1
|
Flöther L, Pötzsch B, Jung M, Jung R, Bucher M, Glowka A, Medenwald D. Treatment effects of palliative care consultation and patient contentment: A monocentric observational study. Medicine (Baltimore) 2021; 100:e24320. [PMID: 33761631 PMCID: PMC9282054 DOI: 10.1097/md.0000000000024320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 12/03/2020] [Accepted: 12/22/2020] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT Palliative care is a central component of the therapy in terminally ill patients. During treatment in non-palliative departments this can be realized by consultation.To analyze the change in symptom burden during palliative care consultation.In this observational study, we enrolled all cancer cases (n = 163) receiving inpatient treatment for 2015 to 2018 at our institution. We used the MDASI-questionnaire (0 = 'not present' and 10 = "as bad as you can imagine") and the FAMCARE-6 (1 = very satisfied, 5 = very dissatisfied) to analyze the treatment effect and patient satisfaction, respectively.We examined the association of symptom burden and patient satisfaction using Spearman-correlation. Comparing mean values, we applied the Wilcoxon-test and one-way ANOVA.An improvement in MDASI-core-items after treatment completion was significant (P < .05) in 14/18 symptoms. The change in perception of pain showed the strongest improvement (median: 5 to 3). Initially the MDASI-items "activity" (median = 8) and emotional distress (median = 5 and 6) were viewed as especially incriminating. There was no evidence for a correlation between patients' age, the type of diagnosis and time since diagnosis.The analysis of FAMCARE-6 patient contentment was lower or equal to two in all of the six items. There was a weak negative association between the change in symptom burden of psycho-emotional items "distress/feeling upset" (P = .006, rSp = -0,226), "sadness" and patient satisfaction in FAMCARE-6.A considerable improvement of the extensive symptom burden particularly of pain relief was achieved by integrating palliative consultation in clinical practice.
Collapse
Affiliation(s)
- Lilit Flöther
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Barabara Pötzsch
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Maria Jung
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Robert Jung
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Michael Bucher
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - André Glowka
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Daniel Medenwald
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
| |
Collapse
|
2
|
Quinn KL, Stukel T, Stall NM, Huang A, Isenberg S, Tanuseputro P, Goldman R, Cram P, Kavalieratos D, Detsky AS, Bell CM. Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study. BMJ 2020; 370:m2257. [PMID: 32631907 PMCID: PMC7336238 DOI: 10.1136/bmj.m2257] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level. DESIGN Population based matched cohort study. SETTING Ontario, Canada between 2010 and 2015. PARTICIPANTS 113 540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex. MAIN OUTCOME MEASURES Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities). RESULTS In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13 384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home. CONCLUSIONS These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.
Collapse
Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Therese Stukel
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Nathan M Stall
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anjie Huang
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
| | - Sarina Isenberg
- Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Tanuseputro
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Russell Goldman
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
- Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | | | - Allan S Detsky
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| |
Collapse
|
3
|
Maley JH, Landon BE, Stevens JP. Regional Variation in Use of End-of-Life Care at Hospitals, Intensive Care Units, and Hospices Among Older Adults With Chronic Illness in the US, 2010 to 2016. JAMA Netw Open 2020; 3:e2010810. [PMID: 32692369 DOI: 10.1001/jamanetworkopen.2020.10810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jason H Maley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Beth Israel Deaconess Center for Healthcare Delivery Science, Boston, Massachusetts
| | - Bruce E Landon
- Beth Israel Deaconess Center for Healthcare Delivery Science, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jennifer P Stevens
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Beth Israel Deaconess Center for Healthcare Delivery Science, Boston, Massachusetts
| |
Collapse
|
4
|
Wu LF, Lin C, Hung YC, Chang LF, Ho CL, Pan HH. Effectiveness of palliative care consultation service on caregiver burden over time between terminally ill cancer and non-cancer family caregivers. Support Care Cancer 2020; 28:6045-6055. [PMID: 32296981 DOI: 10.1007/s00520-020-05449-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 04/01/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The responsibility of taking care of terminal patients is accepted as a role of family members in Taiwan. Only a few studies have focused on the effect of palliative care consultation service (PCCS) on caregiver burden between terminal cancer family caregivers (CFCs) and non-cancer family caregivers (NCFCs). Therefore, the purpose of this study is to address the effect of PCCS on caregiver burden between CFC and NCFC over time. METHODS A prospective longitudinal study was conducted in a medical center in northern Taiwan from July to November 2017. The participants were both terminally ill cancer and non-cancer patients who were prepared to receive PCCS, as well as their family caregivers. Characteristics including family caregivers and terminal patients and Family Caregiver Burden Scale (FCBS) were recorded pre-, 7, and 14 days following PCCS. A generalized estimating equation model was used to analyze the change in the level of family caregiver burden (FCB) between CFC and NCFC. RESULTS The study revealed that there were no statistically significant differences in FCB between CFC and NCFC 7 days and 14 days after PCCS (p > 0.05). However, FCB significantly decreased in both CFC and NCFC from pre-PCCS to 14 days after PCCS (β = - 12.67, p = 0.013). PPI of patients was the key predictor of FCB over time following PCCS (β = 1.14, p = 0.013). CONCLUSIONS This study showed that PCCS can improve FCB in not only CFC but also NCFC. We suggest that PCCS should be used more widely in supporting family caregivers of terminally ill patients to reduce caregiver burden.
Collapse
Affiliation(s)
- Li-Fen Wu
- Department of Nursing, Tri-Service General Hospital, Taipei City, Taiwan
- School of Nursing, National Defense Medical Center, Taipei City, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei City, Taiwan
| | - Yu-Chun Hung
- Department of Nursing, Tri-Service General Hospital, Taipei City, Taiwan
- School of Nursing, National Defense Medical Center, Taipei City, Taiwan
| | - Li-Fang Chang
- Department of Nursing, Tri-Service General Hospital, Taipei City, Taiwan
- School of Nursing, National Defense Medical Center, Taipei City, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Liang Ho
- Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
| | - Hsueh-Hsing Pan
- Department of Nursing, Tri-Service General Hospital, Taipei City, Taiwan.
- School of Nursing, National Defense Medical Center, Taipei City, Taiwan.
| |
Collapse
|
5
|
Lueckel SN, Teno JM, Stephen AH, Benoit E, Kheirbek T, Adams CA, Cioffi WG, Thomas KS. Population of Patients With Traumatic Brain Injury in Skilled Nursing Facilities: A Decade of Change. J Head Trauma Rehabil 2020; 34:E39-E45. [PMID: 29863612 PMCID: PMC6274633 DOI: 10.1097/htr.0000000000000393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe the natural history of patients with traumatic brain injury (TBI) admitted to skilled nursing facilities (SNFs) following hospitalizations. SETTING Between 2005 and 2014. PARTICIPANTS Adults who had incident admissions to skilled nursing facilities (SNFs) with a diagnosis of TBI. DESIGN Retrospective review of the Minimum Data Set. MAIN MEASURES Main variables were cognitive and physical function, length of stay, presence of feeding tube, terminal condition, and dementia. RESULTS Incident admissions to SNFs increased annually from 17 247 patients to 20 787 from 2005 to 2014. The percentage of patients with activities of daily living score 23 or more decreased from 25% to 14% (P < .05). The overall percentage of patients with severe cognitive impairment decreased from 18% to 10% (P < .05). More patients had a diagnosis of dementia in 2014 compared with previous years (P < .05), and the presence of a terminal condition increased from 1% to 1.5% over the 10-year period (P < .05). The percentage of patients who stayed fewer than 30 days was noted to increase steadily over the 10 years, starting with 48% in 2005 and ending with 53% in 2013 (P < .05). CONCLUSION Understanding past trends in TBI admissions to SNFs is necessary to guide appropriate discharge and predict future demand, as well as inform SNF policy and practice necessary to care for this subgroup of patients.
Collapse
Affiliation(s)
- Stephanie N Lueckel
- Department of Surgery (Drs Lueckel, Stephen, Benoit, Kheirbek, and Cioffi), Rhode Island Hospital, Warren Alpert Medical School at Brown University, Providence, Rhode Island; Department of Medicine, Division of Gerontology and Geriatric Medicine at University of Washington, Seattle (Dr Teno); and School of Public Health at Brown University, Providence Veterans Affairs Medical Center, Rhode Island (Dr Thomas)
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Stein A, Dalton L, Rapa E, Bluebond-Langner M, Hanington L, Stein KF, Ziebland S, Rochat T, Harrop E, Kelly B, Bland R. Communication with children and adolescents about the diagnosis of their own life-threatening condition. Lancet 2019; 393:1150-1163. [PMID: 30894271 DOI: 10.1016/s0140-6736(18)33201-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 01/10/2023]
Abstract
When a child is diagnosed with a life-threatening condition, one of the most challenging tasks facing health-care professionals is how to communicate this to the child, and to their parents or caregivers. Evidence-based guidelines are urgently needed for all health-care settings, from tertiary referral centres in high-income countries to resource limited environments in low-income and middle-income countries, where rates of child mortality are high. We place this Review in the context of children's developing understanding of illness and death. We review the effect of communication on children's emotional, behavioural, and social functioning, as well as treatment adherence, disease progression, and wider family relationships. We consider the factors that influence the process of communication and the preferences of children, families, and health-care professionals about how to convey the diagnosis. Critically, the barriers and challenges to effective communication are explored. Finally, we outline principles for communicating with children, parents, and caregivers, generated from a workshop of international experts.
