered.

Referrals to a voluntary sector cancer day care centre: a descriptive study

In the UK, recent guidance on supportive and palliative care has acknowledged the contribution of voluntary organizations, including their role in palliative day care. Similarly, research has tended to focus exclusively on palliative day care as opposed to comparable care for people with cancer, regardless of prognosis. This paper describes a case record review study conducted at a nurse-led voluntary sector cancer day care centre. The study focused on referrals over a one-year period in terms of user demographics, referral sources/reasons and subsequent care given. It was found that 220 referrals (including 106 self-referrals) were made during the year. Of these, 70.9% were people with cancer and the remainder were carers/bereaved people. Those referred broadly reflected national statistics on age, gender and cancer diagnosis. Carers were rarely referred by professionals, few lived in inner-city neighbourhoods and some had no informal support. Non-specific referral reasons, such as 'support', tended to be translated into specific therapies, such as complementary therapies and counselling, at initial assessment. Care offered at the centre appeared to supplement and complement that provided by local statutory services. The study raised issues for practice and further research that may be relevant to those working in similar centres.

Is the Palliative Care Outcome Scale useful to staff in a day hospice unit?

AIM

this study was undertaken to elicit a day hospice team's experience of using the Palliative Care Outcome Scale (POS), with the intention of determining its usefulness to staff. An adapted version of POS was used for the purpose of the study.

SAMPLE

a multiprofessional team of eight day hospice staff took part in the study. All had used POS on a weekly basis for a minimum period of 3 months.

DESIGN

a focus group was conducted at the hospice. It was tape-recorded and transcribed verbatim. The data were analysed using an interpretive phenomenological approach.

RESULTS

staff felt POS had limited value as an outcome measure for use in this day hospice. Other simultaneous organizational changes at the hospice may also have influenced staff negatively. Further research is needed to explore similar implementation issues in more depth, as practice developments may be abandoned for potentially the wrong reasons.

Systematic review of specialist palliative day-care for adults with cancer

GOAL OF WORK

To inform future practice, research and policy in specialist palliative day-care by systematically reviewing the evidence for how the structure and process of this form of care relate to outcomes for adults with cancer.

PATIENTS AND METHODS

Medical, nursing and social science computerized databases were searched up until December 2003 for studies of palliative day-care reporting information on service structure, care processes or outcomes including symptom control, quality of life, social and psychological support, and patient and relative satisfaction with care. Qualitative and quantitative studies were assessed for methodological quality and graded, and the findings synthesized into the review.

MAIN RESULTS

Twelve observational studies were found that showed the difficulties of evaluating a service already operating and of recruiting a vulnerable population of patients as they deteriorated. Most services are nurse-led, but varied in the facilities, staff mix, care models, activities and places they offered. Patients attending seemed a selected group of those already receiving palliative care who were mostly white, aged over 60 years and retired, with needs for emotional and social support and pain control. There were insufficient studies to provide conclusive evidence of improved symptom control or health-related quality of life, but all qualitative studies found patients valued the social support and opportunity to take part in activities that day-care provided.

CONCLUSIONS

There is evidence for high satisfaction among patients selected into day-care, but not yet sufficient to judge whether this improves symptom control or health-related quality of life. Further research should explore selection and access into care, the most effective models of care, its cost, and potential benefits for relatives and carers. Comparison with models of care for older adults and those with mental illness would also be informative.

A new approach to eliciting patients' preferences for palliative day care: the choice experiment method

Palliative day care (PDC) provides individualized care to meet patients' needs and preferences and has posed problems for economic evaluation. Current methods are limited in their ability to capture relevant outcomes. The choice experiment elicits preferences for multiple aspects of care rather than a single outcome. A choice experiment was undertaken at four centers in England. A random effects probit model was used. Interaction terms relating to patient and service characteristics were explored. Seventy-nine patients participated. All characteristics of PDC except bathing and hairdressing were significant (P < 0.001). Access to specialist therapies was three times as important as medical support and twice as important as staying all day. Interaction terms were not significant, except for age and preference for specialist therapies, although the sample may not have been adequate to detect differences. Choice experiments provided useful insights by quantifying preferences for services, providing an alternative to cost-effectiveness analysis.

A qualitative evaluation of the impact of palliative care day services: the experiences of patients, informal carers, day unit managers and volunteer staff

OBJECTIVES

To explore the experiences of people involved in UK palliative care day services (PCDS) and identify the important outcomes of this service.

