Lay carers' satisfaction with community palliative care: results of a postal survey. South Tyneside MAAG Palliative Care Study Group

The quality of end-of-life care for Danish cancer patients who have received non-specialized palliative care: a national survey using the Danish version of VOICES-SF

PURPOSE

About half of Danish patients dying from cancer have never been in contact with specialized palliative care. Non-specialized palliative care in Denmark, i.e., somatic hospital departments, community nurses, and general practitioners, has rarely been described or evaluated. We aim to assess how non-specialized palliative care was evaluated by bereaved spouses, and to test whether distress when completing the questionnaire and ratings of aspects of end-of-life care was associated with satisfaction with place of death and overall quality of end-of-life care.

METHODS

Bereaved spouses of 792 cancer patients who had received non-specialized palliative care were invited to answer the Views of Informal Carers-Evaluation of Services-Short Form (VOICES-SF) and the Hospital Anxiety and Depression Scale (HADS) 3-9 months after the patient's death.

RESULTS

A total of 280 (36%) of invited spouses participated. In the last 3 months of the patient's life, the quality of all services taken together was rated as good, excellent, or outstanding in 70% of the cases. Satisfaction was associated with respondent's current distress (p = 0.0004). Eighty percent of bereaved spouses believed that the patient had died in the right place. Satisfaction with place of death was associated with place of death (p = 0.012) and the respondent's current distress (p = 0.0016).

CONCLUSION

Satisfaction with place of death and overall quality of services was generally high but was rated lower by spouses reporting higher levels of distress when completing the questionnaire. Distress should be taken into account whenever services are evaluated by bereaved relatives.

The quality of end of life care for Danish cancer patients who have received specialized palliative: a national survey using the Danish version of VOICES-SF

BACKGROUND

National recommendations state that Danish patients with complex palliative needs should have access to specialized palliative care but little is known about the perceived quality of this care or end of life care in general.

AIM

To assess how end of life care was evaluated by the bereaved spouses and to investigate whether the perceived quality was associated with (1) quantity of specialized palliative care provided, (2) place of death, and (3) emotional state when completing the questionnaire.

DESIGN

The bereaved spouses of 1584 cancer patients who had received specialized palliative care were invited to answer the Views Of Informal Carers - Evaluation of Services - Short Form (VOICES-SF) and the Hospital Anxiety and Depression Scale (HADS) approximately 3-9 months after the patient's death.

RESULTS

A total of 787 (50%) of the invited spouses participated. In the last 3 months of the patient's life, the quality of all services taken together was rated as good, excellent, or outstanding in 83% of the cases and it was significantly associated with place of death (p = 0.0051, fewest considered it "fair" or "poor" if the patient died at home). In total, 93% reported that the patient died at the right place although only 74% died at the patient's preferred place. Higher levels of anxiety (p = 0.01) but not depression at the time of questionnaire completion was associated with lower satisfaction with the overall quality of care.

CONCLUSION

The quality of care was rated very highly by bereaved spouses of patients receiving specialized palliative care.

Unmet needs of patients with cancer in their last year of life as described by caregivers in a developing world setting: a qualitative study

BACKGROUND

Palliative care is in its infancy in most of the developing world. We set out to explore the lived experiences of families and caregivers of recently deceased cancer patients in Trinidad and Tobago and to determine the unmet needs of the patients and what recommendations could be derived to improve the current services.

METHODS

A phenomenological approach with purposeful sampling was used. Participants were referred by key health professionals. Face-to-face interviews were conducted. Interviews were transcribed verbatim, with analysis and data collection occurring concurrently. Thematic content analysis was used to determine common domains, themes and sub-themes.

RESULTS

Interviews were completed with 15 caregivers. All were spouses or children of the deceased. Ages of the deceased ranged from 43 to 93, the average being 65.5 years. The deceased experienced a variety of cancers including lung, colorectal and oesophageal. Unmet needs were identified under 4 domains of institutions, community, the family unit and the wider society. Institutional unmet needs were delayed diagnosis and treatment and poor inter-institution coordination. Medical and nursing care failed in the areas of health care providers' attitudes, pain management and communication. The family unit lacked physical and psychosocial support for the caregiver and financial aid for the family unit. Societal needs were for public education to address myths and cultural beliefs around cancer.

CONCLUSION

There is need for systemic interventions to improve the care of those dying from cancer in Trinidad and Tobago. Stakeholders need to commit to palliative care as a public health priority, implementing education, planning services and mobilizing community resources.

Quality of dying and death desired by residents of Kagawa Prefecture, Japan: a qualitative study

Background

Achieving a desirable death is an urgent aging-related problem in Japan. However, measures of the quality of death and dying in Japan are lacking. This study aimed to identify components of a desirable death in the residents of Kagawa prefecture, Japan, through focus group interviews.

Methods

A group interview was conducted with 30 residents aged 20–80 (M_age = 50.9, SD = 22.1 years; 43.3% ≥ 65 years; 40.0% unemployed) who had experienced the death of a closely associated person. Participants were grouped into four generations with diverse characteristics (e.g., age, sex, occupation). The interview lasted 1–2 h and involved one interviewer, one observer, and one recorder. The interview theme was “What is a desirable death?” Participants were asked “What do you want to achieve before you die?” or “What would a close friend want to experience when death is near?” We then extracted important items related to “desirable death” using serialization and observation records, while also consulting three analysts. The analysis results of the four generations were ultimately integrated into final categories.

Results

The most common experience of a familiar death was that of parents, followed by grandparents. Half of participants had witnessed the death. Through category analysis, eight important categories related to desirable death were ultimately extracted. Nine items were identified as common to all generations. While the elderly generation had wide-ranging opinions, the younger generations’ opinions tended to concentrate on satisfaction with life and family relations.

Conclusion

Eight concepts were extracted as important factors of a desirable death from the residents of Kagawa prefecture, Japan.

