Changing concepts in palliative care

Mission statements: an example of exclusive language in palliative care?

This article discusses the language used in palliative care and the possibility of exclusive language being a barrier to uptake of services by users. The author illustrates this with an analysis of mission statements from palliative care services in an Australia state. Although language is just one aspect affecting service use, this author argues that services need sensitivity about the language they use, so that public statements are understandable and remain consistent with the philosophy of care.

Good enough death: autonomy and choice in Australian palliative care

This paper draws upon Australian fieldwork to trace the changing notions of a good death held by hospice and palliative care practitioners. Palliative care practitioners search for an ideology to inform their practice within the context of a complex society for which there is no one good death. Social demographics, the multicultural nature of society and institutional constraints frame the experience of dying in complex ways, while contemporary social responses to dying reflect the uncertainties held by many Australians. Despite the fragmentation evident within contemporary Australian society, the hospice movement in Australia and in other Western contexts has sought to reintroduce a ritual for dying. The good death ideology of the original hospice movement proposed a manner of dying in which open communication and acceptance of death were actively encouraged. The hospice model of a good death, however, has become increasingly inappropriate in the current climate of patient autonomy and consumer choice. The practice of palliative care, a holistic form of care for dying people, which follows the individualistic ethic of choice, has emerged from and replaced the original hospice movement. Consequently, the good death of the original hospice movement has been abandoned in favour of a philosophy of a 'good enough' death. However, what may appear a compromise informed by ethical practice masks a return to routine medical practices and a hierarchy of care which prioritises the physical management of symptoms. It appears that while palliative care practitioners may often fail in their facilitation of a good death for their patients, they can be proactive in alleviating their patients' pain and physical discomfort.

Provider perspectives on palliative care needs at a major teaching hospital

Jericho Metropolitan Hospital (JMH) is a major Australian teaching hospital which lacked a designated palliative care service at the time this study was conducted. A questionnaire addressing palliative care service needs, and educational and support needs of staff, was sent to 267 multi-disciplinary oncology staff at JMH. A response rate of 83% was achieved. Staff identified a number of palliative care needs that were being particularly poorly addressed by existing services. These included: spiritual support, cultural needs, grief and bereavement support, pleasant surroundings, adequate privacy and facilities for families. The majority of respondents identified the following issues as critical problems in palliative care provision: lack of a designated palliative care service, lack of palliative care education of staff, unmanageable caseloads and inadequate physical facilities for the provision of care. Only 24% of respondents reported having had any palliative care education, and 92% of respondents expressed a need for further education. The majority of respondents (79%) expressed a need for improved staff support. There was a significant association between perceived need for improved support and professional discipline (chi2 = 31.33, P < 0.002), with medical staff being significantly less likely than other staff groups to report a need for improved support. Overall, the health providers surveyed identified major deficiencies in the provision of palliative care to cancer patients at JMH and in the palliative care education and support for staff caring for terminally ill cancer patients. The findings support the need for a designated palliative care service at JMH to improve the standard of care of dying cancer patients, and the need for improved palliative care education and support for staff.

Mainstreaming palliative care for cancer patients in the acute hospital setting

Palliative care is now emerging as an integrated part of mainstream health care delivery. The importance of patient choice regarding place of dying means that a substantial proportion of palliative care provision occurs in community settings. In part, this is due to the inappropriateness of the acute hospital setting for the care of dying patients. However, most patients with cancer and other terminal illnesses are diagnosed and treated in acute hospitals. Acute hospitals are also the most common setting where people actually die. Therefore, there remains a need for skilled and compassionate provision for the care of dying patients in the acute hospital setting. This paper presents a case for the provision of palliative care services in teaching hospitals. It further argues that a high level of integration between cancer treatment services and palliative care services is needed to optimize the care of cancer patients.

Coverage of cancer patients by hospice services, South Australia, 1990 to 1993

A population-based observational study of South Australian cancer patients was used to identify: the level of coverage of cancer patients by hospice services; the types of patients who miss out on hospice care; and the place of death of hospice and other cancer patients. We reviewed patients who died in 1990 and 1993 using the Central Cancer Registry database together with an identifier of hospice involvement. In 1990, 56 per cent of cancer patients who died had care from a hospice service, and this proportion increased to 63 per cent in 1993. Elderly patients, rural residents and those with a haematological malignancy were less likely than other patients to receive care from a hospice service, while patients aged between 40 and 60 years, longer survivors and those born in the United Kingdom and Europe were more likely to receive hospice care. Hospice involvement increased significantly between 1990 and 1993 for patients who died at home (59 to 73 per cent), in nursing homes (20 to 45 per cent), private hospitals (33 to 52 per cent) and public hospitals (48 to 55 per cent), but the proportion of patients with hospice involvement who died in country hospitals remained at 45 per cent. The increase in hospice coverage of terminal cancer patients reflects the continued integration of hospice care into the mainstream of health care delivery. The types of patients who miss out on hospice services should be given special consideration in the future planning of terminal care services.

Professional needs of palliative care nurses in New South Wales

A survey of 108 palliative care nurses practising in New South Wales, Australia, was undertaken to explore their professional needs and clinical knowledge. Opportunity for improved training was the most frequently nominated professional need. Only 12% of the sample had postgraduate qualifications in palliative care and fewer than 20% were currently undertaking postgraduate training. Sixty-three per cent of nurses indicated that a lack of opportunity for formal study was a problem for them. The results of the knowledge survey revealed a need for additional training. Many nurses did not have the clinical knowledge identified as minimal by an expert committee. Those nurses who had a postgraduate qualification in oncology scored more highly on the knowledge questionnaire than did those whose general nursing training was undertaken outside Australia. The implications of these findings for training and other professional support are discussed.

General practitioners and palliative care

A randomly selected sample of 158 South Australian general practitioners (GPs) were sent a questionnaire which assessed opinions and management practices in the palliative care of terminally ill patients. A total of 117 responses (74%) were received. Most GPs were at least moderately satisfied with the care they were able to give their terminally ill patients, although a substantial number reported difficulties in pain and other symptom control, dealing with relatives' emotional distress and attending to patients' psychosocial needs. There was considerable support for continuing education in these aspects of palliative care. More than half were at least somewhat concerned by opioid side effects and impairment of cognitive function, although opioid dependence was not a concern. Considerable dissatisfaction was expressed with public hospital care for the terminally ill and most felt excluded from decision-making once their patients were admitted. The findings suggest that continuing education is required for GPs and that palliative care should become an integral part of undergraduate education. There is also a need to enhance communication and co-ordination between hospital and community-based services for the terminally ill.

Pain syndromes in HIV infection

Pain causes considerable disability and discomfort in HIV (Human Immunodeficiency Virus) infected individuals. A large number of patients infected with HIV suffer from one or more pain-related syndromes. Pain is under-reported and suboptimally managed in these patients. An outline of the different pain syndromes, including headache, oral cavity pain, chest pain, abdominal pain, anorectal pain, musculoskeletal pain and peripheral neuropathic pain, and their aetiologies are discussed. Current pain management modalities, including non-narcotic and narcotic analgesics, tricyclic antidepressants, anticonvulsants, physical therapy and psychological techniques, are outlined. Treatment should be based on the same principles applied to the management of cancer-related pain. A multi-disciplinary, comprehensive approach to pain management will assist these individuals to achieve improved levels of comfort, function and quality of life in this ultimately terminal illness.