Collapse
Affiliation(s)
- Alan Stein
- Department of Psychiatry, University of Oxford, Oxford, UK; School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Louise Dalton
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Elizabeth Rapa
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Myra Bluebond-Langner
- The Louis Dundas Centre for Children's Palliative Care, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Lucy Hanington
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tamsen Rochat
- Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Human Sciences Research Council, Johannesburg, South Africa
| | - Emily Harrop
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Helen & Douglas House, Oxford, UK
| | - Brenda Kelly
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ruth Bland
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Institute of Health and Wellbeing, Glasgow, UK; University of Glasgow and Royal Hospital for Children, Glasgow, UK
| |
Collapse
|
7
|
|
8
|
Kawai N, Yuasa N. Laboratory prognostic score for predicting 30-day mortality in terminally ill cancer patients. Nagoya J Med Sci 2018; 80:571-582. [PMID: 30587871 PMCID: PMC6295427 DOI: 10.18999/nagjms.80.4.571] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/11/2018] [Indexed: 02/07/2023]
Abstract
Conventional prognostic scores for terminally ill cancer patients may have less objectivity because they include subjective or categorical variables that do not consider intensity or severity. The aim of this study was to identify prognostic factors for 30-day mortality from routine blood examination of terminally ill cancer patients. A total of 1308 study patients in a hospice setting were divided into investigation (n=761) and validation (n=547) groups. Twenty laboratory blood parameters were analyzed. Multivariate analysis revealed that ten variables (C-reactive protein ≥5.4 mg/dL, serum albumin <2.8 g/dL, blood urea nitrogen ≥21 mg/dL, white blood cell count ≥8.600 × 103/μL, eosinophil percentage <0.8%, neutrophil-to-lymphocyte ratio ≥11.1, hemoglobin level ≥ 13.2 g/dL, mean corpuscular volume ≥ 93.7 fl, red cell distribution width ≥ 16, and platelet count < 159 × 103/μL) were significant independent prognostic factors for 30-day survival. The laboratory prognostic score (LPS) was calculated by the sum of blood indices among the ten variables. The LPS showed acceptable accuracy for 30-day mortality in the investigation and validation groups. LPS 5 (including any five factors) predicted death within 30 days, with a sensitivity of 85%, a specificity of 55%, a positive predictive value of 72%, and a negative predictive value of 74%. The predictive value of LPS was comparable to those of conventional prognostic scores, which include signs and symptoms. The LPS can provide additional information to conventional prognostic scores.
Collapse
Affiliation(s)
- Natsuko Kawai
- Department of Palliative Medicine, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Norihiro Yuasa
- Department of Palliative Medicine, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| |
Collapse
|
9
|
Huey NS, Guan NC, Gill JS, Hui KO, Sulaiman AH, Kunagasundram S. Core Symptoms of Major Depressive Disorder among Palliative Care Patients. Int J Environ Res Public Health 2018; 15:E1758. [PMID: 30115817 PMCID: PMC6121226 DOI: 10.3390/ijerph15081758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 06/30/2018] [Accepted: 07/15/2018] [Indexed: 01/20/2023]
Abstract
A valid method to diagnose depression in palliative care has not been established. In this study, we aim to determine the prevalence of depression and the discriminant validity of the items of four sets of diagnostic criteria in palliative care. This is a cross-sectional study on 240 palliative care patients where the presence of depression was based on the Diagnostic and Statistical Manual of Mental Disorders, DSM⁻IV Criteria, Modified DSM⁻IV Criteria, Cavanaugh Criteria, and Endicott's Criteria's. Anxiety, depression, and distress were measured with Hospital Anxiety and Depression Scale and Distress Thermometer. The prevalence of depression among the palliative care patients was highest based on the Modified DSM⁻IV Criteria (23.3%), followed by the Endicott's Criteria (13.8%), DSM⁻IV Criteria (9.2%), and Cavanaugh Criteria (5%). There were significant differences (p < 0.05) in the depressive symptoms showed by DSM⁻IV item 1 (dysphoric mood), item 2 (loss of interest or pleasure), and Endicott's criteria item 8 (brooding, self-pity, or pessimism) among the palliative patients, even after adjustment for the anxiety symptoms and distress level. We found that dysphoric mood, loss of interest, and pessimism are the main features of depression in palliative patients. These symptoms should be given more attention in identifying depression in palliative care patients.
Collapse
Affiliation(s)
- Ng Su Huey
- Hospital Bahagia Ulu Kinta, Jalan Besar, 31259 Tanjong Rambutan, Perak, Malaysia.
| | - Ng Chong Guan
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Jesjeet Singh Gill
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Koh Ong Hui
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Ahmad Hatim Sulaiman
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Sharmilla Kunagasundram
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| |
Collapse
|
10
|
Abstract
BACKGROUND Ensuring adequate end-of-life care for prisoners is a critical issue. In France, data investigating the impact of laws allowing release of seriously ill prisoners are lacking. AIM To assess the number and characteristics of prisoners requiring palliative care in French prisons. DESIGN A prospective, national survey collecting data over a 3-month period. SETTING/PARTICIPANTS All healthcare units ( n = 190) providing care for prisoners in France. The prison population was 66,698 during the study period. Data collection concerned prisoners requiring end-of-life care, that is, with serious, advanced, progressive, or terminal illness and life expectancy <1 year. RESULTS Estimated annual prevalence of ill prisoners requiring end-of-life care was 15.2 (confidence interval: 12.5-18.3) per 10,000 prisoners. The observed number of prisoners requiring palliative care ( n = 50) was twice as high as the expected age- and sex-standardized number based on the general population and similar to the expected number among persons 10 years older in the free community. In all, 41 of 44 (93%) of identified ill prisoners were eligible for temporary or permanent compassionate release, according to their practitioner. Only 33 of 48 (68%) of ill prisoners requested suspension or reduction in their sentence on medical grounds; half (16/33) received a positive answer. CONCLUSION The proportion of prisoners requiring palliative care is higher than expected in the general population. The general frailty and co-existing conditions of prisoners before incarceration and the acceleration of these phenomena in prison could explain this increase in end-of-life situations among prisoners.
Collapse
Affiliation(s)
- Lionel Pazart
- Inserm CIC 1431, University Hospital Besançon, CHRU de Besançon, Besançon, France
- EA 481, Université de Bourgogne Franche-Comté, Besançon, France
| | - Aurélie Godard-Marceau
- Inserm CIC 1431, University Hospital Besançon, CHRU de Besançon, Besançon, France
- EA 481, Université de Bourgogne Franche-Comté, Besançon, France
- Département douleur-Soins palliatifs, CHRU de Besançon, Besançon, France
| | - Aline Chassagne
- Inserm CIC 1431, University Hospital Besançon, CHRU de Besançon, Besançon, France
- Département douleur-Soins palliatifs, CHRU de Besançon, Besançon, France
| | - Aurore Vivot-Pugin
- Inserm CIC 1431, University Hospital Besançon, CHRU de Besançon, Besançon, France
| | - Elodie Cretin
- Inserm CIC 1431, University Hospital Besançon, CHRU de Besançon, Besançon, France
- EA 481, Université de Bourgogne Franche-Comté, Besançon, France
- Département douleur-Soins palliatifs, CHRU de Besançon, Besançon, France
- L’Espace de Réflexion Ethique Bourgogne Franche-Comté, Besançon, France
| | - Edouard Amzallag
- L’Unité Hospitalière Sécurisée Interrégionale (UHSI), Centre Hospitalier Lyon-Sud, Lyon, France
| | - Regis Aubry
- Inserm CIC 1431, University Hospital Besançon, CHRU de Besançon, Besançon, France
- EA 481, Université de Bourgogne Franche-Comté, Besançon, France
- Département douleur-Soins palliatifs, CHRU de Besançon, Besançon, France
- L’Espace de Réflexion Ethique Bourgogne Franche-Comté, Besançon, France
| |
Collapse
|
11
|
Hung YS, Lee SH, Hung CY, Wang CH, Kao CY, Wang HM, Chou WC. Clinical characteristics and survival outcomes of terminally ill patients undergoing withdrawal of mechanical ventilation. J Formos Med Assoc 2017; 117:798-805. [PMID: 29032021 DOI: 10.1016/j.jfma.2017.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/29/2017] [Accepted: 09/30/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Withdrawal of mechanical ventilation is an important, but rarely explored issue in Asia during end-of-life care. This study aimed to describe the clinical characteristics and survival outcomes of terminally ill patients undergoing withdrawal of mechanical ventilation in Taiwan. METHODS One-hundred-thirty-five terminally ill patients who had mechanical ventilation withdrawn between 2013 and 2016, from a medical center in Taiwan, were enrolled. Patients' clinical characteristics and survival outcomes after withdrawal of mechanical ventilation were analyzed. RESULTS The three most common diagnoses were organic brain lesion, advanced cancer, and newborn sequelae. The initiator of the withdrawal process was family, medical personnel, and patient him/herself. The median survival time was 45 min (95% confidence interval, 33-57 min) after the withdrawal of mechanical ventilation, and 102 patients (75.6%) died within one day after extubation. The median time from diagnosis of disease to receiving life-sustaining treatment and artificial ventilation support, receiving life-sustaining treatment and artificial ventilation support to "Withdrawal meeting," "Withdrawal meeting" to ventilator withdrawn, and ventilator withdrawn to death was 12.1 months, 19 days, 1 day, and 0 days, respectively. Patients with a diagnosis of advanced cancer and withdrawal initiation by the patients themselves had a significantly shorter time interval between receiving life-sustaining treatment and artificial ventilation support to "Withdrawal meeting" compared to those with non-cancer diseases and withdrawal initiation by family or medical personnel. CONCLUSION This study is the first observational study to describe the patients' characteristics and elaborate on the survival outcome of withdrawal of mechanical ventilation in patients who are terminally ill in an Asian population. Understanding the clinical characteristics and survival outcomes of mechanical ventilation withdrawal might help medical personnel provide appropriate end-of-life care and help patients/families decide about the withdrawal process earlier.