Examining the Perspectives of Family Members Involved in the Delivery of Palliative Care at Home

This ethnographic study examined the social context of home-based palliative caregiving. Data were composed of observation field notes, interviews, and textual documents, and were analyzed using constant comparative methods. Findings show that home-based palliative caregiving resulted in life-enriching experiences for many caregivers. However, assumptions about dying at home and health care reforms resulted in some caregivers feeling “pressured” to provide home care, and consequently, left them feeling their obligations to care were exploited by the health care system. Shifts toward providing care closer to home not only changed caregivers, but also changed the home setting where palliative care was provided. Findings indicate a need for interventions designed to improve support for caregivers at home, and to explore how assumptions influence and sometimes drive the provision of home health care.

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.

Measuring the quality of end-of-life care: Development, testing, and cultural validation of the Danish version of Views of Informal Carers' Evaluation of Services-Short Form

BACKGROUND

The perspectives of patients and relatives are important in the improvement of the quality of health care. However, the quality of end-of-life care has not been systematically evaluated in Scandinavia.

AIM

To develop or adapt and subsequently validate a questionnaire assessing the quality of end-of-life care in Denmark. The questionnaire was intended for bereaved relatives in order to assess the quality of care in the last 3 months of the patient's life and the circumstances surrounding death.

DESIGN AND DATA SOURCES

Based on the literature and interviews with 15 bereaved relatives and 17 healthcare professionals, relevant topics to include in a questionnaire were identified. The topics were prioritized by 100 bereaved relatives and subsequently compared to existing questionnaires. The chosen questionnaire was tested by cognitive interviews with 36 bereaved relatives.

RESULTS

Most of the important topics were covered by the Views of Informal Carers' Evaluation of Services-Short Form, but not all Danish settings (e.g. home care by a palliative team) were covered. These settings were added to the Views of Informal Carers' Evaluation of Services-Short Form, and a few adaptations were made before a Danish version of the Views of Informal Carers' Evaluation of Services-Short Form was tested by cognitive interviews. This cultural validation showed that the slightly adapted Danish version was perceived as relevant, understandable, and acceptable. Furthermore, the cognitive interviews gave insight in the comprehension and interpretation of Views of Informal Carers' Evaluation of Services-Short Form items.

CONCLUSION

With a few adaptations, the British Views of Informal Carers' Evaluation of Services-Short Form was relevant in a Danish setting.

Family Members' Perceptions of the Quality of Long-Term Care

The aim of the study is to assess family members' perceptions of the quality of nursing care of older people and its relationships between demographic factors and family involvement. Data were gathered from family members of four residential homes ( N= 474) using structured questionnaires. Data were analyzed using descriptive statistics, correlation, and predictive analyses. The results imply that family members' perceptions of quality were fairly positive. Age, educational background, and the frequency of visits on the ward were related with the quality perception. The association between quality perceptions and family involvement in care proved to be strong. The information and support from the staff and possibilities to participate in decision making were associated with high-quality ratings. The results demonstrate the need for formulating ward policies and training the nursing staff to allow increased family involvement and to support it in an appropriate way.

Home care by general practitioners for cancer patients in the last 3 months of life: An epidemiological study of quality and associated factors

BACKGROUND

Stronger generalist end-of-life care at home for people with cancer is called for but the quality of end-of-life care delivered by general practitioners has been questioned.

AIM

To determine the degree of and factors associated with bereaved relatives' satisfaction with home end-of-life care delivered by general practitioners to cancer patients.

DESIGN

Population-based mortality followback survey.

SETTING/PARTICIPANTS

Bereaved relatives of people who died of cancer in London, United Kingdom (identified from death registrations in 2009-2010), were invited to complete a postal questionnaire surveying the deceased's final 3 months of life.

RESULTS

Questionnaires were completed for 596 decedents of whom 548 spent at least 1 day at home in the last 3 months of life. Of the respondents, 55% (95% confidence interval: 51%-59%) reported excellent/very good home care by general practitioners, compared with 78% (95% confidence interval: 74%-82%) for specialist palliative care providers and 68% (95% confidence interval: 64%-73%) for district/community/private nurses. The odds of high satisfaction (excellent/very good) with end-of-life care by general practitioners doubled if general practitioners made three or more compared with one or no home visits in the patient's last 3 months of life (adjusted odds ratio: 2.54 (95% confidence interval: 1.52-4.24)) and halved if the patient died at hospital rather than at home (adjusted odds ratio: 0.55 (95% confidence interval: 0.31-0.998)).

CONCLUSION

There is considerable room for improvement in the satisfaction with home care provided by general practitioners to terminally ill cancer patients. Ensuring an adequate offer of home visits by general practitioners may help to achieve this goal.

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.

Hidden patients: the relatives of patients in need of palliative care

BACKGROUND

When identifying patients for palliative care, medical specialists find it necessary to disclose "hidden" patients: the patient's relatives. The issue has been discussed sporadically in Bulgaria; the present study was part of a larger investigation that examined the opinion of medical specialists, patients, and their relatives.

METHOD

The study protocol was explained to participants who gave written informed consent. Patients (n=211) were followed up on by their general practitioners (GPs) (n=42) during one year. All relatives were invited, and 173 (82%) agreed and participated. A questionnaire created by the authors was used. The data were analyzed by frequency distribution (descriptive statistics) and nonparametric tests (Pearson's χ(2)) and statistically processed using SPSS 17.0 (SPSS Inc., Chicago, IL).

RESULTS

Relatives providing care were predominantly women, two-thirds over 60 years of age. There was a one-to-one ratio between caregivers for oncological and nononcological patients. The duration of care was more than one year in 53% of cases. Most relatives reported their loved ones found physical suffering "very hard to bear" (53%), while approximately 17% could not assess the extent of psychological suffering. The vast majority stated that they had difficulties in providing care, and 68% had financial problems in that respect.

CONCLUSION

Including relatives as users and part of the palliative care team has been discussed in the literature. In Bulgaria, participation is solely due to the lack of organized services for palliative care. Relatives participate in activities that are performed by trained staff in countries with developed palliative care; these activities, along with negative emotional experiences and economic difficulties, overburden these caregiving relatives significantly.

Acting with dedication and expertise: Relatives' experience of nurses' provision of care in a palliative unit

OBJECTIVES

Admission of a cancer patient to a palliative unit when near the final stage of their disease trajectory undoubtedly impacts their relatives. The aim of our study was to illuminate and interpret relatives' lived experiences of health personnel's provision of care in a palliative ward.

