A survey of psychosocial service provision within hospices

Access to and adequacy of psychological services for adult patients in UK hospices: a national, cross-sectional survey

BACKGROUND

Providing psychological support to people living with terminal illness is a fundamental part of hospice care. Recent research on delivery of psychological services in hospices in the United Kingdom (UK) on a national level, including inequalities or variation in practice, is limited. A nationwide survey will highlight any differences in provision and in doing so help focus future research and inform best practice both within the UK, and internationally. The specific objectives of this survey are to (1) chart the types of psychological support available to adult patients in hospices in the UK in line with the National Institute for Health and Care Excellence model; (2) explore how services are organised; and (3) gather service perspectives on adequacy of care, and facilitators and barriers to appropriate practice.

METHODS

A cross-sectional online survey emailed to adult hospices in the UK in November-December 2019. One staff member involved in the delivery and/or organisation of psychological support was invited to participate per hospice. Of 193 invited hospices, 116 took part.

RESULTS

Sixteen percent rated their hospice psychological service as wholly adequate. The majority reported that services can access specialist professionals, but many relied on external referrals. Barriers to best practice included funding and staff capacity; facilitators included clear referral structures, audit and appropriate needs and outcome assessments.

CONCLUSIONS

Access to psychological professionals has improved since the last survey 15 years ago, but the majority of responders felt their overall service was not wholly adequate. Basic emotional support is largely felt to be sufficient, but our results indicate a need for improvements in access to more specialist care. Partnerships with external mental health services may be key. Our findings highlight core facilitators and barriers to providing good psychological care at the end of life that should be considered by services both within the UK and on an international level.

Psychological Services in Hospices in the UK and Republic of Ireland

OBJECTIVE

To evaluate the level of psychological services available to patients and staff in hospices.

DESIGN

Questionnaire analysis.

SETTING

Hospices in the UK and Republic of Ireland.

PARTICIPANTS

224 hospices.

MAIN OUTCOME MEASURES

The availability of professional psychological support for those with advanced disease.

RESULTS

Responses were received from 166 hospices (74%). Only 50 hospices (30%) have access to a psychiatrist, whilst 68 (41%) have access to a clinical psychologist and 92 (45%) have neither. Only 21 hospices (12%) have service level agreements with local mental health trusts. Counsellors, complementary therapists and spiritual advisors such as chaplains were more plentiful.

CONCLUSIONS

Delivery of the NICE guidelines, especially tier four, may be compromised by limited availability of specialist services. This has implications for the psychological assessment of applicants for voluntary euthanasia under an Assisted Dying Act.

Psychological services in hospices in the UK and Republic of Ireland

OBJECTIVE

To evaluate the level of psychological services available to patients and staff in hospices.

DESIGN

Questionnaire analysis.

SETTING

Hospices in the UK and Republic of Ireland.

PARTICIPANTS

224 hospices.

MAIN OUTCOME MEASURES

The availability of professional psychological support for those with advanced disease.

RESULTS

Responses were received from 166 hospices (74%). Only 50 hospices (30%) have access to a psychiatrist, whilst 68 (41%) have access to a clinical psychologist and 92 (45%) have neither. Only 21 hospices (12%) have service level agreements with local mental health trusts. Counsellors, complementary therapists and spiritual advisors such as chaplains were more plentiful.

CONCLUSIONS

Delivery of the NICE guidelines, especially tier four, may be compromised by limited availability of specialist services. This has implications for the psychological assessment of applicants for voluntary euthanasia under an Assisted Dying Act.

A prospective study of the roles, responsibilities and stresses of chaplains working within a hospice

Spiritual care is an integral part of palliative care and if asked, most members of a palliative care team would state they address spiritual issues. The majority of hospices have support from a chaplain. This study was to determine the roles of chaplains within hospices and to look at their levels of stress. A questionnaire containing both open and closed questions was sent to chaplains working within hospices in the UK. The questionnaire enquired about number of sessions, specific roles of chaplain, whether they were members of the multidisciplinary team and their sources of internal support. Stress was measured on a 10-point Likert scale and the GHQ12. One hundred and fifteen questionnaires were returned, with a 72% response rate. The majority (62%) defined their denomination as Church of England and Free Church (24%); 71% of respondents had parish commitments in addition to their hospice role. Roles were predominantly defined as spiritual care of patients and staff (95%) and bereavement support of relatives (76%) and 75% regularly attended the multidisciplinary meetings. Senior medical and nursing staff and other chaplains were perceived as providing most support. Median Likert score for stressfulness was 5, and 23% scored at or above the threshold on the GHQ12 for identifiable psychological morbidity. Clear role definition was associated with less perceived stress whereas the provision of bereavement support was associated with statistically significant increased perceived stress. The role of a chaplain within a hospice is varied and this study suggests that the provision of training and formal support is to be recommended.

How do palliative medicine physicians assess and manage depression

Depression is a significant symptom for approximately 25% of palliative care patients, but is frequently unrecognized and untreated. This study was carried out to determine how senior doctors working in palliative medicine in the UK assessed and managed depression in their patients. A questionnaire was sent to all palliative care units with a designated consultant or medical director. Questions were asked about assessment and management of depression (pharmacological and nonpharmacological); difficulties encountered, qualifications and current post. The response rate was 63%; two-thirds (90) of respondents were consultants and a further 21 medical directors. The majority (73%) routinely assessed for depression with 27% using the Hospital Anxiety and Depression (HAD) Scale and 10% asking the patient 'are you depressed'? The most frequently prescribed medication was SSRI (80%). Less than 6% prescribed psychostimulants. Respondents reported difficulties with the assessment and management of depression which mainly focused on distinguishing symptoms of depression from sadness and whether it was appropriate to treat patients when life expectancy was short. Difficulties were identified in accessing psychiatric input by 47%. Depression is identified as being a difficult symptom to manage by many senior palliative care physicians in the UK and suggestions are made as to how some of theses issues can be addressed.

Assessing depression in palliative care patients using the visual analogue scale: a pilot study

It is widely recognised that depression is not detected and therefore not treated in patients who are terminally ill. It is difficult to distinguish depression from sadness at the end of life and many of the criteria for diagnosing depression are not appropriate in the terminally ill patient. There has been considerable interest in using screening tools at the time of referral or admission to a hospice, but to date none of these have been validated for use in palliative care patients. This pilot study of 25 patients admitted to a hospice found that a 100-mm linear visual analogue scale (VAS) correlated well with both the depression sub scale and total score of the Hospital Anxiety and Depression Scale (HADS) and was found to be quick and easy to complete by most patients. The finding suggest that the VAS may be useful as a screening tool for depression in patients with advanced metastatic disease and that larger studies comparing VAS to clinical psychiatric interviews should be undertaken.