Collapse
Affiliation(s)
- Yu-Shin Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Shu-Hui Lee
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Taiwan
| | - Chia-Yen Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan; Department of Hematology-Oncology, Division of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chao-Hui Wang
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Taiwan
| | - Chen-Yi Kao
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Hung-Ming Wang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Wen-Chi Chou
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan.
| |
Collapse
|
12
|
Hsiu Chen C, Wen FH, Hou MM, Hsieh CH, Chou WC, Chen JS, Chang WC, Tang ST. Transitions in Prognostic Awareness Among Terminally Ill Cancer Patients in Their Last 6 Months of Life Examined by Multi-State Markov Modeling. Oncologist 2017; 22:1135-1142. [PMID: 28684551 DOI: 10.1634/theoncologist.2017-0068] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/02/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Developing accurate prognostic awareness, a cornerstone of preference-based end-of-life (EOL) care decision-making, is a dynamic process involving more prognostic-awareness states than knowing or not knowing. Understanding the transition probabilities and time spent in each prognostic-awareness state can help clinicians identify trigger points for facilitating transitions toward accurate prognostic awareness. We examined transition probabilities in distinct prognostic-awareness states between consecutive time points in 247 cancer patients' last 6 months and estimated the time spent in each state. METHODS Prognostic awareness was categorized into four states: (a) unknown and not wanting to know, state 1; (b) unknown but wanting to know, state 2; (c) inaccurate awareness, state 3; and (d) accurate awareness, state 4. Transitional probabilities were examined by multistate Markov modeling. RESULTS Initially, 59.5% of patients had accurate prognostic awareness, whereas the probabilities of being in states 1-3 were 8.1%, 17.4%, and 15.0%, respectively. Patients' prognostic awareness generally remained unchanged (probabilities of remaining in the same state: 45.5%-92.9%). If prognostic awareness changed, it tended to shift toward higher prognostic-awareness states (probabilities of shifting to state 4 were 23.2%-36.6% for patients initially in states 1-3, followed by probabilities of shifting to state 3 for those in states 1 and 2 [9.8%-10.1%]). Patients were estimated to spend 1.29, 0.42, 0.68, and 3.61 months in states 1-4, respectively, in their last 6 months. CONCLUSION Terminally ill cancer patients' prognostic awareness generally remained unchanged, with a tendency to become more aware of their prognosis. Health care professionals should facilitate patients' transitions toward accurate prognostic awareness in a timely manner to promote preference-based EOL decisions. IMPLICATIONS FOR PRACTICE Terminally ill Taiwanese cancer patients' prognostic awareness generally remained stable, with a tendency toward developing higher states of awareness. Health care professionals should appropriately assess patients' readiness for prognostic information and respect patients' reluctance to confront their poor prognosis if they are not ready to know, but sensitively coach them to cultivate their accurate prognostic awareness, provide desired and understandable prognostic information for those who are ready to know, and give direct and honest prognostic information to clarify any misunderstandings for those with inaccurate awareness, thus ensuring that they develop accurate and realistic prognostic knowledge in time to make end-of-life care decisions.
Collapse
Affiliation(s)
- Chen Hsiu Chen
- Department of Nursing, University of Kang Ning, Taipei and Graduate Institute of Clinical Medical Science, Chang Gung University, Tao-Yuan, Taiwan
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, and School of Medicine, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, and School of Medicine, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, and School of Medicine, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, and School of Medicine, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, and School of Medicine, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Siew Tzuh Tang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, and Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou
| |
Collapse
|
13
|
Aoun S, Slatyer S, Deas K, Nekolaichuk C. Family Caregiver Participation in Palliative Care Research: Challenging the Myth. J Pain Symptom Manage 2017; 53:851-861. [PMID: 28062338 DOI: 10.1016/j.jpainsymman.2016.12.327] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/10/2016] [Accepted: 12/07/2016] [Indexed: 11/17/2022]
Abstract
CONTEXT Despite international guidelines emphasizing consumer-directed care and autonomous decisions in research participation, there is a common myth that research can be an additional and unwanted burden on patients and their family members. OBJECTIVES To examine the experiences and impact of research involvement on family caregivers (FCs) of terminally ill people, focusing within home-based palliative care. METHODS Three hundred sixteen of 322 participants (98.1%), who completed an FC support intervention through a stepped-wedge cluster trial (Australia, 2012-2015), participated in a postintervention telephone interview on their study experiences, which included quantitative and qualitative questions. RESULTS Ninety-seven percent of both the control (n = 89) and intervention (n = 227) groups perceived positive aspects, whereas almost all did not report any negative aspects of being involved in this research; the majority rated their involvement as very/extremely beneficial (control 77%; intervention 83%). The qualitative analysis generated three major themes: "intrapersonal-inward directed"; "connection with others-outward directed"; and "interpersonal-participant-researcher relationship." CONCLUSIONS This study provided quantitative and qualitative evidence challenging the myth. In contrast to health professional concerns, FCs appreciated the opportunity to participate and benefited from their involvement in research. Research protocols need to be specifically tailored to the needs of family caregivers and include debriefing opportunities for all participants at the end of intervention studies, regardless of which group they have been assigned. Strategies that facilitate health professionals' understanding of the research and risk benefits may help reduce gatekeeping and improve the validity of research findings.
Collapse
Affiliation(s)
- Samar Aoun
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.
| | - Susan Slatyer
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia; Centre for Nursing Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Kathleen Deas
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Cheryl Nekolaichuk
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
14
|
Abstract
BACKGROUND Hospice care is most appropriate when a patient no longer benefits from curative treatment and has limited life expectancy. These patients may suffer from any type of life-limiting illness, including end-stage cancer, end-stage heart disease, end-stage renal failure, AIDS, and Alzheimer's disease, among other illnesses. Patients are managed on their pain and symptoms and home hospice care manages these patients in the comfort of their own home, enabling patients to spend their last days with dignity and have a good quality of life. OBJECTIVE To describe the home hospice patients at HCA Hospice Care (HHC) Singapore from 2000 to 2010. Description of home care patients in terms of their sociodemographic profile and diagnosis at admission. We reviewed the Electronic Medical Records of patients admitted into HHC from 2000 to 2010. RESULTS Patients had multiple admissions into HHC home hospice as identified in the Electronic Medical Records (EMR) between January 1, 2000, and December 31, 2010, but we only selected patient's first admission into HHC home hospice for this analysis. Of the 25,065 patients in the entire samples, 47.3% were males, 65.2% were married, and 84.3% were Chinese. 50.9% of the patients died at home, 75.5% were referred from public hospitals, 53.9% of primary caregivers were children, and the mean age of the patients was 68.0 years. Among all cancer patients admitted into HHC home hospice, lung cancer (23.6%) was the most common principal diagnosis for admission, followed by colorectal (10.5%) and liver cancers (7.7%). Among noncancer patients, renal failure (7.0%) was the most common diagnosis. Among male patients admitted into HHC home hospice, lung cancer (29.6%) was the most common diagnosis, followed by liver cancer (10.8%), colorectal cancer (10.0%), and end-stage renal failure (5.5%). For female patients, lung cancer (16.9%) was the most common diagnosis, followed by breast cancer (15.9%), colorectal cancer (11.0%), and end-stage renal failure (8.7%). Ten-year trends of the sociodemographic profile and diagnosis at admission were further analyzed to determine home hospice services utilization and the needs of the home care patients. CONCLUSION With an increasing emphasis to encourage aging and dying in the community and more attention given to building up the home hospice industry's capacity and capability, it is important to understand the profile of the patients who have been utilizing home hospice services. This also helps to plan and develop similar services in other parts of the world.
Collapse
Affiliation(s)
- Benedict John Ho
- 1 Saw Swee Hock School of Public Health, National University of Singapore , Singapore, Singapore
| | | | - Grace Su Yin Pang
- 3 Lee Kong Chian School of Medicine, Imperial College and Nanyang Technological University , Singapore, Singapore
| | - Gerald Choon Huat Koh
- 1 Saw Swee Hock School of Public Health, National University of Singapore , Singapore, Singapore
| |
Collapse
|
15
|
Mirza A, Kad R, Ellison NM. Cardiopulmonary resuscitation is not addressed in the admitting medical records for the majority of patients who undergo CPR in the hospital. Am J Hosp Palliat Care 2016; 22:20-5. [PMID: 15736603 DOI: 10.1177/104990910502200107] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cardiopulmonary resuscitation (CPR) is routinely performed on patients who develop cardiopulmonary arrest in the hospital. In some situations, it is performed on terminally or critically ill patients where death is predicted to be inevitable despite CPR. Since prior consent is not required for this procedure, CPR may be performed without patient consent or foreknowledge. Many of these patients may not want CPR if the anticipated outcome is reviewed with them. This study investigated the frequency of occurrence of a CPR discussion at the time of hospital admission for patients who undergo CPR during hospitalization. Results showed that CPR is infrequently addressed in the hospital orders or medical records in patients who undergo CPR during their hospital stay. In addition, the severity of illness at the time of admission does not appear to influence whether physicians discuss CPR with patients and their families.