METHODS

A phenomenological/hermeneutic approach was employed that was inspired by the philosophical tradition of Heidegger and Ricoeur and further developed by Lindseth and Nordberg. The perspectives of the narrator and the text were interpreted by highlighting relatives' views on a situation in which they have to face existential challenges. The analysis was undertaken in three steps: naïve reading, structural analysis, and comprehensive understanding, including the authors' professional experiences and theoretical background.

RESULTS

Six subthemes appeared: the dying person, the bubble, the sight, the cover, the provision for children's needs, and the availability of immediate help. These components were further constructed into three themes: the meaning of relating, the meaning of action, and the meaning of resources. Our comprehensive understanding of the results suggests that the most important theme is "acting with dedication and expertise."

SIGNIFICANCE OF RESULTS

The following aspects are crucial for relatives of cancer patients hospitalized in a palliative ward: time and existence, family dynamics, and care adjusted to the situation. Our study results led to reflections on the impact of how nurses behave when providing care to patients during the palliative phase, and how they interact with relatives in this situation. We found that cancer patients in a palliative unit most appreciate nurses who act with dedication and expertise.

Living with advanced illness: longitudinal study of patient, family, and caregiver needs

BACKGROUND AND OBJECTIVES

Inpatient palliative care (IPC) consults are associated with improved quality of care and less intensive utilization. However, little is known about how the needs of patients with advanced illness and the needs of their families and caregivers evolve or how effectively those needs are addressed. The objectives of this study were 1) to summarize findings in the literature about the needs of patients with advanced illness and the needs of their families and caregivers; 2) to identify the primary needs of patients, families, and caregivers across the continuum of care from their vantage point; and 3) to learn how IPC teams affect the care experience.

METHODS

We used a longitudinal, video-ethnographic approach to observe and to interview 12 patients and their families before, during, and after an IPC consult at 3 urban medical centers. Additional interviews took place up to 12 months after discharge.

RESULTS

Five patient/family/caregiver needs were important to all family units. IPC teams responded effectively to a variety of needs that were not met in the hospital, but some postdischarge needs, beyond the scope of IPC or health care coverage, were not completely met.

CONCLUSION

Findings built upon the needs identified in the literature. The longitudinal approach highlighted changes in needs of patients, families, and caregivers in response to emerging medical and nonmedical developments, from their perspective. Areas for improvement include clear, integrated communications in the hospital and coordinated, comprehensive postdischarge support for patients not under hospice care and for their caregivers.

Transfer of information on palliative home care during the out-of-hours period

BACKGROUND

Continuity of end-of-life care for patients receiving palliative care is an important challenge for out-of-hours services in general practice.

AIM

To investigate how frequent information is transferred on patients receiving palliative care from GPs to the out-of-hours services, to explore the perceptions of GP's on this information transfer and to study the relation between information transfer and the used GP information systems.

METHODS

This is a mixed-method design study. The frequency of information transfer to the out-of-hours services was investigated by analyzing a regional out-of-hours database. Barriers and promoting factors for this transfer of information were investigated by using semi-structured interviews among a purposive sample of GPs from the same region. The relation between information transfer and the GP information system was investigated by a postal questionnaire in a national random selection of GPs.

RESULTS

When a palliative patient contacted the out-of-hours service, for 20% of these patients, a transfer of information was available and only half of these transfers included an anticipating end-of-life plan. All interviewed GPs considered continuity of care for these patients as important. However, some doubted whether a transfer of information is relevant for the quality of care. There was no relation between the information transfer and the used GP information systems.

CONCLUSION

For only a minority of patients receiving palliative care, a transfer of information including an anticipating management plan was present. There is a large variation in the opinions of GPs on how to organize continuity of end-of-life care.

Positive and negative interactions with health professionals: a qualitative investigation of the experiences of informal cancer carers

BACKGROUND

Empathic and informative interactions with health professionals are important for the well-being of people with cancer. However, there is a dearth of research examining the construction and experience of interactions with health professionals from the perspective of informal cancer carers.

OBJECTIVE

The aim of this study was to explore how cancer carers subjectively position their experiences of interactions with health professionals, in particular, their construction of experiences as positive or negative, and the perceived consequences of such interactions. Positioning theory is used to examine how the sociomedical construction of health professionals shapes carers' experiences of interactions with them.

METHOD

Semistructured interviews were carried out with 53 informal cancer carers across a range of cancer types and stages, analyzed using thematic decomposition.

RESULTS

Carers positioned positive interactions as those involving health professionals who were warm and genuine, accessible and approachable, and who made carers feel accepted and comfortable. In the case of allied health professionals, the provision of a space for carers' cathartic release was also constructed positively. Negative interactions were positioned as those involving poor communication and a lack of empathy, poor or absent information provision, and absence of guidance about additional support.

CONCLUSIONS

Positive experiences with health professionals were positioned by carers as leading to feelings of empowerment, value, and recognition, and negative interactions as leading to distress, anger, frustration, and feelings of isolation.

IMPLICATIONS FOR PRACTICE

It is important for health professionals to be supportive of carers' needs, to communicate in an empathic manner, to be approachable and accessible, and to recognize carers needs and concerns.

Role of the community pharmacy in palliative care: a nationwide survey in Japan

PURPOSE

The role of the community pharmacy in palliative care may become increasingly important in Japan. There has been however no investigation to date of community pharmacies in Japan that takes into account their role in enabling palliative care in the home. The aims of the present study were thus to evaluate (1) the availability of narcotics through community pharmacies and the experience of pharmacists in prescribing narcotics; (2) availability of patient counseling provided by pharmacists; (3) pharmacist-perceived difficulties in treating cancer patients with narcotics; and (4) useful strategies to make narcotics more easily available to patients.

METHODS

We sent 3000 questionnaires to community pharmacies as a representative national sample, and 1036 responses were analyzed (response rate: 34.5%).

RESULTS

We found that 77% of community pharmacies had a narcotics retailer license, and that approximately 50% received prescriptions for and prepared narcotics each month. Approximately 70% of community pharmacies received however only 3 narcotics prescriptions each month. Half of the pharmacists reported that they did not counsel patients, primarily because they lacked information about the patient. The most common area reported by pharmacists as being extremely difficult was communicating with terminally ill cancer patients. To make narcotics more easily available to patients, 76% of community pharmacists felt it was important to be able to return narcotics to wholesalers.

