A scale to measure satisfaction of bereaved family receiving inpatient palliative care

Preferences on advance care planning and end-of-life care in patients hospitalized for heart failure

AIMS

Early engagement in advance care planning (ACP) is recommended in heart failure (HF) management. We investigated the preferences of patients with HF regarding ACP and end-of-life (EOL) care, including their desired timing of ACP initiation.

METHODS AND RESULTS

Data were collected using a 92-item questionnaire survey, which was directly distributed to hospitalized patients by dedicated physicians and nurses in a university hospital setting. One-hundred eighty-seven patients agreed to participate (response rate: 92.6%), and 171 completed the survey [valid response rate: 84.7%; men: 67.3%; median age: 73.0 (63.0-81.0) years]. Logistic regression analyses were conducted to identify the predictors of positive attitudes towards ACP. Most recognized ACP as important for their care (n = 127, 74.3%), 48.1% stated that ACP should be initiated after repeated HF hospitalizations in the past year, and 29.0% preferred ACP to begin during the first or second HF hospitalization. Only 21.7% of patients had previously engaged in ACP conversations during HF management. Positive attitudes towards ACP were associated with lower depressive symptoms [two-item Patient Health Questionnaire; odds ratio (OR): 0.75, 95% confidence interval (CI): 0.61-0.92, P-value: 0.006], marriage (OR: 2.53, 95% CI: 1.25-5.12, P-value: 0.010), and a high educational level (OR: 2.66, 95% CI: 1.28-5.56, P-value: 0.009), but not with severity of HF (represented by Seattle Heart Failure Model risk score). Regarding EOL care, while 'Saying what one wants to tell loved ones' (83.4%), 'Dying a natural death' (81.8%), and 'Being able to stay at one's favorite place' (75.6%) were the three most important factors for patients, preferences for 'Receiving sufficient treatment' (56.5%) and 'Knowing what to expect about future condition' (50.3%) were divergent.

CONCLUSIONS

Despite patients' preferences for ACP conversations, there was a discrepancy between preference and engagement in ACP among patients hospitalized for HF. Patients' preferences regarding EOL care may differ; physicians need to consider the appropriate ACP approach to align with patients' care goals.

The quality of care of the dying in hospital-next-of-kin perspectives

Purpose

Providing high-quality care for the dying is essential in palliative care. Quality of care can be checked, compared, and improved by assessing responses from bereaved next-of-kin. The objectives of this study are to examine quality of care in the last 2 days of life of hospitalized patients considering specific aspects of their place of care.

Methods

The “Care of the Dying Evaluation” (CODE^™) questionnaire, validated in German in 2018 (CODE-GER), examines quality of care for the patient and support of next-of-kin, allocating values between 0 (low quality) and 4 (high quality). The total score (0–104) is divided into subscales which indicate support/time given by doctors/nurses, spiritual/emotional support, information/decision-making, environment, information about the dying process, symptoms, and support at the actual time of death/afterwards. Next-of-kin of patients with an expected death in specialized palliative care units and other wards in two university hospitals between April 2016 and March 2017 were included.

Results

Most of the 237 analyzed CODE-GER questionnaires were completed by the patient’s spouse (42.6%) or children (40.5%) and 64.1% were female. Patients stayed in hospital for an average of 13.7 days (3–276; SD 21.1). Half of the patients died in a specialized palliative care unit (50.6%). The CODE-GER total score was 85.7 (SD 14.17; 25–104). Subscales were rated significantly better for palliative care units than for other wards. Unsatisfying outcomes were reported in both groups in the subscales for information/decision-making and information about the dying process.

Conclusion

The overall quality of care for the dying was rated to be good. Improvements of information about the dying process and decision-making are needed.

Trial registration

DRKS00013916

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05465-2) contains supplementary material, which is available to authorized users.

Cultural Adaptation and Validation of the Portuguese Version of the CANHELP Lite Bereavement Questionnaire

BACKGROUND

Satisfaction with care is an important outcome measure in end-of-life care. Validated instruments are necessary to evaluate and disseminate interventions that improve satisfaction with care at the end of life, contributing to improving the quality of care offered at the end of life to the Portuguese population. The purpose of this study was to perform a cross-cultural adaptation and psychometric analysis of the Portuguese version of the CANHELP Lite Bereavement Questionnaire.

METHODS

Methodological research with an analytical approach that includes translation, semantic, and cultural adaptation.

RESULTS

The Portuguese version comprised 24 items. A panel of experts and bereaved family members found it acceptable and that it had face and content validity. A total of 269 caregivers across several care settings in the northern region of Portugal were recruited for further testing. The internal consistency analysis of the adapted instrument resulted in a global alpha value of 0.950. The correlation between the adapted CANHELP questionnaire and a global rating of satisfaction was of 0.886 (p < 0.001).

CONCLUSIONS

The instrument has good psychometric properties. It was reliable and valid in assessing caregivers' satisfaction with end-of-life care and can be used in both clinical and research settings.

Tools Measuring Quality of Death, Dying, and Care, Completed after Death: Systematic Review of Psychometric Properties

Introduction

Measuring the quality of care at the end of life and/or the quality of dying and death can be challenging. Some measurement tools seek to assess the quality of care immediately prior to death; others retrospectively assess, following death, the quality of end-of-life care. The comparative evaluation of the properties and application of the various instruments has been limited.