Collapse
Affiliation(s)
- Ayoub Mirza
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | | |
Collapse
|
16
|
Abstract
The extensive use of sedative and analgesic medication at the end of life is often controversial due to the perception that death may be hastened as a result of progressive drug escalation. Physician attitudes toward prescribing medication in this setting vary, resulting in widely differing prescribing patterns for patients with advanced cancer. This investigation attempted to identify overall prescribing patterns and variation in the use of sedation and analgesia in an inpatient hospice setting at the end of life. A retrospective case review was undertaken of 102 consecutive patients who died in a palliative care hospice. A detailed review of medication prescription, with particular attention to sedation and analgesia in the last week of life, was performed. The review revealed that regular sedation was prescribed in 68 percent of the patients. Almost two-thirds of the patients began regular sedation on admission or within seven days of admission. Although survival was higher in patients who received regular sedation (mean, 36.5 days) versus those that did not (mean, 17 days), the difference was not significant (p = 0.1). Overall, regular sedation with moderate dose increases was observed. In patients prescribed morphine from the time of admission, morphine oral equivalents increased from a mean of 111 mg on admission to a mean of 346 mg at time of death for a mean escalation of 311 percent. The mean duration of admission was 26 days with an opioid-escalation index of 12 percent per day. Survival is a multifactorial phenomenon and was unrelated to the level of analgesia in this cohort. Findings showed that sedation dose increased modestly toward the end of life, and that the increase was not associated with a significant reduction in survival. Further, there was no significant impact on survival related to an individual physician's prescribing pattern at the end of life. These results suggest that, in the institution where the review was conducted, neither sedation nor individual variation in physician prescribing habits in terminally ill patients was associated with hastening of death. Overall, the amount of sedative drugs required for adequate symptom control during terminal care was moderate.
Collapse
Affiliation(s)
- Luis Vitetta
- Centre for Molecular Biology and Medicine, Epworth Hospital Medical Centre, Melbourne, Victoria, Australia
| | | | | |
Collapse
|
17
|
Holmes SM, Rabow MW, Dibble SL. Screening the soul: Communication regarding spiritual concerns among primary care physicians and seriously ill patients approaching the end of life. Am J Hosp Palliat Care 2016; 23:25-33. [PMID: 16450660 DOI: 10.1177/104990910602300105] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to explore the spiritual concerns of seriously ill patients and the spiritual-care practices of primary care physicians (PCPs). Questionnaires were administered to outpatients (n = 65, 90 percent response rate) with end-stage illness and to PCPs (n = 67, 87 percent response rate) in a diverse general medicine practice. Most patients (62 percent) and PCPs (68 percent) considered it important that physicians attend to patients’ spiritual concerns. However, few patients reported receiving such care, and most (62 percent) did not think it was the PCP’s job to talk about spiritual concerns. Although both seriously ill outpatients and PCPs assert the importance of spiritual concerns, PCPs often do not provide spiritual care. Appropriate provision of spiritual care within a diverse population of seriously ill outpatients is complex, necessitating appropriate and attentive screening.
Collapse
Affiliation(s)
- Seth M Holmes
- Department of Anthropology, History, and Social Medicine, University of California at San Francisco, San Francisco, California 94115, USA
| | | | | |
Collapse
|
18
|
Gigon A. [Surge in assisted suicides in 2015]. Rev Med Suisse 2016; 12:527. [PMID: 27089649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
|
19
|
Mason E, Jenkins D, Williams M, Davies J. Unscheduled care admissions at end-of-life - what are the patient characteristics? Acute Med 2016; 15:68-72. [PMID: 27441308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Unscheduled acute hospital admissions and subsequent deaths in hospitals of patients considered palliative are increasing, despite many patients' preference to die at home. A large proportion of these patients are admitted via acute medical units or emergency departments. The integration of primary and secondary care within Wales should enhance the delivery of end-of-life care at home but unscheduled admission for patients with palliative care needs remains prevalent. The aim of our study was to explore the characteristics amongst patients who die shortly after unscheduled hospital admission. A retrospective, observational study was conducted in all unscheduled admissions at end-of-life at a single health board in South Wales, UK over a period of one month. The result showed that 47% of patients who died within 48hrs of unscheduled admission are considered to be palliative. The majority of these patients were admitted via 999 ambulances and out of normal working hours (65%). They were elderly (median age 80) and had a poor performance status (78%). Over 1/3 (39%) were admitted from a nursing or residential home. Less than a quarter (22%) had an advance care plan in place.
Collapse
Affiliation(s)
- Emma Mason
- Consultant in Acute Medicine and Honorary Senior Lecturer in Palliative Medicine, Royal Gwent Hospital, Aneurin Bevan University, Health Board, Newport, NP20 2UB
| | | | - Meg Williams
- Consultant in Palliative Medicine, Nevill Hall Hospital
| | | |
Collapse
|
20
|
Affiliation(s)
- Myra Bluebond-Langner
- Louis Dundas Centre for Children's Palliative Care, UCL-Institute of Child Health, London WC1N 1EH, UK
| | - Emma Beecham
- Marie Curie Palliative Care Research Unit, UCL Mental Health Sciences Unit, University College Medical School, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Unit, UCL Mental Health Sciences Unit, University College Medical School, London, UK
| | - Richard Langner
- Louis Dundas Centre for Children's Palliative Care, UCL-Institute of Child Health, London WC1N 1EH, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Unit, UCL Mental Health Sciences Unit, University College Medical School, London, UK
| |
Collapse
|
21
|
Affiliation(s)
- Scott A Murray
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, Medical School, Edinburgh EH8 9AG, UK
| | | |
Collapse
|
22
|
Affiliation(s)
- Kristian Pollock
- Nottingham University, School of Health Sciences, Queen's Medical Centre, Nottingham NG7 2HA, UK
| |
Collapse
|
23
|
Guerriere D, Husain A, Marshall D, Zagorski B, Seow H, Brazil K, Kennedy J, McLernon R, Burns S, Coyte PC. Predictors of Place of Death for Those in Receipt of Home-Based Palliative Care Services in Ontario, Canada. J Palliat Care 2015. [PMID: 26201209 DOI: 10.1177/082585971503100203] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many cancer patients die in institutional settings despite their preference to die at home. A longitudinal, prospective cohort study was conducted to comprehensively assess the determinants of home death for patients receiving home-based palliative care. Data collected from biweekly telephone interviews with caregivers (n = 302) and program databases were entered into a multivariate logistic model. Patients with high nursing costs (odds ratio [OR]: 4.3; confidence interval [CI]: 1.8-10.2) and patients with high personal support worker costs (OR: 2.3; CI: 1.1-4.5) were more likely to die at home than those with low costs. Patients who lived alone were less likely to die at home than those who cohabitated (OR: 0.4; CI: 0.2-0.8), and those with a high propensity for a home-death preference were more likely to die at home than those with a low propensity (OR: 5.8; CI: 1.1-31.3). An understanding of the predictors of place of death may contribute to the development of effective interventions that support home death.
Collapse
|
24
|
Ling J, O'Reilly M, Balfe J, Quinn C, Devins M. Children with life-limiting conditions: establishing accurate prevalence figures. Ir Med J 2015; 108:93. [PMID: 25876306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
|
25
|
Thomas JR. Normal vital signs as death approaches: commentary on Bruera et al. J Pain Symptom Manage 2014; 48:499. [PMID: 24937165 DOI: 10.1016/j.jpainsymman.2014.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 05/27/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Jay R Thomas
- Comprehensive Care Program, HealthCare Partners, Arcadia, California, USA.
| |
Collapse
|
26
|
Greer JA, Pirl WF, Jackson VA, Muzikansky A, Lennes IT, Gallagher ER, Prigerson HG, Temel JS. Perceptions of health status and survival in patients with metastatic lung cancer. J Pain Symptom Manage 2014; 48:548-57. [PMID: 24680623 DOI: 10.1016/j.jpainsymman.2013.10.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 10/09/2013] [Accepted: 10/30/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Cognitive awareness of having a terminal illness is associated with critical treatment decisions and outcomes. However, little is known about the course and correlates of such perceptions in patients with metastatic lung cancer. OBJECTIVES We explored changes in perceptions of health status over time in patients with metastatic non-small cell lung cancer (NSCLC) and whether awareness of having a terminal illness was associated with survival. METHODS For this secondary analysis of clinical trial data, we assessed perceptions of health status at baseline, 12, 18, and 24 weeks. At each time point, patients with metastatic NSCLC completed a measure of quality of life (Functional Assessment of Cancer Therapy-Trial Outcome Index) and also reported whether they were "relatively healthy," "seriously but not terminally ill," or "seriously and terminally ill." We reviewed patients' medical records to gather data on clinical characteristics. RESULTS At baseline, 49.3% reported being relatively healthy, whereas the remainder self-identified as seriously but not terminally ill (38.2%) or seriously and terminally ill (12.5%). Over multiple assessments, 24.8% reported having a terminal illness. Adjusting for known prognostic factors, patients' time-varying perceptions of health status remained a significant predictor of survival (hazards ratio = 1.50, 95% CI = 1.07-2.09, P = 0.019). CONCLUSION A minority of patients with metastatic NSCLC acknowledged being terminally ill. Those reporting that they were seriously and terminally ill had shorter survival compared with those who did not consider themselves terminally ill, even after adjusting for decline in physical and functional well-being.