CONCLUSION

The present study suggests that there are many problems in community pharmacy that need to be addressed to improve access to palliative care in the home, including (1) increased sharing of patient information; (2) increasing community pharmacists' communication skills; and (3) changing current regulations regarding the distribution of narcotics. If these issues are addressed, palliative care in the home could become more widely accepted.

Associations between successful palliative trajectories, place of death and GP involvement

OBJECTIVE

General practitioner (GP) involvement may be instrumental in obtaining successful palliative cancer trajectories. The aim of the study was to examine associations between bereaved relatives' evaluation of palliative cancer trajectories, place of death, and GP involvement.

DESIGN

Population-based, cross-sectional combined register and questionnaire study.

SETTING

The former Aarhus County, Denmark.

SUBJECTS

Questionnaire data on GPs' palliative efforts and relatives' evaluations of the palliative trajectories were obtained for 153 cases of deceased cancer patients.

MAIN OUTCOME MEASURES

A successful palliative trajectory as evaluated retrospectively by the relatives.

RESULTS

Successful palliative trajectories were statistically significantly associated with home death (PR 1.48 (95% CI 1.04; 2.12)). No significant associations were identified between the evaluations of the palliative trajectory at home and GP involvement. "Relative living with patient" (PR 1.75 (95% CI: 0.87; 3.53)) and "GP having contact with relatives" (PR 1.69 (95% CI 0.55; 5.19)) were not significantly associated, but this may be due to the poor number of cases included in the final analysis.

CONCLUSION

This study indicates that home death is positively associated with a higher likelihood that bereaved relatives will evaluate the palliative trajectory at home as successful. No specific GP services that were statistically significantly associated with higher satisfaction among relatives could be identified, but contact between GPs and relatives seems important and the impact needs further investigation.

Part 1: Home-based family caregiving at the end of life: a comprehensive review of published quantitative research (1998-2008)

The changing context of palliative care over the last decade highlights the importance of recent research on home-based family caregiving at the end of life. This article reports on a comprehensive review of quantitative research (1998-2008) in this area, utilizing a systematic approach targeting studies on family caregivers, home settings, and an identified palliative phase of care (n = 129). Methodological challenges were identified, including: small, non-random, convenience samples; reliance on descriptive and bivariate analyses; and a dearth of longitudinal research. Robust evidence regarding causal relationships between predictor variables and carer outcomes is lacking. Findings suggest the need for knowledge regarding: family caregiving for patients with non-malignant terminal conditions; whether needs and outcomes differ between family caregivers at the end of life and comparison groups; and caregiver outcomes in bereavement. Clear definitions of 'family caregiving', 'end of life', and 'needs' are required as well as greater application and testing of theoretical and conceptual explanations.

Variations in the quality and costs of end-of-life care, preferences and palliative outcomes for cancer patients by place of death: the QUALYCARE study

Background

Emerging trends and new policies suggest that more cancer patients might die at home in the future. However, not all have equal chances of achieving this. Furthermore, there is lack of evidence to support that those who die at home experience better care and a better death than those who die as inpatients. The QUALYCARE study aims to examine variations in the quality and costs of end-of-life care, preferences and palliative outcomes associated with dying at home or in an institution for cancer patients.

Methods/Design

Mortality followback survey (with a nested case-control study of home vs. hospital deaths) conducted with bereaved relatives of cancer patients in four Primary Care Trusts in London. Potential participants are identified from death registrations and approached by the Office for National Statistics in complete confidence. Data are collected via a postal questionnaire to identify the informal and formal care received in the three months before death and the associated costs, relatives' satisfaction with care, and palliative outcomes for the patients and their relatives. A well-established questionnaire to measure relatives' views on the care integrates four brief and robust tools - the Client Service Receipt Inventory, the Palliative Outcome Scale, the EQ-5 D and the Texas Revised Inventory of Grief. Further questions assess patients and relatives' preferences for place of death. The survey aims to include 500 bereaved relatives (140 who experienced a home death, 205 a hospital death, 115 a hospice death and 40 a nursing home death). Bivariate and multivariate analyses will explore differences in place of death and place of end-of-life care, in preferences for place of death, patients' palliative outcomes and relatives' bereavement outcomes, in relation to place of death. Factors influencing death at home and the costs of end-of-life care by place of death will be identified.

Discussion

Collecting data on end-of-life care retrospectively from bereaved relatives has ethical, practical and scientific challenges. QUALYCARE has been carefully designed to address these challenges in a robust and ethically sound population-based survey. By discovering variations in the underlying individual reality of place of death for people dying from cancer and their families, this study will advance our understanding of end-of-life care and, we hope, improve care for cancer patients and their families in the future.

Trial registration

National Institute of Health Research (NIHR) Clinical Research Network Portfolio. UKCRN7041.

Retrospective evaluation of palliative care in Romania: the perspective of the involved professionals

OBJECTIVE

Palliative care at home is a new service provision in Romania. This study evaluated retrospectively, after the patient's death, the provision of care at home from the perspective of professionals directly involved in the care process. The evaluation included assessment of the role of the professional, the functioning of the team, communication with patients and family, and overall judgment. The study is part of the development of palliative care at home, by multidisciplinary teams in Romania.

METHODS

Over a period of eighteen months five teams with a total of 19 professionals, provided palliative care for 103 patients with cancer in its terminal stage. During this period 80 patients died. A questionnaire was sent to the professionals involved. All responded resulting in 181 evaluations. These evaluations are the basis for analysis. The data were analyzed using SPSS.

RESULTS

Of the 181 cases evaluated, 63 indicated an emotional burden on the professionals. GP's and nurses reported such a burden more frequently. A lack of knowledge of how to treat a special case was reported 56 times. This was especially so when a case was judged to be different from other cases, which often included (unexpected) complications. GP's reported cases with complications more frequently than oncologists and nurses. The multidisciplinary teams functioned very satisfactorily in treating patients. Although communication with patients/families was generally judged positively, communication with patients was sometimes viewed as problematic. The overall verdict was that the care delivered to the 80 patients was positive. Most professionals reported that they would deal with the cases in the same way again.