METHODS

Focus groups were carried out separately with patients, informal carers and volunteers from four purposively selected palliative care day units and with day unit managers from 11 units.

RESULTS

Patients benefited from both the support of PCDS professionals and social support of fellow PCDS patients, which contributed to a perceived improvement in their quality of life. Carers appreciated both the respite and support from PCDS, but acknowledged that they still had a poor quality of life. The challenges facing PCDS include the difficulties of discharging patients and the future role of volunteers.

DISCUSSION

PCDS improved patients' perceived quality of life and future evaluations on patient outcomes could use concepts such as self-esteem, self-worth and confidence. Future service provision could explore the possibility of a mixed service using both the traditional and appointment-based system.

Patients' views of using an outcome measure in palliative day care: a focus group study

Outcome measures are being increasingly used in palliative care. Palliative day care is significantly different to other specialist palliative care settings, as patients may attend for much longer periods of time. The aim of this study was to elicit patients' views on using an adapted version of the Palliative Care Outcome Scale (POS) and to determine its value in identifying their individual needs. This qualitative study involved a focus group of nine patients who had used POS weekly for a minimum of 3 months. The focus group discussion was tape recorded and transcribed verbatim. Data were analysed using an interpretive phenomenological approach. Participants found POS to be a useful communication tool, which helped them to identify their individual needs.

Systematic review of the problems and issues of accessing specialist palliative care by patients, carers and health and social care professionals

OBJECTIVES

To determine the problems and issues of accessing specialist palliative care by patients, informal carers and health and social care professionals involved in their care in primary and secondary care settings.

DATA SOURCES

Eleven electronic databases (medical, health-related and social science) were searched from the beginning of 1997 to October 2003. Palliative Medicine (January 1997-October 2003) was also hand-searched.

STUDY SELECTION

Systematic search for studies, reports and policy papers written in English.

DATA EXTRACTION

Included papers were data-extracted and the quality of each included study was assessed using 10 questions on a 40-point scale.

RESULTS

The search resulted in 9921 hits. Two hundred and seven papers were directly concerned with symptoms or issues of access, referral or barriers and obstacles to receiving palliative care. Only 40 (19%) papers met the inclusion criteria. Several barriers to access and referral to palliative care were identified including lack of knowledge and education amongst health and social care professionals, and a lack of standardized referral criteria. Some groups of people failed to receive timely referrals e.g., those from minority ethnic communities, older people and patients with nonmalignant conditions as well as people that are socially excluded e.g., homeless people.

CONCLUSIONS

There is a need to improve education and knowledge about specialist palliative care and hospice care amongst health and social care professionals, patients and carers. Standardized referral criteria need to be developed. Further work is also needed to assess the needs of those not currently accessing palliative care services.

Respite in palliative care: a review and discussion of the literature

Family caregivers, who are patients' relatives and friends (hereafter called carers), play a significant and arguably most important role in enabling patients to make choices about their place of care during advanced disease and in the terminal phase. Relatively little attention has been directed towards identifying the needs of carers who find themselves in this position and what interventions (if any) might best support them in continuing to provide care to the patient during the illness and dying trajectory. What evidence there is suggests that while some aspects of caring are looked on positively, carers also experience challenges in maintaining their physical and psychological health and their social and financial wellbeing. One common recommendation is that respite facilities be provided. The purpose of this paper is to consider the definitions and assumptions that underpin the term 'respite' and its impact on the physical, psychological and social outcomes of carers in palliative care contexts. We conducted a review of the literature, which involved searching five electronic databases: Web of Science, Medline, CINHAHL, Cochrane Database System Review and Social Sciences Citation Index. The search identified 260 papers, of which 28 related directly to adult respite care in specialist palliative care. These papers were largely concerned with descriptive accounts of respite programmes, guidance on referral criteria to respite services or were evaluating the effects of respite on the patient rather than the impact on the carer. We did not identify any empirical studies assessing the effects of respite provided by specialist palliative care services on carer outcomes. There is insufficient evidence to draw conclusions about the efficacy of offering respite care to support carers of patients with advanced disease. We, therefore, draw on the wider literature on carers of adults with chronic disease to consider the impact of respite services and offer suggestions for further research.

Palliative day care: what does it cost to run a centre and does attendance affect use of other services?

AIM

To describe the cost of palliative day care (PDC), assessing the value of all resources whether paid for or not. To examine different patterns of resource use resulting from attending PDC.