Collapse
Affiliation(s)
- Joseph A Greer
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA.
| | - William F Pirl
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Vicki A Jackson
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Alona Muzikansky
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Inga T Lennes
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Emily R Gallagher
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | | | - Jennifer S Temel
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| |
Collapse
|
27
|
Bruera S, Chisholm G, Dos Santos R, Crovador C, Bruera E, Hui D. Variations in vital signs in the last days of life in patients with advanced cancer. J Pain Symptom Manage 2014; 48:510-7. [PMID: 24731412 PMCID: PMC4197073 DOI: 10.1016/j.jpainsymman.2013.10.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/07/2013] [Accepted: 10/30/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Few studies have examined variation in vital signs in the last days of life. OBJECTIVES We determined the variation of vital signs in the final two weeks of life in patients with advanced cancer and examined their association with impending death in three days. METHODS In this prospective, longitudinal, observational study, we enrolled consecutive patients admitted to two acute palliative care units and documented their vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature) twice a day serially from admission to death or discharge. RESULTS Of 357 patients, 203 (57%) died in hospital. Systolic blood pressure (P < 0.001), diastolic blood pressure (P < 0.001), and oxygen saturation (P < 0.001) decreased significantly in the final three days of life, and temperature increased slightly (P < 0.04). Heart rate (P = 0.22) and respiratory rate (P = 0.24) remained similar in the last three days. Impending death in three days was significantly associated with increased heart rate (odds ratio [OR] = 2; P = 0.01), decreased systolic blood pressure (OR = 2.5; P = 0.004), decreased diastolic blood pressure (OR = 2.3; P = 0.002), and decreased oxygen saturation (OR = 3.7; P = 0.003) from baseline readings on admission. These changes had high specificity (≥ 80%), low sensitivity (≤ 35%), and modest positive likelihood ratios (≤ 5) for impending death within three days. A large proportion of patients had normal vital signs in the last days of life. CONCLUSION Blood pressure and oxygen saturation decreased in the last days of life. Clinicians and families cannot rely on vital sign changes alone to rule in or rule out impending death. Our findings do not support routine vital signs monitoring of patients who are imminently dying.
Collapse
Affiliation(s)
- Sebastian Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Gary Chisholm
- Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Renata Dos Santos
- Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil
| | - Camila Crovador
- Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
| |
Collapse
|
28
|
Balia S, Brau R. A country for old men? Long-term home care utilization in Europe. Health Econ 2014; 23:1185-1212. [PMID: 24009166 DOI: 10.1002/hec.2977] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 06/12/2013] [Accepted: 06/26/2013] [Indexed: 05/27/2023]
Abstract
This paper investigates long-term home care utilization in Europe. Data from the first wave of the Survey on Health, Ageing and Retirement (SHARE) on formal (nursing care and paid domestic help) and informal care (support provided by relatives) are used to study the probability and the quantity of both types of care. The overall process is framed in a fully simultaneous equation system that takes the form of a bivariate two-part model where the reciprocal interaction between formal and informal care is estimated. Endogeneity and unobservable heterogeneity are addressed using a common latent factor approach. The analysis of the relative impact of age and disability on home care utilization is enriched by the use of a proximity to death (PtD) indicator built using the second wave of SHARE. All these indicators are important predictors of home care utilization. In particular, a strong significant effect of PtD is found in the paid domestic help and informal care models. The relationship between formal and informal care moves from substitutability to complementarity depending on the type of care considered, and the estimated effects are small in absolute size. This might call for a reconsideration of the effectiveness of incentives for informal care as instruments to reduce public expenditure for home care services.
Collapse
Affiliation(s)
- Silvia Balia
- Department of Economics and Business, University of Cagliari and CRENoS, Cagliari, Italy
| | | |
Collapse
|
29
|
Fischer DJ, Epstein JB, Yao Y, Wilkie DJ. Oral health conditions affect functional and social activities of terminally ill cancer patients. Support Care Cancer 2014; 22:803-10. [PMID: 24232310 DOI: 10.1007/s00520-013-2037-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 10/28/2013] [Indexed: 01/03/2023]
Abstract
PURPOSE Oral conditions are established complications in terminally ill cancer patients. Yet despite significant morbidity,the characteristics and impact of oral conditions in these patients are poorly documented. The study objective was to characterize oral conditions in terminally ill cancer patients to determine the presence, severity, and the functional and social impact of these oral conditions. METHODS This was an observational clinical study including terminally ill cancer patients (2.5–3-week life expectancy). Data were obtained via the Oral Problems Scale (OPS) that measures the presence of subjective xerostomia, orofacial pain, taste change, and the functional/social impact of oral conditions and a demographic questionnaire. A standardized oral examination was used to assess objective salivary hypofunction, fungal infection, mucosal erythema, and ulceration. Regression analysis and t test investigated the associations between measures. RESULTS Of 104 participants, most were ≥50 years of age,female, and high-school educated; 45 % were African American, 43 % Caucasian, and 37 % married. Oral conditions frequencies were: salivary hypofunction (98 %), mucosal erythema (50 %), ulceration (20 %), fungal infection(36 %), and other oral problems (46 %). Xerostomia, taste change, and orofacial pain all had significant functional impact; p <.001, p =.042 and p <.001, respectively. Orofacial pain also had a significant social impact (p <.001). Patients with oral ulcerations had significantly more orofacial pain with a social impact than patients without ulcers (p =.003). Erythema was significantly associated with fungal infection and with mucosal ulceration (p <.001). CONCLUSIONS Oral conditions significantly affect functional and social activities in terminally ill cancer patients. Identification and management of oral conditions in these patients should therefore be an important clinical consideration.
Collapse
|
30
|
Trueland J. End of life care: the importance of home. Health Serv J 2014; 123:6-7. [PMID: 24956730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
|
31
|
Wright AA, Zhang B, Keating NL, Weeks JC, Prigerson HG. Associations between palliative chemotherapy and adult cancer patients' end of life care and place of death: prospective cohort study. BMJ 2014; 348:g1219. [PMID: 24594868 PMCID: PMC3942564 DOI: 10.1136/bmj.g1219] [Citation(s) in RCA: 208] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine whether the receipt of chemotherapy among terminally ill cancer patients months before death was associated with patients' subsequent intensive medical care and place of death. DESIGN Secondary analysis of a prospective, multi-institution, longitudinal study of patients with advanced cancer. SETTING Eight outpatient oncology clinics in the United States. PARTICIPANTS 386 adult patients with metastatic cancers refractory to at least one chemotherapy regimen, whom physicians identified as terminally ill at study enrollment and who subsequently died. PRIMARY OUTCOMES intensive medical care (cardiopulmonary resuscitation, mechanical ventilation, or both) in the last week of life and patients' place of death (for example, intensive care unit). SECONDARY OUTCOMES survival, late hospice referrals (≤ 1 week before death), and dying in preferred place of death. RESULTS 216 (56%) of 386 terminally ill cancer patients were receiving palliative chemotherapy at study enrollment, a median of 4.0 months before death. After propensity score weighted adjustment, use of chemotherapy at enrollment was associated with higher rates of cardiopulmonary resuscitation, mechanical ventilation, or both in the last week of life (14% v 2%; adjusted risk difference 10.5%, 95% confidence interval 5.0% to 15.5%) and late hospice referrals (54% v 37%; 13.6%, 3.6% to 23.6%) but no difference in survival (hazard ratio 1.11, 95% confidence interval 0.90 to 1.38). Patients receiving palliative chemotherapy were more likely to die in an intensive care unit (11% v 2%; adjusted risk difference 6.1%, 1.1% to 11.1%) and less likely to die at home (47% v 66%; -10.8%, -1.0% to -20.6%), compared with those who were not. Patients receiving palliative chemotherapy were also less likely to die in their preferred place, compared with those who were not (65% v 80%; adjusted risk difference -9.4%, -0.8% to -18.1%). CONCLUSIONS The use of chemotherapy in terminally ill cancer patients in the last months of life was associated with an increased risk of undergoing cardiopulmonary resuscitation, mechanical ventilation or both and of dying in an intensive care unit. Future research should determine the mechanisms by which palliative chemotherapy affects end of life outcomes and patients' attainment of their goals.
Collapse
Affiliation(s)
- Alexi A Wright
- Harvard Medical School, Department of Medical Oncology, Dana-Farber Cancer Institute, Dana 1133, 450 Brookline Avenue, Boston, MA 02215, USA
| | | | | | | | | |
Collapse
|
32
|
Perrels AJ, Fleming J, Zhao J, Barclay S, Farquhar M, Buiting HM, Brayne C. Place of death and end-of-life transitions experienced by very old people with differing cognitive status: retrospective analysis of a prospective population-based cohort aged 85 and over. Palliat Med 2014; 28:220-33. [PMID: 24317193 DOI: 10.1177/0269216313510341] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite fast-growing 'older old' populations, 'place of care' trajectories for very old people approaching death with or without dementia are poorly described and understood. AIM To explore end-of-life transitions of 'older old' people across the cognitive spectrum. DESIGN Population-based prospective cohort (United Kingdom) followed to death. SETTING/PARTICIPANTS Mortality records linked to 283 Cambridge City over-75s Cohort participants' cognitive assessments <1 year before dying aged ≥ 85 years. RESULTS Overall, 69% were community dwelling in the year before death; of those with severe cognitive impairment 39% were community dwelling. Only 6% subsequently changed their usual address. However, for 55% their usual address on death registration was not their place of death. Dying away from the 'usual address' was associated with cognition, overall fewer moving with increasing cognitive impairment - cognition intact 66%, mildly/moderately impaired 55% and severely impaired 42%, trend p = 0.003. This finding reflects transitions being far more common from the community than from institutions: 73% from the community and 28% from institutions did not die where last interviewed (p < 0.001). However, severely cognitively impaired people living in the community were the most likely group of all to move: 80% (68%-93%). Hospitals were the most common place of death except for the most cognitively impaired, who mostly died in care homes. CONCLUSION Most very old community-dwelling individuals, especially the severely cognitively impaired, died away from home. Findings also suggest that long-term care may play a role in avoidance of end-of-life hospital admissions. These results provide important information for planning end-of-life services for older people across the cognitive spectrum, with implications for policies aimed at supporting home deaths. MESH TERMS: Cognitive impairment, Dementia, Aged, 80 and over, Aged, frail elderly, Patient Transfer, Residential characteristics, Homes for the aged, Nursing Homes, Delivery of Health Care, Terminal care Other key phrases: Older old, Oldest old, Place of death, Place of care, End-of-life care.