Objective

This systematic review identified and critically appraised the psychometric properties and applicability of tools used after death.

Method

We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by systematically searching MEDLINE, Embase, CINAHL, and PsycINFO for relevant studies. We then appraised the psychometric properties and the quality of reporting of the psychometric properties of the identified tools using the COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) checklist. The protocol of this systematic review has been registered on PROSPERO (CRD42016047296).

Results

The search identified 4751 studies. Of these, 33 met the inclusion criteria, reporting on the psychometric properties of 67 tools. These tools measured quality of care at the end of life (n = 35), quality of dying and death (n = 22), or both quality of care at the end of life and dying and death (n = 10). Most tools were completed by family carers (n = 57), with some also completed by healthcare professionals (HCPs) (n = 2) or just HCPs (n = 8). No single tool was found to be adequate across all the psychometric properties assessed. Two quality of care at the end of life tools—Care of the Dying Evaluation and Satisfaction with Care at the End of Life in Dementia—had strong psychometric properties in most respects. Two tools assessing quality of dying and death—the Quality of Dying and Death and the newly developed Staff Perception of End of Life Experience—had limited to moderate evidence of good psychometric properties. Two tools assessing both quality of care and quality of dying and death—the Quality Of Dying in Long-Term Care for cognitively intact populations and Good Death Inventory (Korean version)—had the best psychometric properties.

Conclusion

Four tools demonstrated some promise, but no single tool was consistent across all psychometric properties assessed. All tools identified would benefit from further psychometric testing.

Electronic supplementary material

The online version of this article (10.1007/s40271-018-0328-2) contains supplementary material, which is available to authorized users.

Determinants of Family Satisfaction with Inpatient Palliative Care in Korea

Objective: We aimed to identify which structures and processes of care are key determinants of overall satisfaction with palliative care. Methods: A nationwide, multicentre, cross-sectional questionnaire survey was conducted with 501 bereaved family members of terminal cancer patients (effective response rate: 20.9 percent). Structures and processes were evaluated using the Care Evaluation Scale (CES). Results: In univariate analyses, all domains of the CES were significantly associated with overall satisfaction with care. In multivariate analyses, the domains of physical care by physician, physical care by nurse, environment, and coordination positively influenced overall satisfaction. After case-mix adjustment, physical care by nurse, age of patient, and lower education level of bereaved family member remained as significant determinants. Conclusion: Our finding that nursing is the most critical determinant of overall satisfaction within many structure and process domains has an important implication for clinical quality improvement and resource allocation.

The Japan hospice and palliative evaluation study 4: a cross-sectional questionnaire survey

BACKGROUND

Constant evaluation is important for maintaining and improving the quality of end-of-life care. We therefore conduct the fourth Japan Hospice and Palliative Evaluation Study (J-HOPE4) as a continuous evaluation study. In this present paper, we describe the design of J-HOPE4. The main purposes of J-HOPE4 are as follows:1) to evaluate the processes, structures, and outcomes of palliative care acute hospitals, palliative care units, and home hospice services; 2) to examine bereaved family members' self-reported psychosocial conditions, such as grief and depression as bereavement outcomes;3) to provide data to ensure and improve the quality of care provided by participating institutions via feedback based on the results from each institution; and 4) provide clinical and academic information concerning the implications of various issues in palliative care by conducting additional studies.

METHODS

We will conduct a cross-sectional, anonymous, self-reported questionnaire survey. In total, 190 institutions will participate in this study, meaning that 12,000 bereaved family members will be sent a questionnaire.

DISCUSSION

This is one of the largest cross-sectional surveys involving hospice and palliative care, both in Japan and worldwide. Because this study will have a large sample size, the findings are expected to be generalizable to other settings.

The Japan hospice and palliative evaluation study 4: a cross-sectional questionnaire survey

Background

Constant evaluation is important for maintaining and improving the quality of end-of-life care. We therefore conduct the fourth Japan Hospice and Palliative Evaluation Study (J-HOPE4) as a continuous evaluation study. In this present paper, we describe the design of J-HOPE4. The main purposes of J-HOPE4 are as follows:1) to evaluate the processes, structures, and outcomes of palliative care acute hospitals, palliative care units, and home hospice services; 2) to examine bereaved family members’ self-reported psychosocial conditions, such as grief and depression as bereavement outcomes;3) to provide data to ensure and improve the quality of care provided by participating institutions via feedback based on the results from each institution; and 4) provide clinical and academic information concerning the implications of various issues in palliative care by conducting additional studies.

Methods

We will conduct a cross-sectional, anonymous, self-reported questionnaire survey. In total, 190 institutions will participate in this study, meaning that 12,000 bereaved family members will be sent a questionnaire.

Discussion

This is one of the largest cross-sectional surveys involving hospice and palliative care, both in Japan and worldwide. Because this study will have a large sample size, the findings are expected to be generalizable to other settings.

Dying in the Hospital: Perspectives of family members

Background

Although most patients express a preference to die at home, many (over 30 percent) still die in hospital. This study's purpose was to explore the experience of hospital death from the perspective of patients’ family members.