CONCLUSIONS

The patients who received palliative care and died, were treated well according to the professionals who evaluated the care process. Improvement of palliative care services at home may be achieved by provision of additional information on (acute) complications. Since palliative care at home is a new phenomenon in Romania, professionals working closely with the patient have to learn to cope with the emotional burden certain cases may include.

A palliative cancer care flexible education program for Australian community pharmacists

OBJECTIVE

To implement and evaluate a flexible palliative care education program for Australian community pharmacists.

DESIGN

After identifying pharmacists' education needs, the program content and format were developed. This included identifying expert writers to create modules, assigning education and palliative care specialists to review content, and designing Web hosting of materials. The program was comprised of 11 modules and 79 activities.

ASSESSMENT

An average of 28 responses was posted for each of the 20 noticeboard activities. Of the 60 pharmacists who began the program, 15 contributed to the discussion group, with an average of 3 posts each. Participants' responses to an online questionnaire indicated the program addressed their education needs and improved their knowledge and confidence in providing palliative cancer care.

CONCLUSION

A program that pharmacists could access at a time and place convenient to them via the Internet was developed. Pharmacists indicated the program positively impacted their practice.

Associations between successful palliative cancer pathways and community nurse involvement

Background

Most terminally ill cancer patients and their relatives wish that the patient dies at home. Community nurses (CNs) are often frontline workers in the patients' homes and CN involvement may be important in attaining successful palliative pathways at home.

The aim of the present study was to examine associations between bereaved relatives' evaluation of palliative treatment at home and 1) place of death and 2) CN involvement.

Methods

The study is a population-based, cross-sectional combined register and questionnaire study performed in Aarhus County, Denmark. CN questionnaires were used to obtain data on CNs' efforts, GP-questionnaires were used to obtain data on pathway characteristics and relatives answered questionnaires to evaluate the palliative pathway at home. Questionnaires addressed the palliative pathway of a total of 599 deceased cancer patients. Associations between bereaved relatives' evaluation of palliative pathways at home and place of death and CN involvement were analysed.

Results

'A successful palliative pathway at home' was positively associated with home-death and death at a nursing home compared with death at an institution. No significant associations were identified between the evaluations of the palliative pathway at home and the involvement of CNs.

Conclusions

Our study indicates that dying at home is positively associated with a higher likelihood that the bereaved relative will evaluate the palliative pathway at home as successful. The absence of any significance of involvement of CNs may be ascribed to the variables for involvement chosen in the study. More research is needed on CNs' impact on palliative pathways.

Exploring preferences for place of death with terminally ill patients: qualitative study of experiences of general practitioners and community nurses in England

OBJECTIVE

To explore the experiences and perceptions of general practitioners and community nurses in discussing preferences for place of death with terminally ill patients.

DESIGN

Qualitative study using semistructured interviews and thematic analysis.

PARTICIPANTS

17 general practitioners and 19 nurses (16 district nurses, three clinical nurse specialists).

SETTING

15 general practices participating in the Gold Standards Framework for palliative care from three areas in central England with differing socio-geography. Practices were selected on the basis of size and level of adoption of the standards framework.

RESULTS

All interviewees bar one had experience of discussing preferred place of death with terminally ill patients. They reported that preferences for place of death frequently changed over time and were often ill defined or poorly formed in patients' minds. Preferences were often described as being co-created in discussion with the patient or, conversely, inferred by the health professional without direct questioning or receiving a definitive answer from the patient. This inherent uncertainty challenged the practicability, usefulness, and value of recording a definitive preference. The extent to which the assessment of enabling such preferences can be used as a proxy for the effectiveness of palliative care delivery is also limited by this uncertainty. Generally, interviewees did not find discussing preferred place of death an easy area of practice, unless the patient broached the subject or led the discussions.

CONCLUSIONS

Further research is needed to enable development of appropriate training and support for primary care professionals. Better understanding of the importance of place of death to patients and their carers is also needed.

A narrative review of interventions to support family carers who provide physical care to family members with cancer

OBJECTIVES

Most reports of cancer caregivers' needs focus on information and psychosocial needs. Less is known about practical knowledge and support carers need to provide physical care in the home. This review aimed to identity and critique studies of the development and/or evaluation of interventions to enable family carers to provide physical/practical care to a family member with cancer.

DESIGN

Narrative review.

DATA SOURCES

Studies which included adult carers who provided care to a family member with cancer (any stage). Search sources included Psych Info., Cochrane Central Register of Controlled Trials, Embase Ovid, Embase, Ovid Medline, CINAHL, other databases, systematic and other reviews.

REVIEW METHODS

All types of study designs were included. Initially, multiple and broadly defined search strategies and terms were used to capture the range of potential studies; later more refined procedures were applied.

RESULTS

In total, 19 studies were included in the review. Interventions focused on skills development (n=1), managing symptoms (n=9), problem solving (n=5) and learning (n=4). Few studies were identified with well-defined and evaluated interventions to assist carers to provide physical care for their family member with cancer.

CONCLUSIONS

Future research is needed to develop well-defined interventions on practical skills and evaluate the outcomes for patients and caregivers.

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

AIMS

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

BACKGROUND

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

DESIGN

Systematic review.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Palliative care services for Indian migrants in australia: experiences of the family of terminally ill patients

BACKGROUND

The way that health care systems in developing countries like India care for dying patients, has an impact on the expectations of such care for those who migrate to other countries faces. At the end of life, cultural issues may impact on the quality of life remaining and for that reason, it is important that particular cultural practices are understood. This paper describes a study that investigated the cultural issues of access to palliative care services for Indian migrants in Australia.

PURPOSE OF THE STUDY

To investigate the experiences of the family members of terminally ill Indian migrants in Victoria, Australia.

OBJECTIVE OF THE STUDY

To explore the issues related to accessing palliative care services for Indian migrants; to identify the effectiveness of palliative care in supporting the patient and family and to recommend strategies for improving this care.