Collapse
Affiliation(s)
- Anouk J Perrels
- 1Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | | | | | | | | | | | | |
Collapse
|
33
|
Sutradhar R, Atzema C, Seow H, Earle C, Porter J, Howell D, Dudgeon D, Barbera L. Is performance status associated with symptom scores? A population-based longitudinal study among cancer outpatients. J Palliat Care 2014; 30:99-107. [PMID: 25058987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Symptom scores and performance status are both important measures for patients with cancer. However, since performance status is not often part of routinely collected data, there is interest in exploring whether it can be calculated from symptom scores. METHODS This was a population-based longitudinal study of cancer outpatients in Ontario, Canada in the year following their cancer diagnosis and among the subset of patients during the last year of their lives. RESULTS In the first year after diagnosis, there was a significant relationship between performance status and fatigue and appetite; fatigue and well-being had a significant association with performance status in the last year of life. In both periods, the associations, although statistically significant, were not large enough to be clinically meaningful. CONCLUSION Performance status is an important measurement that cannot be substituted or captured with symptom scores; it is important for healthcare providers to record performance scores on a regular basis.
Collapse
|
34
|
Guadagnolo BA, Huo J, Buchholz TA, Petereit DG. Disparities in hospice utilization among American Indian Medicare beneficiaries dying of cancer. Ethn Dis 2014; 24:393-398. [PMID: 25417419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVE We sought to compare hospice utilization for American Indian and White Medicare beneficiaries dying of cancer. METHODS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases to analyze claims for 181,316 White and 690 American Indian patients dying of breast, cervix, colorectal, kidney, lung, pancreas, prostate cancer, or stomach cancer from 2003 to 2009. RESULTS A lower proportion of American Indians enrolled in hospice compared to White patients (54% vs 65%, respectively; P < .0001). While the proportion of White patients who used hospice services in the last 6 months of life increased from 61% in 2003 to 68% in 2009 (P < .0001), the proportion of American Indian patients using hospice care remained unchanged (P = .57) and remained below that of their White counterparts throughout the years of study. CONCLUSION Continued efforts should be made to improve access to culturally relevant hospice care for American Indian patients with terminal cancer.
Collapse
|
35
|
Weinberger LE, Sreenivasan S, Garrick T. End-of-life mental health assessments for older aged, medically ill persons with expressed desire to die. J Am Acad Psychiatry Law 2014; 42:350-361. [PMID: 25187288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In recent years, assisted suicide has been legalized in four states for those who are terminally ill and wish to end their lives with the assistance of lethal doses of medications prescribed by a physician. The ethics-related and legal questions raised by end-of-life suicide and decisional capacity to refuse treatment assessments are complex. In treating patients with end-stage medical conditions or disorders that severely affect the future quality of their lives, clinicians tend to engage in suicide prevention at all costs. Overriding the patient's expressed desire to die conflicts with another value, however, that of the individual's right to autonomy. We provide a framework for understanding these difficult decisions, by providing a review of the epidemiology of suicide in later life; reviewing findings from a unique dataset of suicides among the elderly obtained from the Los Angeles County Coroner's Office, as well as data from states with legalized assisted suicide; presenting a discussion of the two frameworks of suicidal ideation as a pathological versus an existential reaction; and giving a case example that highlights the dilemmas faced by clinicians addressing decisional capacity to refuse treatment in an elderly, medically ill patient who has expressed the wish to die.
Collapse
Affiliation(s)
- Linda E Weinberger
- Dr. Weinberger is Professor of Clinical Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Chief Psychologist, USC Institute of Psychiatry, Law, and Behavioral Science, Los Angeles, CA. Dr. Sreenivasan is Clinical Professor of Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Director, Forensic Outreach Services, Greater Los Angeles VA Medical Center, Los Angeles, CA. Dr. Garrick is Professor of Psychiatry, Geffen School of Medicine, University of California, Los Angeles and Chief of General Hospital Psychiatry, Greater Los Angeles VA Medical Center, Los Angeles, CA.
| | - Shoba Sreenivasan
- Dr. Weinberger is Professor of Clinical Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Chief Psychologist, USC Institute of Psychiatry, Law, and Behavioral Science, Los Angeles, CA. Dr. Sreenivasan is Clinical Professor of Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Director, Forensic Outreach Services, Greater Los Angeles VA Medical Center, Los Angeles, CA. Dr. Garrick is Professor of Psychiatry, Geffen School of Medicine, University of California, Los Angeles and Chief of General Hospital Psychiatry, Greater Los Angeles VA Medical Center, Los Angeles, CA
| | - Thomas Garrick
- Dr. Weinberger is Professor of Clinical Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Chief Psychologist, USC Institute of Psychiatry, Law, and Behavioral Science, Los Angeles, CA. Dr. Sreenivasan is Clinical Professor of Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Director, Forensic Outreach Services, Greater Los Angeles VA Medical Center, Los Angeles, CA. Dr. Garrick is Professor of Psychiatry, Geffen School of Medicine, University of California, Los Angeles and Chief of General Hospital Psychiatry, Greater Los Angeles VA Medical Center, Los Angeles, CA
| |
Collapse
|
36
|
Wertheimer D. VA health care system: increasing all veterans' access to end-of-life care. Md Med 2014; 15:25-26. [PMID: 25715509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
|
37
|
Claessen SJJ, Francke AL, Sixma HJ, de Veer AJE, Deliens L. Measuring relatives' perspectives on the quality of palliative care: the Consumer Quality Index Palliative Care. J Pain Symptom Manage 2013; 45:875-84. [PMID: 23017623 DOI: 10.1016/j.jpainsymman.2012.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 05/08/2012] [Accepted: 05/14/2012] [Indexed: 10/27/2022]
Abstract
CONTEXT A Consumer Quality Index (CQ-index) is a questionnaire assessing the actual care experiences and how important the recipient finds certain care aspects, as well as the priorities for improving quality. A CQ-index Palliative Care (CQ-index PC) for bereaved relatives was developed to measure the quality of palliative care. OBJECTIVES This article provides insight into the development and psychometric characteristics of this questionnaire, as well as quality improvement priorities. METHODS The content of the CQ-index PC was based on existing questionnaires, literature, and interviews and focus group discussions with relatives, patients, and caregivers. The questionnaire was tested in 31 care facilities providing palliative care. Close relatives/contact persons of patients who died non-suddenly six weeks to six months earlier were eligible for inclusion. Psychometric analyses were performed to shorten the questionnaire and to assess its reliability. "Need for improvement scores" also were computed to identify care aspects with the highest priority for quality improvement. RESULTS Three hundred ninety-two bereaved relatives were eligible for inclusion. The net response was 52% (n=204). Psychometric analyses resulted in six scales (Cronbach's alphas ranging from 0.71 to 0.90). The quality aspects relatives considered most important were dying peacefully, getting help in good time in acute situations, and personal attention. Aftercare was the aspect with the highest priority for quality improvement. CONCLUSION The CQ-index PC for relatives can be used to assess the quality of palliative care from the perspective of bereaved relatives. This instrument gives health care professionals insight into care aspects with the highest priority for quality improvement.
Collapse
Affiliation(s)
- Susanne J J Claessen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
38
|
Asghar-Ali AA, Wagle KC, Braun UK. Depression in terminally ill patients: dilemmas in diagnosis and treatment. J Pain Symptom Manage 2013; 45:926-33. [PMID: 23571209 DOI: 10.1016/j.jpainsymman.2012.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 11/27/2012] [Accepted: 12/01/2012] [Indexed: 12/25/2022]
Affiliation(s)
- Ali Abbas Asghar-Ali
- Mental Health Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | | | | |
Collapse
|
39
|
Chiarchiaro J, Olsen MK, Steinhauser KE, Tulsky JA. Admission to the intensive care unit and well-being in patients with advanced chronic illness. Am J Crit Care 2013; 22:223-31. [PMID: 23635931 DOI: 10.4037/ajcc2013346] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PURPOSE To describe the association of intensive care with trajectories of functional, emotional, social, and physical well-being in patients with 3 common advanced illnesses. METHODS Cross-sectional cohort study of 42 patients admitted to the intensive care unit selected from 210 patients with stage IV breast, prostate, or colon cancer or stage IIIb or IV lung cancer; New York Heart Association class III or IV congestive heart failure; and chronic obstructive pulmonary disease with hypercapnea (Pco2 > 46 mm Hg). Scores on subscales of the Functional Assessment of Chronic Illness Therapy-General survey were measured monthly for 6 months before and after admission to the intensive care unit and were analyzed by using the unit admission date as a point of discontinuous change to illustrate trajectories before and after the admission. RESULTS Overall, trajectories of well-being declined sharply after admission to the intensive care unit. Declines in physical, functional, and emotional well-being were statistically significant. During the 6 months after admission, physical, functional, and emotional well-being scores trended back up to baseline while social well-being scores continued to decline. CONCLUSIONS Well-being trajectories declined sharply after admission to the intensive care unit, with recovery in the subsequent 6 months, and may be characterized by common patterns. These results help to better describe intensive care as a marker for advancing illness in patients with advanced chronic illness.