Methods

Interviews were conducted with family members of patients who had died at hospitals affiliated with a large tertiary referral centre in the United States. Content analysis was used to analyze findings.

Findings

We interviewed 30 family members by phone. Themes were arranged by time frame: before death, time of death, and after death.

Conclusion

Families do not interpret clinical cues leading up to death in the same way healthcare providers do; families need clear and direct explanations from providers. Clinicians should assess patient and family understandings of prognosis and communicate clearly and directly. Family members value being with their loved one at the time of death, and they value spending time with the body after death; this should be facilitated in clinical practice.

Association between family satisfaction and caregiver burden in cancer patients receiving outreach palliative care at home

Objective:

Little is known about the associations between family satisfaction with end-of-life care and caregiver burden. We conducted a researcher-assisted questionnaire survey to clarify the impact of caregiver burden on family satisfaction and to determine the types of burden that decrease family satisfaction.

Method:

Bereaved family caregivers of patients with advanced cancer who received our outreach palliative care service were retrospectively identified. Family satisfaction with the end-of-life care provided by the palliative care service and caregiver burden were quantified using the Japanese versions of the FAMCARE Scale and the Zarit Burden Interview (ZBI), respectively.

Results:

Our study subjects included 23 family caregivers. The mean scores on the FAMCARE Scale and the ZBI for the total population were 72.8 ± 11.2 and 22.8 ± 17.3, respectively, indicating moderate-to-high satisfaction and low-to-moderate burden. Caregiver burden had a strong negative correlation to family satisfaction with end-of-life care (Spearman's rho [ρ] = −0.560, p = 0.005), which remained after adjustment for potential confounders (standardized beta [β] = −0.563, p = 0.01). Several burden items—including loss of control, personal time, social engagement with others, feeling angry with the patient, feeling that the patient wants more help than he/she needs, and a wish to leave the care to someone else—were associated with decreased satisfaction. The major cause of dissatisfaction for family members included the information provided regarding prognosis, family conferences with medical professionals, and the method of involvement of family members in care decisions.

Significance of results:

Caregiver burden can be a barrier to family satisfaction with end-of-life care at home. A home care model focused on caregiver burden could improve end-of-life experiences for patients and family caregivers.

Measuring family satisfaction with inpatient rehabilitation care

PURPOSE

The purpose of this paper is to investigate the psychometric characteristics of the Questionnaire of Family members' Satisfaction about the Rehabilitation (QFSR), a new questionnaire assessing the satisfaction of patients' families with the in-hospital rehabilitation service, i.e., the organizational procedure, medical treatment, relationship with nurses/other health workers, and outcome.

DESIGN/METHODOLOGY/APPROACH

The QFSR (13 items) was administered to 1,226 (F=60.4 percent; mean age=57.4, SD 15 years) family members of patients admitted to two units for inpatient rehabilitation, i.e., cardiovascular and neuromotor.

FINDINGS

Confirmatory factor analysis (CFA) confirmed the theoretical four-factor structure of the questionnaire in a subsample of 308 respondents randomly selected from the sample (SB χ² (61)=57.4, p=0.61; RMSEA=0.0; 90 percent CI [0.0, 0.031], CFI=1.00). The remaining 708 respondents (393 relatives of cardiovascular unit inpatients and 315 relatives of neuromotor unit inpatients) were used to test measurement invariance between the groups of family members with patients in the two units. The configurial, scalar, and strict factorial invariance provided a good fit to the data.

ORIGINALITY/VALUE

The QFSR, specifically developed to measure the satisfaction of family members of patients undergoing rehabilitation, appears to be a promising brief questionnaire that can provide important indications for continuous improvement in the delivery of healthcare.

Capturing the Palliative Home Care Experience From Bereaved Caregivers Through Qualitative Survey Data: Toward Informing Quality Improvement

CONTEXT

Measuring palliative care experience using patient-reported outcomes is becoming important for assessing and improving quality, although most validated outcome tools solely use scaled questions.

OBJECTIVES

We analyzed open-text survey responses from bereaved caregivers to identify strengths and weaknesses in the quality of end-of-life care services and to assess the usefulness of qualitative survey data for quality improvement.

METHODS

This was a retrospective observational study involving bereaved caregivers of decedents who had received palliative home care services in one of six health care regions in Ontario, Canada. Using the U.K.'s validated Views of Informal Carers-Evaluation of Services survey, respondents were asked what was good and what was bad about the services provided in the last three months of life as separate open-text questions. A qualitative constant comparison approach was used to derive themes from the responses.

RESULTS

Among 330 caregivers who completed the survey, 271 (82%) caregivers responded to the open-text questions: 93% of those commented on something that was good about care and 55% on something that was bad. The care experiences were generally positive, with the exception of specific individuals or settings that were perceived as adverse. The qualitative data were more informative about deficiencies in care compared with the quantitative data.

CONCLUSION

The qualitative survey data in this study provided key recommendations toward making care more responsive to the needs of dying patients and their families. Capturing the narrative responses of bereaved caregivers is feasible and informative for palliative care program development.