MATERIALS AND METHODS

A qualitative descriptive design was utilized. Up to 6 family members were selected for in-depth interviews in understanding cultural issues related to the palliative care services for a family member.

RESULTS

ANALYSIS OF THE INTERVIEWS REVEALED THAT FAMILIES OF INDIAN PATIENTS EXPERIENCE DIFFICULTIES WHILST RECEIVING PALLIATIVE CARE SERVICES, WHICH FELL INTO THREE MAIN CATEGORIES: Indian support systems, cultural issues, and caring experiences. Although each of these issues had a direct influence on the experience of terminal care that their family member received, cultural issues and support systems also influenced the caring experiences.

CONCLUSION

Despite the successful implementation of palliative care services across Australia, there are still problems in accessing and receiving the services among minority and disadvantaged groups like various cultural groups.

Knowledge and information needs of informal caregivers in palliative care: a qualitative systematic review

OBJECTIVES

To review current understanding of the knowledge and information needs of informal caregivers in palliative settings.

DATA SOURCES

Seven electronic databases were searched for the period January 1994--November 2006: Medline, CINAHL, PsychINFO, Embase, Ovid, Zetoc and Pubmed using a meta-search engine (Metalib). Key journals and reference lists of selected papers were hand searched.

REVIEW METHODS

Included studies were peer-reviewed journal articles presenting original research. Given a variety of approaches to palliative care research, a validated systematic review methodology for assessing disparate evidence was used in order to assign scores to different aspects of each study (introduction and aims, method and data, sampling, data analysis, ethics and bias, findings/results, transferability/generalizability, implications and usefulness). Analysis was assisted by abstraction of the key details of each study into a table.

RESULTS

Thirty-four studies were included from eight different countries. The evidence was strongest in relation to pain management, where inadequacies in caregiver knowledge and the importance of education were emphasized. The significance of effective communication and information sharing between patient, caregiver and service provider was also emphasized. The evidence for other caregiver knowledge and information needs, for example in relation to welfare and social support, was weaker. There was limited literature on non-cancer conditions and the care-giving information needs of black and minority ethnic populations. Overall, the evidence base was predominantly descriptive and dominated by small-scale studies, limiting generalizability.

CONCLUSIONS

As palliative care shifts into patients' homes, a more rigorously researched evidence base devoted to understanding caregivers knowledge and information needs is required. Research design needs to move beyond the current focus on dyads to incorporate the complex, three-way interactions between patients, service providers and caregivers in end-of-life care settings.

Palliative care for cancer patients in a primary health care setting: Bereaved relatives' experience, a qualitative group interview study

Background

Knowledge about the quality and organisation of care to terminally ill cancer patients with a relatives' view in a primary health care setting is limited.

The aim of the study is to analyse experiences and preferences of bereaved relatives to terminally ill cancer patients in a primary care setting to explore barriers and facilitators for delivery of good palliative home care.

Methods

Three focus group interviews with fourteen bereaved relatives in Aarhus County, Denmark.

Results

Three main categories of experience were identified: 1) The health professionals' management, where a need to optimize was found. 2) Shared care, which was lacking. 3) The relatives' role, which needs an extra focus.

Conclusion

Relatives experience insufficient palliative care mainly due to organizational and cultural problems among professionals. Palliative care in primary care in general needs improvement and attention should be drawn to the "professionalization" of the relatives and the need to strike a balance between their needs, wishes and resources in end-of-life care and bereavement.

What to do when ‘there is nothing more to do’? A study within a salutogenic framework of family members' experience of palliative home care staff

The aim of this study was to develop a theoretical framework of family members' experience of palliative home care staff based on a secondary analysis of four previous studies. A salutogenic framework was used, i.e. with the origin of health in focus. Data had been collected (semi-structured tape-recorded interviews and postal questionnaires with open-ended questions) from 469 family members of mainly cancer patients referred to advanced palliative home care. Walker and Avant's strategies for theory construction were used. The secondary analysis generated three theoretical blocks: (1) general components of staff input (including five generalized resistance resources (GRRs): competence, support, spectrum of services, continuity, and accessibility); (2) specific interactions with staff (including two GRRs: being in the centre and sharing caring); (3) emotional and existential consequences of staff support (including six health-disease continuums: security-insecurity, hope-hopelessness, congruent inner reality-chaos, togetherness-isolation, self-transcendence-feelings of insufficiency and retained everyday life-disrupted everyday life). It seems important that all three aspects of family members' experience of palliative care staff are to be considered in evaluations of palliative care, in goal-setting and in teaching role models. The study is specific to the Swedish model of palliative home care and replication of the work in other countries is recommended.

The specialist palliative care nurse: A qualitative study of the patients’ perspective

BACKGROUND

Relatively little is known about patients' perceptions of the work and role of the specialist palliative care nurse. Understanding the patients' perspective can help to evaluate services, improve quality of care, and identify misunderstandings.

OBJECTIVES

To explore the experiences of those who said that they had a 'terminal illness', focusing on patients' perceptions of the work and role of these nurses.

DESIGN

Qualitative study with narrative interviews.

SETTING

England and Wales.

PARTICIPANTS

Forty-one people recruited through those working in hospices, community nurses, general practitioners, support groups, a national newspaper, and a conference on palliative care. Twenty-five people talked about the work of specialist palliative care nurses.

METHOD

Interviews were fully transcribed; followed by a thematic analysis with constant comparison.

RESULTS

Patients valued the nurses' work, particularly their advice on practical matters, information given about their disease, emotional support, advice on symptoms, and help with communication. They were glad that help was readily available. However, some patients who had been referred to the service did not realise that specialist palliative care nurses may be involved at a relatively early stage in a person's illness, and sometimes felt distressed by an early referral. One woman felt she had not had the emotional support she needed and another knew of women who had been upset because these nurses had discussed topics such as place of death 'too early'. However, people recognised the difficulties nurses faced in their work.

CONCLUSIONS

Although our study differs from other studies, particularly in the way people were recruited, our findings support previous studies that have shown that specialist palliative care nurses are highly valued by those who have a terminal illness. It is important for people to understand that these nurses may be involved from the time of diagnosis and that roles have changed.