METHODS

Five PDC centres in southern England provided detailed cost and resource use data, both paid and unpaid for. The PDC group were consecutive new referrals to a PDC centre who were well enough to be interviewed. The comparison group were recruited from home care teams. Data were collected at baseline, six to eight weeks and 12-15 weeks, on health and social care utilization in the month prior to interview. Data were divided into cohorts based on time from first interview to death and analysed separately.

MAIN OUTCOMES

Annual cost of running a day care centre, and cost per patient per day. Use of all health and social care resources over time, stratified by time from death. Comparison of health and social care by stage of illness, and by PDC attendance.

RESULTS

PDC cost around pound 54 per person per day in 1999, rising to pound 75 including unpaid resources. 145 patients had data on health and social care use. The patterns of care showed that, overall, patients accessed few services other than PDC. Comparison group patients did not access similar services elsewhere. PDC might substitute home nursing and GP care for patients who attend PDC at least three months before death but this data is not conclusive. Inpatient care was negligible for both groups.

CONCLUSIONS

A full economic evaluation could not be undertaken without robust evidence of the effectiveness of PDC. PDC centres made use of resources that were not paid for and shared resources with inpatient units, reducing costs. Service use was different for patients who attended compared with patients who did not. Similar services were not accessed elsewhere in the community; PDC does not appear to replicate other services for this group of patients.

Pain and health-related quality of life among cancer patients in final stage of life: a comparison between two palliative care teams

A two-centred descriptive study was performed in order to describe and compare pain and health-related quality of life (HRQOL) among cancer patients, in their final stage of life. The patients were cared for by either a nurse-led palliative care team I (PCT I) or a physician-led palliative care team II (PCT II). Forty-six consecutive, stratified patients (PCT I, n = 21 and PCT II, n = 25) participated. The medical outcomes study short form 36 (SF-36) was used for evaluating HRQOL and the Pain-O-Meter for assessing pain. Patients' pain intensity, pain quality and HRQOL showed no significant difference between the two groups PCT I and PCT II. The patients from PCT I had significantly longer survival time (P = 0.017) than those from PCT II. The different composition of the teams being led by nurses or physicians is worth further research; both from the patient's and staff's viewpoint, there may also be cost-benefits worth examining.

Effectiveness of palliative day care in improving pain, symptom control, and quality of life

To evaluate the effectiveness of palliative day care in improving pain, symptom control, and quality of life (QOL), 120 consecutive new referrals to five specialist palliative day care centers were recruited into a prospective comparative study. Fifty-three comparison patients were identified as those patients receiving usual palliative care services (home care, inpatient care), but did not attend day care. Patients were assessed at 3 interviews (baseline, 6-8 weeks, and 12-15 weeks) using measures of health-related quality of life: McGill Quality of Life Questionnaire (MQOL) and Palliative Care Outcome Scale (POS). There were two main analyses: 1) patient demographic data were analyzed using chi-square (chi(2)), and 2) QOL data were compared, based on distribution of scores, using the Mann-Whitney test (MQOL and POS), and Wilcoxon Signed Rank for within group differences (POS data only); P < 0.05 was taken as significant. The patients were representative of those attending palliative day care in the UK. At baseline, the day care group were (non-significantly) worse than the comparison group in the MQOL support domain (P = 0.065). The comparison group had marginally more severe pain at baseline (P = 0.053) and more severe symptoms at second assessment (P = 0.025). Both patient groups maintained overall health-related quality of life during the three months of the study. Palliative day care was not found to improve overall health-related quality of life. The limitations of the QOL measures in identifying the effects (patient outcomes) of palliative day care and the differences between the two patient groups (age, employment, unequal sample sizes) were limitations of the study and indicate the need for further research in this area.

Interprofessional working in hospice day care and the patients’ experience of the service

This in-depth study of hospice day care considers professional team working and patient experience of the service. It includes an analysis of how patients' time is spent. The qualitative single case study design involved patient and staff interviews, observations and document analysis. A theoretical framework of interprofessional working informed the study. Analysis of the data revealed a range of goals, variable communication patterns and the existence of core and extended teams. The results challenge the theoretical literature by suggesting that the presence of a team structure alone did not promote interprofessional working. Patients were also seen as integral members of the team. Their experience of day care was a social one, with a wide range of patients identified unmet needs, day care was largely seen as positive. This was despite interprofessional working not clearly being identified in the results. Suggestions for future research are made and implications for practice discussed.