Development the Care Evaluation Scale Version 2.0: a modified version of a measure for bereaved family members to evaluate the structure and process of palliative care for cancer patient

BACKGROUND

The Care Evaluation Scale (CES1.0) was designed to allow bereaved family members to evaluate the structure and process of care, but has been associated with a high frequency of misresponses. The objective of this study was to develop a modified version of CES1.0 (CES2.0) that would eliminate misresponses while maintaining good reliability and validity.

METHODS

We conducted a cross-sectional questionnaire survey by mail in October 2013. The participants were bereaved family members of patients who died from cancer in seven institutions in Japan. All family members were asked to complete CES2.0, the short form CES1.0, items on overall care satisfaction, the Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale, the Patient Health Questionnaire-9 (PHQ-9) and the Brief Grief Questionnaire (BGQ). To examine test-retest reliability, all participants were asked to complete a second CES2.0.

RESULTS

Of 596 questionnaires sent, 461 (77%) were returned and 393 (66%) were analyzed. In the short form CES1.0, 17.1% of the responses were identified as misresponses. No misresponses were found in CES2.0. We identified 10 CES2.0 subscales similar to those in CES1.0 using exploratory factor analysis. Cronbach's alpha was 0.96, and the intraclass correlation coefficient was 0.83. Correlations were found between CES2.0 and overall satisfaction (r = 0.83) and FAMCARE (r = 0.58). In addition, total CES2.0 scores were negatively correlated with the PHQ-9 (r = -0.22) and BGQ (r = -0.10).

CONCLUSION

These results suggest that CES2.0 eliminated misresponses associated with CES1.0 while maintaining good reliability and validity and greatly improving test-retest reliability.

Development the Care Evaluation Scale Version 2.0: a modified version of a measure for bereaved family members to evaluate the structure and process of palliative care for cancer patient

BACKGROUND

The Care Evaluation Scale (CES1.0) was designed to allow bereaved family members to evaluate the structure and process of care, but has been associated with a high frequency of misresponses. The objective of this study was to develop a modified version of CES1.0 (CES2.0) that would eliminate misresponses while maintaining good reliability and validity.

METHODS

We conducted a cross-sectional questionnaire survey by mail in October 2013. The participants were bereaved family members of patients who died from cancer in seven institutions in Japan. All family members were asked to complete CES2.0, the short form CES1.0, items on overall care satisfaction, the Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale, the Patient Health Questionnaire-9 (PHQ-9) and the Brief Grief Questionnaire (BGQ). To examine test-retest reliability, all participants were asked to complete a second CES2.0.

RESULTS

Of 596 questionnaires sent, 461 (77%) were returned and 393 (66%) were analyzed. In the short form CES1.0, 17.1% of the responses were identified as misresponses. No misresponses were found in CES2.0. We identified 10 CES2.0 subscales similar to those in CES1.0 using exploratory factor analysis. Cronbach's alpha was 0.96, and the intraclass correlation coefficient was 0.83. Correlations were found between CES2.0 and overall satisfaction (r = 0.83) and FAMCARE (r = 0.58). In addition, total CES2.0 scores were negatively correlated with the PHQ-9 (r = -0.22) and BGQ (r = -0.10).

CONCLUSION

These results suggest that CES2.0 eliminated misresponses associated with CES1.0 while maintaining good reliability and validity and greatly improving test-retest reliability.

Development of a measure (ICECAP-Close Person Measure) through qualitative methods to capture the benefits of end-of-life care to those close to the dying for use in economic evaluation

BACKGROUND

End-of-life care affects both the patient and those close to them. Typically, those close to the patient are not considered within economic evaluation, which may lead to the omission of important benefits resulting from end-of-life care.

AIM

To develop an outcome measure suitable for use in economic evaluation that captures the benefits of end-of-life care to those close to the dying.

DESIGN

To develop the descriptive system for the outcome measure, in-depth qualitative interviews were conducted with the participants and constant comparative analysis methods were used to develop a descriptive system for the measure.

PARTICIPANTS

Twenty-seven individuals bereaved within the last 2 years or with a close-person currently receiving end-of-life care were purposively recruited into the study. Participants were recruited through newsletters, adverts, snowball sampling and a local hospice.

RESULTS

Twenty-seven individuals were recruited. A measure of capability with six attributes, each with five levels, was developed based on themes arising from the analysis. Attributes comprise the following: good communication with services, privacy and space to be with the loved one, emotional support, practical support, being able to prepare and cope and being free from emotional distress related to the condition of the decedent.

CONCLUSION

This measure is designed to capture the benefits of end-of-life care to close-persons for use in economic evaluation. Further research should value the measure and develop methods for incorporating outcomes for close-persons into economic evaluation.

Use of an Item Bank to Develop Two Short-Form FAMCARE Scales to Measure Family Satisfaction With Care in the Setting of Serious Illness

CONTEXT

Family satisfaction is an important and commonly used research measure. Yet current measures of family satisfaction are lengthy and may be unnecessarily burdensome--particularly in the setting of serious illness.

OBJECTIVES

To use an item bank to develop short forms of the Family Satisfaction with End-of-Life Care (FAMCARE) scale, which measures family satisfaction with care.