Relatives in end-of-life care--part 1: a systematic review of the literature the five last years, January 1999-February 2004

AIM

To review systematically research conducted during the past five years focusing on the relatives' situation and needs in end-of-life care.

BACKGROUND AND AIM

That relatives make a large contribution in the care of the dying is well-known. In this situation, relatives often have to solve many new practical problems in the care as well as dealing with the sorrow of both themselves and the dying person. In recent years, palliative care has been developed in many countries and many new studies have been carried out.

METHODS

A systematic search of the literature was performed in the CINAHL and Medline databases. Of the 94 papers analysed, there were 59 qualitative and 35 quantitative studies with differing designs. The studies were carried out in 11 countries and were published in 34 different journals.

RESULTS

The results were categorized in two main themes with several subthemes: (1) being a close relative--the situation: (i) exposed position--new responsibility, (ii) balance between burden and capacity and (iii) positive values; (2) being a close relative--needs: (i) good patient care, (ii) being present, (iii) knowing and communicating and (iv) support from and trusting relationship with the professional. The relative's feelings of security and trust in the professional were found to be of great importance.

CONCLUSION

More than twice as many studies had a descriptive/explorative design, which is of importance in the assessment of evidence. However, different studies complement one another and in summary, it can be said that analytic evidence is unequivocal: good patient care, communication, information and the attitude of the professional are of decisive importance regarding relatives' situation. These results are also in accord with earlier review studies.

RELEVANCE TO CLINICAL PRACTICE

Staff members have a great deal of responsibility for assuring that the patient feels as good as possible, facilitating relatives' involvement based on the family's wishes and limiting the stress and difficulties experienced by the family. The results showed that the relative's satisfaction could depend on the attitude of the professional as well as on good communication, good listening and good information. This can also be viewed as a prerequisite for the professional to get to know the family and to provide 'care in the light'.

Hospice at home service: the carer's perspective

GOALS OF THE WORK

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

MATERIALS AND METHODS

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

MAIN RESULTS

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

CONCLUSIONS

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

Decompression surgery for lumbar spinal stenosis in the elderly: preoperative expectations and postoperative satisfaction

STUDY DESIGN

Retrospective cohort examination.

OBJECTIVES

Data on expectations and satisfaction rates in elderly patients operated for lumbar spinal stenosis (LSS) are limited. The present study aimed to investigate these issues as well as the factors that might affect them.

SETTING

A university affiliated hospital.

PATIENTS AND METHODS

A follow-up study of 367 consecutive patients aged 65 years and older (mean age 71.4 years), who underwent surgery for degenerative LSS between 1990 and 2000. Data collection included patients' preoperative expectation, demographic data, body mass index, operative risk, duration of symptoms, clinical presentation and patients' satisfaction on follow-up, pain level, activities of daily living level and walking ability. Data were recorded before operation and on follow-up. Preoperative and follow-up data were analyzed by univariate and multivariable models.

RESULTS

The response rate on follow-up was 81% (298 patients). A logistic regression analysis showed that advanced age, male gender and high education level were independently associated with positive expectations, while a great number of covariates were associated with patients' satisfaction. High patients' expectations were positively interrelated with satisfaction (r=0.332, P<0.001).

CONCLUSIONS

In the elderly, preoperative expectations reasonably predict their postoperative satisfaction rate. It is suggested that a greater effort should be made to narrow the gaps between expectations and satisfaction, perhaps by providing more accurate preoperative information data regarding the outcomes of planned surgery.

Palliative care for patients with cancer: what are the educational needs of community pharmacists?

AIMS

The objective of this study was to determine the educational needs of community pharmacists in Australia related to palliative cancer care, to guide the development of an online educational program for pharmacists.

METHODS

Questionnaires were posted to a random sample of community pharmacies in Australia. The questionnaire sought information pertaining to pharmacists': demographics; educational needs by rating the importance of learning more about 18 palliative cancer care topics and self-perceived level of knowledge of them; preference for format(s) for the program; willingness to participate in the program; and perception regarding their practice of palliative cancer care. Results were analysed using Statistical Package for the Social Sciences (SPSS) version 11.5 software.

MAIN RESULTS

A questionnaire return rate of 10.3% was achieved. The characteristics of respondents were reflective of community pharmacy practice in Australia when compared with the latest available labour force figures by the Australian Institute of Health and Welfare. Pharmacists rated all 18 topics as "important/essential", and their level of knowledge of them as "poor/good". Pharmacists preferred information provided in these formats: text (89.8%), case studies (80.6%) and multi-choice questions (69.4%). Most pharmacists (85.2%) indicated that they would participate in the program. The majority of pharmacists (71.3%) reported that they deliver palliative cancer care services; usually less-than-monthly (24.1%) or weekly (21.3%).

CONCLUSIONS

Educational needs of community pharmacists in palliative cancer care were identified. The information gathered will assist in guiding the development of an online educational program for pharmacists to improve their knowledge and skills in palliative cancer care.

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

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

Specialist palliative care: patients' experiences

BACKGROUND

Nursing research generally, and palliative care research in particular, has been criticized for generating numerous small scale, often qualitative and/or evaluative studies, from which it is difficult to draw generalizations.

AIMS

Our aim in this study was to conduct a synthesis of three evaluative studies of palliative care services in the United Kingdom (UK), to ascertain patients' reported expectations and experiences of specialist care. We also demonstrate how secondary data analysis and synthesis can identify commonalities and differences between services.

METHODS

Secondary qualitative data analysis was conducted on interview data gathered from 37 patients during three evaluation studies of specialist palliative care services. All studies used formative evaluation methodology.

FINDINGS

Four themes were identified: (1) knowledge and information about services, (2) meeting practical and psychosocial needs, (3) lack of control, and (4) family atmosphere. Data are presented to illustrate the presence or absence of these themes in patients' accounts of their expectations and experiences of each service.

STUDY LIMITATIONS

Data were collected at different times between 1998 and 2000, and interviews were conducted by different researchers.

CONCLUSIONS

Synthesizing findings from small scale qualitative studies offers the possibility of demonstrating their applicability beyond local and specific contexts. It is imperative to listen to the experiences of patients and carers as a basis for developing interventions and guidelines for services. The methods proposed in this paper offer the potential for these voices of experience to be heard more widely.