Collapse
Affiliation(s)
- Jared Chiarchiaro
- Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA.
| | | | | | | |
Collapse
|
40
|
Gibbins J, Reid CM, Bloor S, Burcombe M, McCoubrie R, Forbes K. Overcoming barriers to recruitment in care of the dying research in hospitals. J Pain Symptom Manage 2013; 45:859-67. [PMID: 23026545 DOI: 10.1016/j.jpainsymman.2012.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 04/13/2012] [Accepted: 05/08/2012] [Indexed: 11/24/2022]
Abstract
CONTEXT Approximately 40% of the U.S. and 60% of the U.K. population die in hospital. Many reports have highlighted variability in the care received by these patients and national initiatives have proposed strategies to improve this care. No studies have demonstrated whether any improvements in end-of-life care have been achieved, as research in this area is challenging. OBJECTIVES We designed a study to assess the feasibility of a novel method of identifying patients likely to die during an acute hospital admission and a model of prior consent from patients and/or assent from their relatives. METHODS A study for collecting data on patients' symptoms before and after the introduction of an end-of-life tool (comprising medical and nursing checklists, prescribing guidance, and a symptom observation chart) within five wards in a major U.K. teaching hospital was conducted. We asked the screening question to a senior member of staff, "Is this patient so unwell that you feel they could die on this admission?" to identify appropriate patients, and recruited using the consent procedure. Patients were enrolled in the study if they became more unwell and data were then collected until they died. RESULTS In total, 6642 patients were screened. The ward staff answered "yes" to the screening question for 327 of 6642 (4.9%) patients. Patient's prior consent or relative's assent to enroll in the study was obtained for 117 of 327 (35.8%) patients, of whom 70 of 117 (59.8%) enrolled for the study and died within the study period. The staff found that the methods used were appropriate. CONCLUSION We have shown that identifying and involving dying patients in research is possible and acceptable to patients and carers.
Collapse
Affiliation(s)
- Jane Gibbins
- Cornwall Hospice Care, St. Julia's Hospice, Hayle, Cornwall.
| | | | | | | | | | | |
Collapse
|
41
|
Maciejewski PK, Prigerson HG. Emotional numbness modifies the effect of end-of-life discussions on end-of-life care. J Pain Symptom Manage 2013; 45:841-7. [PMID: 22926093 PMCID: PMC3511666 DOI: 10.1016/j.jpainsymman.2012.04.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Revised: 03/31/2012] [Accepted: 04/03/2012] [Indexed: 11/16/2022]
Abstract
CONTEXT Overall, end-of-life (EOL) discussions are unrelated to psychological distress and associated with lower rates of aggressive care near death. Nevertheless, patients who report that they feel emotionally numb about their illness might encounter difficulties cognitively processing an EOL discussion. OBJECTIVES We hypothesized that emotional numbness would modify the effect of EOL discussions on the receipt of less aggressive EOL care. METHODS Data were derived from structured interviews with 290 participants in the federally-funded Coping with Cancer Study, a multisite, prospective cohort study of patients with advanced cancer followed-up till their death. Patients' reports of EOL discussions with their physician and emotional numbness were assessed at a median of 4.6 months before their death. Information about aggressive EOL care (i.e., ventilation, resuscitation in the last week of life, death in the intensive care unit) was obtained from postmortem caregiver interviews and medical charts. Main and interactive effects of EOL discussions and emotional numbness on aggressive EOL care, adjusting for potential confounds, were evaluated using multiple logistic regression. RESULTS The likelihood of aggressive EOL care associated with having EOL discussions increased by a factor of nine (adjusted odds ratio=9.02, 95% CI 1.37, 59.6, P=0.022) for every unit increase in a patient's emotional numbness score. CONCLUSION Emotional numbness diminishes a patient's capacity to benefit from EOL discussions. The EOL decision making may be more effective if clinical communications with emotionally numb patients are avoided.
Collapse
Affiliation(s)
- Paul K Maciejewski
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
42
|
Ruppe MD, Feudtner C, Hexem KR, Morrison WE. Family factors affect clinician attitudes in pediatric end-of-life decision making: a randomized vignette study. J Pain Symptom Manage 2013; 45:832-40. [PMID: 23017620 DOI: 10.1016/j.jpainsymman.2012.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/08/2012] [Accepted: 05/14/2012] [Indexed: 11/23/2022]
Abstract
CONTEXT Conflicts between families and clinicians in pediatric end-of-life (EOL) care cause distress for providers, dissatisfaction for patients' families, and potential suffering for terminally ill children. OBJECTIVES We hypothesized that family factors might influence clinician decision making in these circumstances. METHODS We presented vignettes concerning difficult EOL decision making, randomized for religious objection to therapy withdrawal and perceived level of family involvement, to clinicians working in three Children's Hospital intensive care units. Additionally, attitudes about EOL care were assessed. RESULTS Three hundred sixty-four respondents completed the questionnaire, for an overall response rate of 54%. Respondents receiving the "involved family" vignette were more likely to agree to continue medical care indefinitely (P<0.0005). Respondents were marginally more likely to pursue a court-appointed guardian for those patients whose families had nonreligious objections to withdrawal (P=0.05). Respondents who thought that a fear of being sued affected decisions were less likely to pursue unilateral withdrawal (odds ratio 0.8, 95% CI=0.6-0.9). Those who felt personal distress as a result of difficult EOL decision making, thought they often provided "futile" care, or those who felt EOL care was effectively addressed at the institution were less likely to want to defer to the parents' wishes (range of odds ratios 0.7-1). CONCLUSION In this randomized vignette study, we have shown that family factors, particularly how involved a family seems to be in a child's life, affect what clinicians think is ethically appropriate in challenging EOL cases. Knowledge of how a family's degree of involvement may affect clinicians should be helpful to the clinical ethics consultants and offer some degree of insight to the clinicians themselves.
Collapse
Affiliation(s)
- Michael D Ruppe
- Division of Critical Care Medicine, University of Louisville, Louisville, Kentucky, USA
| | | | | | | |
Collapse
|
43
|
Piers RD, van Eechoud IJ, Van Camp S, Grypdonck M, Deveugele M, Verbeke NC, Van Den Noortgate NJ. Advance Care Planning in terminally ill and frail older persons. Patient Educ Couns 2013; 90:323-329. [PMID: 21813261 DOI: 10.1016/j.pec.2011.07.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 06/23/2011] [Accepted: 07/08/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Advance Care Planning (ACP) - the communication process by which patients establish goals and preferences for future care - is encouraged to improve the quality of end-of-life care. Gaining insight into the views of elderly on ACP was the aim of this study, as most studies concern younger patients. METHODS We conducted and analysed 38 semi-structured interviews in elderly patients with limited prognosis. RESULTS The majority of participants were willing to talk about dying. In some elderly, however, non-acceptance of their nearing death made ACP conversations impossible. Most of the participants wanted to plan those issues of end-of-life care related to personal experiences and fears. They were less interested in planning other end-of-life situations being outside of their power of imagination. Other factors determining if patients proceed to ACP were trust in family and/or physician and the need for control. CONCLUSIONS ACP is considered important by most elderly. However, there is a risk of pseudo-participation in case of non-acceptance of the nearing death or planning end-of-life situations outside the patient's power of imagination. This may result in end-of-life decisions not reflecting the patient's true wishes. PRACTICE IMPLICATIONS Before engaging in ACP conversations, physicians should explore if the patient accepts dying as a likely outcome. Also the experiences and fears concerning death and dying, trust and the need for control should be assessed.
Collapse
Affiliation(s)
- Ruth D Piers
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.
| | | | | | | | | | | | | |
Collapse
|
44
|
Scala R. [Reflections on the use of non-invasive mechanical ventilation in acute respiratory failure]. Recenti Prog Med 2012; 103:584-588. [PMID: 23258244 DOI: 10.1701/1206.13362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Given its prevalence into the clinical practice, non-invasive ventilation (NIV) can be included among the cornerstones of medicine. Just think of the acute applications of NIV which are in constant expansion, from COPD exacerbation to severe de novo hypoxemia, from postoperative distress to extra-hospital use in acute pulmonary edema, from ongoing support of interventional procedures to delicate strategies for end of life in terminally ill oncologic and non-oncologic patients. The thought should be focused on how, by whom, where and to whom is delivered this mode of artificial ventilation to avoid the risk of trivialization and flattening.