METHODS

To shorten the existing 20-item FAMCARE measure, item response theory parameters from an item bank were used to select the most informative items. The psychometric properties of the new short-form scales were examined. The item bank was based on data from family members from an ethnically diverse sample of 1983 patients with advanced cancer.

RESULTS

Evidence for the new short-form scales supported essential unidimensionality. Reliability estimates from several methods were relatively high, ranging from 0.84 for the five-item scale to 0.94 for the 10-item scale across different age, gender, education, ethnic, and relationship groups.

CONCLUSION

The FAMCARE-10 and FAMCARE-5 short-form scales evidenced high reliability across sociodemographic subgroups and are potentially less burdensome and time-consuming scales for monitoring family satisfaction among seriously ill patients.

Measuring Experience With End-of-Life Care: A Systematic Literature Review

CONTEXT

Increasing interest in end-of-life care has resulted in many tools to measure the quality of care. An important outcome measure of end-of-life care is the family members' or caregivers' experiences of care.

OBJECTIVES

To evaluate the instruments currently in use to inform next steps for research and policy in this area.

METHODS

We conducted a systematic review of PubMed, PsycINFO, and PsycTESTS(®) for all English-language articles published after 1990 using instruments to measure adult patient, family, or informal caregiver experiences with end-of-life care. Survey items were abstracted and categorized into content areas identified through an iterative method using three independent reviewers. We also abstracted information from the most frequently used surveys about the identification of proxy respondents for after-death surveys, the timing and method of survey administration, and the health care setting being assessed.

RESULTS

We identified 88 articles containing 51 unique surveys with available content. We characterized 14 content areas variably present across the 51 surveys. Information and care planning, provider care, symptom management, and overall experience were the most frequent areas addressed. There was also considerable variation across the surveys in the identification of proxy respondents, the timing of survey administration, and in the health care settings and services being evaluated.

CONCLUSION

This review identified several comprehensive surveys aimed at measuring the experiences of end-of-life care, covering a variety of content areas and practical issues for survey administration. Future work should focus on standardizing surveys and administration methods so that experiences of care can be reliably measured and compared across care settings.

Care evaluation scale-patient version: measuring the quality of the structure and process of palliative care from the patient's perspective

CONTEXT

Recently, greater emphasis has been placed on patient-reported outcomes. However, there are only a few measures to evaluate the quality of care from the patient's perspective.

OBJECTIVES

To report the development of a scale to measure the quality of the structure and process in palliative care from the patient's perspective and examine the reliability and validity of the scale.

METHODS

A cross-sectional anonymous questionnaire was administered to cancer patients who were being treated on an oncology inpatient ward, who visited an oncology outpatient clinic at Saitama Medical University International Medical Center, or who were in an inpatient palliative unit in Japan between August 2007 and March 2008.

RESULTS

A total of 405 cancer patients participated in the study. Factor analysis revealed that the Care Evaluation Scale-Patient version (CES-P) consisted of 23 items with eight subscales: physical care by physicians, physical care by nurses, psychoexistential care, help with decision making for patients, environment, cost, availability, and coordination/consistency. The total CES-P score was correlated with satisfaction (r = 0.63) but not with quality of life (r = 0.18). The Cronbach α coefficient of the total score was 0.97, and the intraclass correlation coefficient of the total score was 0.67. The CES-P total score was not significantly correlated with the self-reported Eastern Cooperative Oncology Group performance status (ρ = -0.05).

CONCLUSION

The CES-P has sufficient validity and reliability. In addition, this scale is independent of the general physical condition of the patient.

Performance of the Family Satisfaction with the End-of-Life Care (FAMCARE) measure in an ethnically diverse cohort: psychometric analyses using item response theory

OBJECTIVE

The Family Satisfaction with End-of-Life Care (FAMCARE) has been used widely among caregivers to individuals with cancer. The aim of this study was to evaluate the psychometric properties of this measure using item response theory (IRT).

METHODS

The analytic sample was comprised of caregivers to 1,983 patients with advanced cancer. Among the patients, 56 % were females, with mean age 59.9 years (s.d. = 11.8), 20 % were non-Hispanic Black. The majority were family members either living with (44 %) or not living with (35 %) the patient. Factor analyses and IRT were used to examine the dimensionality, information, and reliability of the FAMCARE.

RESULTS

Although a bi-factor model fit the data slightly better than did a unidimensional model, the loadings on the group factors were very low. Thus, a unidimensional model appears to provide adequate representation for the item set. The reliability estimates, calculated along the satisfaction (theta) continuum, were adequate (>0.80) for all levels of theta for which subjects had scores. Examination of the category response functions from IRT showed overlap in the lower categories with little unique information provided; moreover, the categories were not observed to be interval. Based on these analyses, a three-response category format was recommended: very satisfied, satisfied, and not satisfied. Most information was provided in the range indicative of either dissatisfaction or high satisfaction.

CONCLUSIONS

These analyses support the use of fewer response categories and provide item parameters that form a basis for developing shorter-form scales. Such a revision has the potential to reduce respondent burden.

