Changes in quality of life following admission to palliative care units

The primary goal of palliative care is to improve the quality of life (QOL) of people with a terminal illness. Previous studies of the impact of hospice/palliative care have documented improvement in physical and psychological symptoms, but not in overall QOL, due in part to the difficulties of measuring QOL. The McGill Quality of Life Questionnaire (MQOL) was developed to assess QOL in persons with advanced illness. MQOL scores were determined on admission and 7-8 days later for sequential eligible and willing patients admitted to five palliative care units. These 88 patients represented 8% of those admitted to the units during the study period. Following the final MQOL completion, patients were interviewed and asked to describe the nature of the changes in QOL they had experienced since admission. Significant improvements were found in the MQOL total score and subscale scores reflecting physical, psychological and existential well-being. In the interviews patients indicated that they had experienced changes in physical, emotional and interpersonal status, in spiritual outlook, and in their preparation for death. They also described the impact of the palliative care unit environment. This is the first study to demonstrate that hospice/palliative care can improve existential well-being in addition to psychological and physical symptoms. It provides evidence in the patients' own words that improvements in QOL go beyond symptom control following admission to a palliative care unit. However, the study results are generalizable only to those few patients admitted who are well enough to complete a questionnaire 1 week after admission.

Facilitating day-to-day decision making in palliative care

As part of a larger grounded theory study investigating the process by which palliative care patients make everyday choices, a secondary analysis of data was conducted to investigate the ways nurses support or restrict patients' participation in their care. Constant comparative methods were used to generate a detailed, contextually grounded description of nurses' strategies that influenced patients' participation in making everyday choices about their personal and nursing care. Data consisted of field notes derived from observations of patients and their caregivers in two hospital-based palliative care units and from 23 transcripts of interviews with participating nurses and patients. Nurses' efforts to support patients' participation in decision making were described as a four-phase process: getting to know the patient, enhancing opportunities for choice, being open to patient choice, and respecting choice. Factors influencing nurses' use of supportive behaviors and behaviors that restricted patients' participation in everyday choices were identified. Given the importance patients attributed to making choices, these findings provide a foundation for the design of nursing interventions that hold great potential for directly influencing quality of life.

Striving for balance: palliative care patients' experiences of making everyday choices

A fundamental principle of palliative care is the provision of patient-centred care, an approach explicitly based on the patient's perspective. Although much attention has been given to determining patients' preferences for involvement in medical decisions, choices related to personal and nursing care routines have been largely ignored in the literature. Data from participant observations of nurse-patient interactions involving 16 palliative care patients and their nurses as well as 10 in-depth open-ended interviews with patients were analyzed using grounded theory methods. Although the choices made by patients appeared uncomplicated on the surface, the context of unfamiliarity, uncertainty, and unpredictability in palliative care increased the underlying complexity of decision making. Through a process of deliberation and trade-offs, patients attempted to regain or maintain some balance in their lives. This process of striving for balance consisted of three overlapping phases: weighing things up, communicating choice, and living with one's choices.

Implementing a hospital-wide pain management strategy

The purpose of this article is to describe the process of undertaking a large scale nursing pain management initiative, that we entitled "Pain Month." Several educational resources and strategies were employed in an effort to increase nurse's knowledge on the subject of pain management. Pre and post patient satisfaction surveys were conducted to test the effect of the education on actual pain management. The results showed improvements in actual pain scores and in satisfaction with pain management; however, several more improvements were shown to be necessary to achieve excellent pain management for patients. Follow-up initiatives such as a pain resource nurse program, an interdisciplinary pain committee and continued, patient surveys have been implemented to address some of these existing issues.

Participatory control in chronic hospital-based hemodialysis patients

The purpose of this study was to determine chronic hospital-based hemodialysis patients' perceptions of control over selected aspects of hemodialysis care and to compare the patients' ratings with the global ratings of nurses caring for them. Two versions of a 14-item Hemodialysis Control Questionnaire (HCQ) were developed, one for patients (HCQ-P) and one for nurses (HCQ-N). Forty-seven patients and 32 nurses rated both perceived and desired control for each aspect of hemodialysis care on the HCQ. Reasons for their ratings were elicited and recorded. High test-retest reliability was established for both perceived and desired control on the HCQ-P and the desired control component of the HCQ-N. Patients rated their overall perceived and desired control as moderate, likewise the nurses' global score for desired control was rated as moderate. Item-by-item analysis revealed that nurses overestimated the patients' desired control over technical aspects of care but underestimated the patients' desire for more control over nontechnical aspects of care. The content analysis of the verbatim responses supported the quantitative findings.