Palliative care at home: general practitioners working with palliative care teams

Home care is the preferred option for most people with a terminal illness. Providing home care relies on good community-based services, and a general practice workforce competent in palliative care practice and willing to accommodate patients' needs. Structured palliative care training of general practitioners is needed at undergraduate and postgraduate level, with attention to barriers to teamwork and communication. Good palliative care can be delivered to patients at home by GPs (supported by specialist palliative care teams) and community nurses, with access to an inpatient facility when required. To optimise patient care, careful planning and good communication between all members of the healthcare team is crucial.

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

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

Using satisfaction to measure the quality of palliative care: a review of the literature

BACKGROUND

The advent of clinical governance in British health policy has placed increased demands on health care providers and practitioners to ascertain the quality of their services. Traditional indicators of quality of health care, such as death or recovery rates, are not appropriate in palliative care. Thus, it is important to establish alternative approaches to measuring the quality of palliative care services and interventions.

AIMS

Satisfaction levels have been used widely in palliative care to assess quality. A literature review was conducted which aimed to explore the strengths and weaknesses of using satisfaction as an indicator of the quality of palliative care services. It also aimed to provide a solid basis upon which further work could be built.

METHODS

Five electronic databases were searched using key words and phrases and key authors. Hand searches were conducted of four journals that contributed significantly to the concept of satisfaction, and reference lists of reviewed papers were scrutinized. Relevant papers were reviewed, data were extracted and these data were thematically analysed.

FINDINGS

There are a number of important unresolved issues in the literature with regard to using satisfaction as an indicator of the quality of palliative care services. First, few alternatives to satisfaction are available. Secondly, satisfaction is under-theorized and no widely accepted definition exists. Thirdly, there are methodological inconsistencies across studies. It is important to take into account these findings when planning and implementing change following service evaluation using satisfaction as a measure.

CONCLUSIONS

Relying on findings of satisfaction surveys to determine clinical and policy amendments in palliative care may not result in improvements in overall quality of care. Using satisfaction as a method of assessing the quality of health care services is particularly problematic and requires further investigation in both practical and conceptual terms.

Administration of as required subcutaneous medications by lay carers: developing a procedure and leaflet

Good symptom control is considered one of the factors that determines whether patients are able to die at home. This article describes a practice development project to enable carers to administer as required (PRN) subcutaneous medication, via a subcutaneous butterfly device in a community setting. Medications were mainly analgesic injections, although others, such as midazolam, were also given. The article highlights the lack of literature on the topic, reviews relevant background information and presents two successful case histories. It outlines the development of a procedure and accompanying leaflet to support community nurses in teaching relatives how to carry out this task, and the implementation of the process.

How well do general practitioners deliver palliative care? A systematic review

General practitioners (GPs) deliver the majority of palliative care to patients in the last year of life. This article seeks to examine the nature of GP care, perceptions of the GPs themselves and others of that care, the adequacy of palliative care training, issues relating to accessibility of GPs to palliative care patients, and strategies that may be of use in encouraging more effective delivery of palliative care by GPs. Medline and PubMed databases from 1966 to 2000 were searched, and 135 references identified. Sixty-six of these described studies relevant to GP palliative care. GPs value this part of their work. Most of the time, patients appreciate the contribution the GP makes to palliative care particularly if the GP is accessible, takes time to listen, allows patient and carer to ventilate their feelings, and is seen to be making efforts made regarding symptom relief. However, reports from bereaved relatives suggest that palliative care is performed less well in the community than in other settings. GPs express discomfort about their competence to perform palliative care adequately. They tend to miss symptoms which are not treatable by them, or which are less common. However, with appropriate specialist support and facilities, GPs have been shown to deliver sound and effective care. GP comfort working with specialist teams increases with exposure to this form of patient management, as does the understanding of the potential other team members have in contributing to the care of the patient. Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes, patient satisfaction, improve effective use of resources and improve effective physician behaviour in other areas of medicine. Efforts by specialist services to develop formal involvement of GPs in the care of individual patients, may be an effective method of improving GP palliative care skills and appreciation of the roles specialist services can play.

Differences in assessment of symptoms and quality of life between patients with advanced cancer and their specialist palliative care nurses in a home care setting

This study examined differences in the assessment of symptoms and quality of life (QoL) between patients with advanced cancer living at home and their specialist palliative care nurses. Nurses introduced a recently validated outcome measure, the Palliative Care Outcome Scale (POS), to patients referred to their hospice at their first or second home visit. The POS has two components: a patient questionnaire mirrored almost exactly by a staff questionnaire, which are both completed independently. The POS contains 10 core questions examining aspects of symptom control and QoL. Of the 338 patients referred during the study period, 174 (51%) were eligible for inclusion in the study. Of these, 55 (32%) pairs of patient and nurse questionnaires were returned and suitable for assessment. Not all questionnaires were returned by nurse and patient to form a matched pair. There was good agreement and correlation between patients and nurses in the assessment of pain and symptom control. However, important differences were found in other areas explored including anxiety levels of patients and their families, personal thoughts, practical matters and information received. The study confirms the importance of evaluating the needs, feelings and concerns of patients with advanced cancer cared for at home and highlights both the significance and necessity of the patient's contribution to any such assessment.

Community specialist palliative care: experiences of patients and carers

Specialist palliative care provides a range of services for patients and their carers who have complex needs. There is a need to identify what patients and carers gain from contact with the specialist palliative care nurse (SPCN) and what aspects of that care have a positive impact on their quality of life (QoL). The aims of the study were to gain insightful and credible accounts of participants' experiences of the SPCN; to consider those dimensions of care which impact on satisfaction; to discover whether the SPCN provides improvements in QoL and to explore whether experiences match expectations. A qualitative approach focused on the experience and individual meaning; it is the individual narratives produced by each participant that are the rich and interesting outcomes of this study. Both patients and carers reported satisfaction at being given time and being listened to, with the interviewees using words and phrases such as 'confidence', 'trust', knowledge', 'listens to' and 'a sense of being there'. The study shows the patient and carers' lack of knowledge about specialist palliative care while confirming the positive influence of the SPCN.