Understanding bereaved family members' dissatisfaction with end-of-life care in nursing homes

With increasing numbers of older adults identifying a nursing home (NH) as their final place of care, it is important to assess the quality of dying in this setting and understand factors that impact family members' dissatisfaction with end-of-life care. A retrospective bereaved family member survey (N = 208) was conducted in 21 NHs located in urban areas of central Canada. Bereaved family members who were dissatisfied with care identified significantly more concerns in all domains assessed and were more likely to have problems with: (a) receiving confusing information from nursing staff about the resident's care, including medical treatments; (b) receiving inadequate information from nursing staff; and (c) feeling that end-of-life care was different than they had expected. Since the quality of communication between nurses, residents, and family members is the main factor that determines families' dissatisfaction with care, strategies and interventions aimed at reducing unmet information needs will be vital to improving end-of-life care in NHs.

A scale for measuring feelings of support and security regarding cancer care in a region of Japan: a potential new endpoint of cancer care

CONTEXT

Having a sense of security about the availability of care is important for cancer patients and their families.

OBJECTIVES

To develop a scale for the general population to evaluate feelings of support and security regarding cancer care, and to identify factors associated with a sense of security.

METHODS

A cross-sectional anonymous questionnaire was administered to 8000 subjects in four areas of Japan. Sense of security was measured using five statements and using a seven-point Likert scale: "If I get cancer 1) I would feel secure in receiving cancer treatment, 2) my pain would be well relieved, 3) medical staff will adequately respond to my concerns and pain, 4) I would feel secure as a variety of medical care services are available, and 5) I would feel secure in receiving care at home." We performed an exploratory factor analysis as well as uni- and multivariate analyses to examine factors associated with such a sense of security.

RESULTS

The five items regarding sense of security were aggregated into one factor, and Cronbach's α was 0.91. In the Yamagata area where palliative care services were not available, the sense of security was significantly lower than in the other three regions. Female gender (P=0.035), older age (P<0.001), and having cancer (P<0.001) were significantly associated with a strong sense of security.

CONCLUSION

A new scale that evaluates sense of security with regard to cancer care was developed. Future studies should examine whether establishing a regional health care system that provides quality palliative care could improve the sense of security of the general population.

What is the best practical survey method for the comparative assessment of palliative care services: results from a national quality assessment project in Korea

CONTEXT

There is an increasing need for the comparative assessment of palliative care services; however, few systematic empirical studies have been performed to determine the most feasible, representative, efficient survey method.

OBJECTIVES

To investigate the feasibility, representativeness, and efficiency of several survey methods.

METHODS

This study was performed as a part of a national initiative to develop a system to evaluate the quality of palliative care services. Three separate but related surveys of patients, caregivers, and bereaved family members were conducted. These surveys were designed to simulate an independent assessment in a nationwide quality evaluation project.

RESULTS

The effective response rates for the patient, caregiver, and bereavement surveys were 30.4% (105 of 344), 46.5% (160 of 344), and 20.9% (501 of 2398), respectively. Subjects who responded to the patient and caregiver surveys were likely to have better physical and mental conditions, whereas subjects who responded to the bereaved family survey did not differ significantly from nonrespondents in regard to patient characteristics, except for a small difference in patient gender (females: 47.2% vs. 41.7%, P=0.028). The average number of responses per institution was 3.2, 4.8, and 15.2, respectively. The cost of the patient and caregiver surveys was much higher than the cost of the bereaved family member survey.

CONCLUSION

There were significant differences between the three methods. Despite the low response rate, our findings suggest that the bereaved family member survey has strengths in terms of feasibility and efficiency, and could be considered as a practical option for the comparative assessment of palliative care services by an independent body.

A systematic review of instruments related to family caregivers of palliative care patients

Support for family caregivers is a core function of palliative care. However, there is a lack of consistency in the way needs are assessed, few longitudinal studies to examine the impact of caregiving, and a dearth of evidence-based interventions. In order to help redress this situation, identification of suitable instruments to examine the caregiving experience and the effectiveness of interventions is required. A systematic literature review was undertaken incorporating representatives of the European Association for Palliative Care's International Palliative Care Family Caregiver Research Collaboration and Family Carer Taskforce. The aim of the review was to identify articles that described the use of instruments administered to family caregivers of palliative care patients (pre and post-bereavement). Fourteen of the 62 instruments targeted satisfaction with service delivery and less than half were developed specifically for the palliative care context. In approximately 25% of articles psychometric data were not reported. Where psychometric results were reported, validity data were reported in less than half (42%) of these cases. While a considerable variety of instruments have been administered to family caregivers, the validity of some of these requires further consideration. We recommend that others be judicious before developing new instruments for this population.

Reliability testing of the FAMCARE-2 scale: measuring family carer satisfaction with palliative care

Measuring carers' perceived satisfaction with services is crucial if services are going to continually improve their responsiveness to the needs of those they serve. The aim of this study was to assess the reliability of the next generation FAMCARE tool, which was adapted to reflect inpatient and team-based care using palliative care services who are participating in the Australian Palliative Care Outcomes Collaboration. FAMCARE-2 was distributed to a consecutive cohort of carers whilst in the caregiving role nationally. Analyses of internal consistency, generated structure and relationships of satisfaction with service provision by three demographic variables were undertaken. A total of 497 carers were recruited from 29 palliative care services across Australia, a mix of inpatient and community services. The scale achieved a high level of internal consistency (Cronbach's alpha coefficient of 0.93) and item-to-total correlation coefficient of 0.49-0.72. Factor analysis of FAMCARE-2 revealed a 4-factor structure (management of physical symptoms and comfort, provision of information, family support and patient psychological care). Results of the survey indicated satisfaction with service provision across the FAMCARE-2 subscales. Older, female carers without a culturally and linguistically diverse background were more satisfied with service provision. We conclude that FAMCARE-2 is a psychometrically sound instrument useful for measuring family carer satisfaction with service provision in a variety of palliative care settings.