Collapse
|
45
|
Lombardo L, Morelli E, Luciani M, Bellizzi F, Aceto P, Penco I, Lai C. Pre-loss demographic and psychological predictors of complicated grief among relatives of terminally ill cancer patients. Psychother Psychosom 2012; 81:256-8. [PMID: 22678231 DOI: 10.1159/000336428] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 12/18/2011] [Indexed: 11/19/2022]
|
46
|
Borreani C, Brunelli C, Bianchi E, Piva L, Moro C, Miccinesi G. Talking about end-of-life preferences with advanced cancer patients: factors influencing feasibility. J Pain Symptom Manage 2012; 43:739-46. [PMID: 22464353 DOI: 10.1016/j.jpainsymman.2011.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/03/2011] [Accepted: 05/12/2011] [Indexed: 11/30/2022]
Abstract
CONTEXT The End-of-Life Preferences Interview (ELPI) was developed with the purpose of supporting physicians in communicating with advanced cancer patients. OBJECTIVES This study aimed to evaluate ELPI feasibility and compare home care/hospice (HC-H) vs. outpatient (OU) care settings. METHODS Twenty-eight physicians were trained in the use of the ELPI and were asked to apply the new instrument in their daily clinical practice for two months. ELPI feasibility was evaluated through three indices: the percentage of eligible patients, the percentage of patients to whom the ELPI was proposed, and the percentage of completed interviews. RESULTS The 23 physicians participating in the data collection screened 633 patients, and 156 of them (25%, 95% confidence interval 21%-28%) were judged to be eligible. Eligibility in HC-H was lower than that in the OU setting (18% vs. 46%; P<0.0001), whereas the differences were reduced when looking at patients to whom the ELPI was proposed (12% vs. 20%; P=0.017) and who completed the ELPI (8% vs. 18%; P<0.001). The percentage of eligible patients refusing the interview was very low in the entire sample (1.9%). CONCLUSION Results indicate that discussing end-of-life preferences in an earlier disease phase, such as in the OU setting, could be preferable but that its accomplishment in this setting may be more difficult, mainly as a result of organizational reasons. This observation could indicate that the system is not yet ready to offer patients such an opportunity and although communication on these sensitive issues cannot be reduced to a procedure, the ELPI can become a useful tool to help physicians in accomplishing this difficult task.
Collapse
Affiliation(s)
- Claudia Borreani
- Clinical Psychology Unit, IRCCS Foundation, National Cancer Institute, Milan, Italy.
| | | | | | | | | | | |
Collapse
|
47
|
Swart SJ, Rietjens JAC, van Zuylen L, Zuurmond WWA, Perez RSGM, van der Maas PJ, van Delden JJM, van der Heide A. Continuous palliative sedation for cancer and noncancer patients. J Pain Symptom Manage 2012; 43:172-81. [PMID: 21925832 DOI: 10.1016/j.jpainsymman.2011.04.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 03/29/2011] [Accepted: 04/12/2011] [Indexed: 11/26/2022]
Abstract
CONTEXT Palliative care is often focused on cancer patients. Palliative sedation at the end of life is an intervention to address severe suffering in the last stage of life. OBJECTIVES To study the practice of continuous palliative sedation for both cancer and noncancer patients. METHODS In 2008, a structured questionnaire was sent to 1580 physicians regarding their last patient receiving continuous sedation until death. RESULTS A total of 606 physicians (38%) filled out the questionnaire, of whom 370 (61%) reported on their last case of continuous sedation (cancer patients: n=282 [76%] and noncancer patients: n=88 [24%]). More often, noncancer patients were older, female, and not fully competent. Dyspnea (odds ratio [OR]=2.13; 95% confidence interval [CI]: 1.22, 3.72) and psychological exhaustion (OR=2.64; 95% CI: 1.26, 5.55) were more often a decisive indication for continuous sedation for these patients. A palliative care team was consulted less often for noncancer patients (OR=0.45; 95% CI: 0.21, 0.96). Also, preceding sedation, euthanasia was discussed less often with noncancer patients (OR=0.42; 95% CI: 0.24, 0.73), whereas their relatives more often initiated discussion about euthanasia than relatives of cancer patients (OR=3.75; 95% CI: 1.26, 11.20). CONCLUSION The practice of continuous palliative sedation in patients dying of cancer differs from patients dying of other diseases. These differences seem to be related to the less predictable course of noncancer diseases, which may reduce physicians' awareness of the imminence of death. Increased attention to noncancer diseases in palliative care practice and research is, therefore, crucial as is more attention to the potential benefits of palliative care consultation.
Collapse
Affiliation(s)
- Siebe J Swart
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Evans N, Meñaca A, Andrew EVW, Koffman J, Harding R, Higginson IJ, Pool R, Gysels M. Systematic review of the primary research on minority ethnic groups and end-of-life care from the United Kingdom. J Pain Symptom Manage 2012; 43:261-86. [PMID: 22001070 DOI: 10.1016/j.jpainsymman.2011.04.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 04/07/2011] [Accepted: 04/12/2011] [Indexed: 11/25/2022]
Abstract
CONTEXT Patients from minority ethnic groups experience lower rates of referrals to end-of-life (EoL) care services, higher levels of dissatisfaction with services, and perceive some services as culturally inappropriate. OBJECTIVES To systematically review original studies of minority ethnic groups and EoL care in the U.K. and appraise their quality. METHODS Searches were carried out in 13 electronic databases, eight journals, reference lists, and the gray literature. Studies of minority ethnic groups and EoL care in the U.K. were included. Studies were graded for quality and key themes were identified. RESULTS Forty-five studies met inclusion criteria. Study quality was good on average. Identified key themes included age structure; inequality by disease group; referrals; caregivers; place of care and death; awareness of services and communication; and cultural competency. Strategies described for the reduction of inequities were partial and reactive. The format of 10 studies prevented quality grading; these were, however, reviewed as they provided unique insights. Variations in terminology and sampling frames complicated comparison across studies. CONCLUSION The results highlight the multiple and related factors that contribute to low service use and substandard quality of services experienced by minority ethnic groups, and the need for authors to clarify what they mean by "culturally competent" EoL care. The synthesis of diverse and disparate studies underpins a number of key recommendations for health care professionals and policymakers. Tackling these epidemiological, demographic, institutional, social, and cultural factors will require a systematic and organization-wide approach rather than the current piecemeal and reactive interventions.
Collapse
Affiliation(s)
- Natalie Evans
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Waldrop DP, Meeker MA, Kerr C, Skretny J, Tangeman J, Milch R. The nature and timing of family-provider communication in late-stage cancer: a qualitative study of caregivers' experiences. J Pain Symptom Manage 2012; 43:182-94. [PMID: 22248787 DOI: 10.1016/j.jpainsymman.2011.04.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 03/29/2011] [Accepted: 04/12/2011] [Indexed: 10/14/2022]
Abstract
CONTEXT Family members of people with advanced cancer can experience intensified distress and uncertainty during the final stages of their loved one's illness. Enhanced comprehension about disease progression, symptom management, and options for care can help families adapt, cope, and plan for the future. OBJECTIVES Guided by concepts from the Sense of Coherence Theory, which illuminates factors that contribute to adaptation in stressful situations, the objective of this study was to explore and describe family caregivers' accounts of the nature and timing of communication they had with a loved one's health care provider(s) during the advanced stages of cancer and before hospice enrollment. METHODS Retrospective in-depth interviews were conducted with caregivers of 46 people who died of cancer. Interviews were audiotaped, transcribed, and submitted to an iterative process of qualitative data analysis that included 1) systematic coding, 2) the use of data matrices to display summarized results and collapse the codes into themes, 3) and axial coding to characterize the nature of the themes. RESULTS Overall, communication with providers was found to be either 1) satisfactory or 2) unsatisfactory. Satisfactory communication was 1) compassionate, 2) responsive, and/or 3) dedicated. Unsatisfactory communication was described as 1) sparse, 2) conflicted, 3) contradictory, and/or 4) brink of death. CONCLUSION Communication with health care providers is critical for helping family caregivers understand and manage the changes that accompany a life-limiting illness. Timely communication with information and meaningful discussion about disease progression can help families prepare for the advanced stages of an illness and approaching death.
Collapse
Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work, Buffalo, New York 14260, USA.
| | | | | | | | | | | |
Collapse
|
50
|
Minton O, Strasser F, Radbruch L, Stone P. Identification of factors associated with fatigue in advanced cancer: a subset analysis of the European palliative care research collaborative computerized symptom assessment data set. J Pain Symptom Manage 2012; 43:226-35. [PMID: 21839608 DOI: 10.1016/j.jpainsymman.2011.03.025] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 03/21/2011] [Accepted: 03/29/2011] [Indexed: 11/12/2022]
Abstract
CONTEXT This is a subset analysis of fatigue data and associated clinical variables collected as part of the European Palliative Care Research Collaborative Computerized Symptom Assessment (CSA) study. The overall aim of CSA was to determine the prevalence of common symptoms in a mixed advanced cancer group using an electronic data collection system. OBJECTIVES This analysis was conducted to identify factors independently associated with fatigue. METHODS Only patient records containing complete data for all three measured blood parameters in the CSA study (C-reactive protein [CRP], hemoglobin, and albumin) were included in our subset analysis (n=720). Participants with locoregional or metastatic disease of all tumor types were included (with or without concurrent palliative anticancer treatment). A large number of symptoms were recorded using a predesigned computer program and widely used symptom measurement scales. Fatigue was measured using a well-validated three-item fatigue scale taken from the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire. A logistic regression model was developed using a cutoff score based on the available normative data to define the presence or the absence of severe fatigue. RESULTS Cases of fatigue were independently associated with chemotherapy treatment and experiencing other symptoms such as pain and depression. There was a moderate association with hemoglobin level. However, there was no link to cachexia, albumin, or CRP. CONCLUSION Severe fatigue is linked with treatment history and hemoglobin levels rather than CRP, mood, and other common symptoms in a mixed advanced cancer group.
Collapse
Affiliation(s)
- Ollie Minton
- Division of Population Health Sciences and Education, St. George's University of London, London, United Kingdom.
| | | | | | | |
Collapse
|