A survey of family members' satisfaction with the services provided by hospice palliative care volunteers

A total of 22 family members, whose deceased loved ones had used the services of a hospice palliative care volunteer, responded to a brief survey designed to assess the importance of the different kinds of support offered to them (family members) by the volunteer, their impressions of the volunteers' personal qualities/characteristics, their general experiences with the volunteer, and their overall satisfaction with the volunteer services. The kind of support that received the highest importance rating from family members was the opportunity to take a much-needed break from the demands of caring for their loved one, closely followed by emotional support, the volunteer spending time with them, and the volunteer providing them with information. Family members rated volunteers highly on a list of qualities/characteristics that exemplify individuals who are effective in this role. In all, 85% of the family members felt that their volunteer was well trained and 95% did not feel that their or their loved one's privacy had been invaded by having a volunteer. Overall, family members were very satisfied with the volunteer support they received. Some limitations of the study are discussed.

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

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

Good death inventory: a measure for evaluating good death from the bereaved family member's perspective

The aim of this study was to develop a measure for evaluating good death from the bereaved family member's perspective, and to examine the validity and reliability of the assessment. A cross-sectional anonymous questionnaire was administered to bereaved family members of cancer patients who had died in a regional cancer center from September 2004 to February 2006. We measured the Good Death Inventory (GDI), Care Evaluation Scale, and an overall care satisfaction scale. A retest was conducted one month after sending the questionnaire. Of the 344 questionnaires sent to bereaved family members, 189 responses were analyzed (57%). A factor analysis of the responses to the GDI identified 10 core domains: "environmental comfort," "life completion," "dying in a favorite place," "maintaining hope and pleasure," "independence," "physical and psychological comfort," "good relationship with medical staff," "not being a burden to others," "good relationship with family," and "being respected as an individual." Eight optional domains also were identified: "religious and spiritual comfort," "receiving enough treatment," "control over the future," "feeling that one's life is worth living," "unawareness of death," "pride and beauty," "natural death," and "preparation for death." The GDI had sufficient concurrent validity with the Care Evaluation Scale and overall care satisfaction, sufficient internal consistency (alpha=0.74-0.95), and acceptable test-retest reliability (ICC=0.38-0.72). Finally, we developed a short version of the GDI. The GDI is a valid scale to measure end-of-life care comprehensive outcomes from the bereaved family member's perspective in Japan.

The Japan HOspice and Palliative Care Evaluation Study (J-HOPE Study): Study Design and Characteristics of Participating Institutions

This article describes the study design and background data of participating institutions in the Japan HOspice and Palliative care Evaluation (J-HOPE) study. The J-HOPE study is a large nationwide survey about the dying experience of cancer patients. The primary aim of this article is to describe the design of the J-HOPE study for the bereaved family members of Japanese inpatient palliative care units and home hospices. Secondly, the aim was to describe characteristics of participating institutions. The authors conducted a cross-sectional questionnaire survey in 2007. One hundred Japanese inpatient palliative care units and 14 home hospices participated. The questionnaires were sent to 7955 bereaved family members of the Japanese inpatient palliative care units and 447 of the home hospices. The authors describe the structure of the Japanese inpatient palliative care units and home hospices, including type of staff, architectural structure, number of patients, and death. In addition, the authors describe available treatments at the Japanese inpatient palliative care units and home hospices.

How well do current instruments using bereaved relatives' views evaluate care for dying patients?

BACKGROUND

Providing good quality of care for dying patients and their families has been highlighted as a national priority in the UK. Defining and measuring the quality of this care is therefore important. Using the views of patients has practical and ethical difficulties, so an alternative approach is to seek the views of bereaved relatives and close friends after the patients' death.

AIM

To identify and critically appraise instruments previously used with bereaved relatives to measure the quality of care for dying patients and the level of support provided to the family.

METHODS

A literature review was undertaken using Medline, Cinahl, Embase and AMED databases from 1985 to 2005. The search strategy was based on the following headings: quality of care, dying, assessment and relatives. Key criteria were set for the appraisal of each instrument.

RESULTS

Analysis of the 229 articles identified from the searches, yielded seven instruments used with bereaved relatives to assess the quality of 'care for the dying'.

DISCUSSION

Each of these instruments was carefully constructed and all but one had clear documentation of validity and reliability measures. Two instruments used 'satisfaction' as an outcome measure, limiting their ability to discriminate between adequate and excellent care. Only one instrument was developed in the UK making it more 'user-friendly' for direct use in the UK.

CONCLUSION

None of the instruments in their current format could comprehensively evaluate 'care for the dying' in the UK healthcare setting. We would propose to develop and validate a tool specifically assigned for this purpose.

[Factors influencing the death of the elderly at home in an institution specializing home medical care--analysis of survey of the bereaved family]

AIM

To determine factors influencing on the death of the elderly at home in an institution specializing in-home medical care (home death rate: about 80%).

METHODS

This study was an anonymous mailed survey of bereaved families of patients (the caregivers) who died using the home medical care setting provided by an institution specializing in home medical care in Japan. We analyzed the relationship of demographics of the patients and the caregivers with such factors as the anxiety of the caregiver and eventual death at home, and that of such factors as perceived quality of home medical care by the caregiver, and satisfaction with home medical care, satisfaction with death bed nursing, regret for death bed nursing.

RESULTS

The most significant determinant factor associated with home death was that both patients and caregivers preferred death at home (OR=19.42). Determination coefficients (R(2)) in the multiple linear regression analysis of caregiver's satisfaction with home medical care, satisfaction with death bed nursing and regret for death bed nursing were as high as 0.68, 0.55 and 0.62, respectively. Significant influential factors were: peaceful death, psychological consistency of the caregiver, a good relationship with one's physician and fulfillment of the care service system.

CONCLUSIONS

Important components of home medical care and death bed nursing for the realization of death of the elderly at home are 1) peaceful death, 2) psychological consistency of caregivers, 3) a good relationship with one's physician, 4) fulfillment of the care service system.

Methodological challenges in measuring quality care at the end of life in the long-term care environment

Understanding what constitutes quality end-of-life care from the perspective of the patient, their family, and health care professionals has been a priority for many researchers in the past few decades. Literature in this area has helped describe many of the barriers to measuring the quality of care in various environments, such as the hospital, hospice, and home. However, much of the work to date in defining the domains of quality care at the end of life has not been conducted within the long-term care environment. This environment is expected to provide care to an increasing number of dying persons with the concurrent aging of the population in many Western countries and demand for more formal services. In this review, the methodological issues involved in measuring quality care at the end of life are examined, with specific attention given to the challenges encountered in the long-term care environment.

Reliability and validity of the Japanese version of the Support Team Assessment Schedule (STAS-J)

OBJECTIVE

The aim of this project was to develop an appropriate and valid instrument for assessment by medical professionals in Japanese palliative care settings.

METHODS

We developed a Japanese version of the Support Team Assessment Schedule (STAS-J), using a back translation method, and tested its reliability and validity. In the reliability study, 16 nurses and a physician who work in a palliative care unit evaluated 10 hypothetical cases twice at 3-month intervals. For the validity study, external researchers interviewed 50 patients with matignancy and their families and compared the results with ratings by the nurses in the palliative care unit.

RESULTS

Our results with hypothetical cases were: interrater reliability weighted kappa = 0.53-0.77 and intrarater reliability weighted kappa = 0.64-0.85. In the validity study comparing nurse evaluations and the results of interviews with patients and families, complete agreement was 36-70%, and close agreement (+/-1) was 74-100%. As a whole, weighted kappa were low: between -0.07 and 0.51. Our results were similar to those in the United Kingdom and Canada.

SIGNIFICANCE OF RESULTS

Although this research was conducted under methodologically limited conditions, we concluded that the STAS-J is a reliable tool and its validity is acceptable. The STAS-J should become a valuable tool, not only for daily clinical use, but also for research.

Measuring the quality of structure and process in end-of-life care from the bereaved family perspective

Measurement of the structure/process of care is the first step in improving end-of-life care. The primary aim of this study was to psychometrically validate an instrument for directly measuring the bereaved family's perception of the necessity for improvement in structural/procedural aspects of palliative care. Different sets of questionnaires were sent to 800 and 425 families who lost family members at one of 70 certified palliative care units in Japan in the development and validation phases, respectively, and 281 families of the latter group in the follow-up phase. The participants were requested to fill out a newly-developed Care Evaluation Scale (CES), along with outcome measures (the perceived experience and satisfaction levels) and potential covariates (the degree of expectation, the Center for Epidemiologic Studies Depression Scale, and the Social Desirability Scale). We obtained 485, 310, and 202 responses in the development, validation, and follow-up phases (response rates: 64%, 75%, and 72%, respectively). The 28-item CES had an overall Cronbach's coefficient alpha of 0.98; the intra-class correlation coefficient in the test-retest examination was 0.57. A confirmatory factor analysis revealed 10 subscales: physical care (by physicians, by nurses), psycho-existential care, help with decision-making (for patients, for family), environment, family burden, cost, availability, and coordination/consistency. The CES subscales were only moderately correlated with the perceived-experience and satisfaction levels of corresponding areas (r=0.36-0.52 and 0.39-0.60, respectively). The CES score was not significantly associated with the degree of expectation, the changes of depression, or the Social Desirability Scale. The CES is a useful tool to measure the bereaved family's perception of the necessity for improvement in structural/procedural aspects of palliative care. The advantages of the CES are: 1) it specifically evaluates the structure and process of care, 2) it directly identifies needed improvements, 3) it is not affected by the degree of expectation, depression, or social desirability, and 4) it has satisfactory psychometric properties.